Cycle 1
Health 2024-10-24 · Fire 2024-10-24
21 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Orange, CA
Mainplace Post Acute
3-star overall rating with 3-star inspections with 21 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
1835 West La Veta Avenue, Orange, CA
(714) 978-6800
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
169
Certified beds
Average residents
156
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
1987-03-04
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
329 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.41
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.20
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
2.55
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
4.16
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
1.60
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
3.87
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.29
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.11
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.40
CMS adjusted RN staffing hours
Adjusted total hours
4.03
CMS adjusted total nurse staffing hours
Case-mix index
1.41
Higher values indicate more complex resident acuity
RN turnover
20%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
32%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,853
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
38.34
Composite VBP score used to determine payment impact.
Payment multiplier
0.9914
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.64
Baseline 18.24% · Performance 19.28% · Measure score 4.64 · Achievement 4.64 · Improvement 0
Healthcare-associated infections
0.67
Baseline 5.72% · Performance 7.63% · Measure score 0.67 · Achievement 0.67 · Improvement 0
Total nurse turnover
6.99
Baseline 31.88% · Performance 35.10% · Measure score 6.99 · Achievement 6.99 · Improvement 0
Adjusted total nurse staffing
3.03
Baseline 4.01 hours · Performance 3.94 hours · Measure score 3.03 · Achievement 3.03 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.65% |
10.72%
0.9 pts worse
|
No Different than the National Rate · Eligible stays 245 · Observed rate 11.84% · Lower 95% interval 9.01% |
| Discharge to community | 55.99% |
50.57%
5.4 pts better
|
No Different than the National Rate · Eligible stays 228 · Observed rate 50.44% · Lower 95% interval 47.91% |
| Medicare spending per beneficiary | 1.34 |
1.02
0.3 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 247 · Denominator 247 |
| Falls with major injury | 0.81% |
0.77%
About the same
|
Numerator 2 · Denominator 247 |
| Discharge self-care score | 25.6% |
53.69%
28.1 pts worse
|
Numerator 32 · Denominator 125 |
| Discharge mobility score | 31.2% |
50.94%
19.7 pts worse
|
Numerator 39 · Denominator 125 |
| Pressure ulcers or injuries, new or worsened | 0.4% |
2.29%
1.9 pts better
|
Numerator 1 · Denominator 247 · Adjusted rate 0.29% |
| Healthcare-associated infections requiring hospitalization | 7.63% |
7.12%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 187 · Observed rate 8.56% · Lower 95% interval 4.84% |
| Staff COVID-19 vaccination coverage | 8.61% |
8.2%
0.4 pts better
|
Numerator 21 · Denominator 244 |
| Staff flu vaccination coverage | 97.27% |
42%
55.3 pts better
|
Numerator 285 · Denominator 293 |
| Discharge function score | 32.8% |
56.45%
23.7 pts worse
|
Numerator 41 · Denominator 125 |
| Transfer of health information to provider | 98.9% |
95.95%
3 pts better
|
Numerator 90 · Denominator 91 |
| Transfer of health information to patient | 94.44% |
96.28%
1.8 pts worse
|
Numerator 85 · Denominator 90 |
| Resident COVID-19 vaccinations up to date | 9.85% |
25.2%
15.3 pts worse
|
Numerator 13 · Denominator 132 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.5 |
2.3
0.2 pts worse
|
1.9
0.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 4.0 · Expected 3.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.8 |
1.6
0.2 pts worse
|
1.8
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 2.1 · Expected 1.9 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
98.5%
1.5 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
98.2%
1.8 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.7% |
1.6%
0.9 pts better
|
3.3%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 0.9% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.3% |
6.8%
5.5 pts better
|
11.4%
10.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 0.0% · Q3 0.0% · Q4 1.9% · 4Q avg 1.3% |
| Percentage of long-stay residents who lose too much weight | 5.1% |
4.1%
1 pts worse
|
5.4%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 9.5% · Q3 4.4% · Q4 4.0% · 4Q avg 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.0% |
13.7%
2.3 pts worse
|
19.6%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.9% · Q2 16.2% · Q3 14.9% · Q4 14.7% · 4Q avg 16.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 6.0% |
14.2%
8.2 pts better
|
16.7%
10.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 6.6% · Q3 5.9% · Q4 8.0% · 4Q avg 6.0% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.4%
0.4 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 21.3% |
11.0%
10.3 pts worse
|
16.3%
5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.4% · Q2 26.5% · Q3 14.7% · Q4 22.6% · 4Q avg 21.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 18.7% |
10.7%
8 pts worse
|
14.9%
3.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.7% · Q2 19.5% · Q3 20.2% · Q4 17.7% · 4Q avg 18.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.0%
1 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.5% |
1.2%
0.7 pts better
|
1.7%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 0.0% · Q3 1.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 17.5% |
10.9%
6.6 pts worse
|
19.8%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.9% · Q2 26.9% · Q3 13.0% · Q4 17.2% · 4Q avg 17.5% |
| Percentage of long-stay residents with pressure ulcers | 4.0% |
4.7%
0.7 pts better
|
5.1%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 3.0% · Q3 5.1% · Q4 4.6% · 4Q avg 4.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.9% |
94.0%
5.9 pts better
|
81.7%
18.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 99.7% · 4Q avg 99.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 14.7% |
11.2%
3.5 pts worse
|
12.0%
2.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 14.7% · Observed 16.1% · Expected 12.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.3% |
1.5%
0.2 pts better
|
1.6%
0.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.6% · Q2 2.7% · Q3 1.4% · Q4 0.5% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.7% |
93.2%
5.5 pts better
|
79.7%
19 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.0% |
23.2%
2.8 pts worse
|
23.9%
2.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.0% · Observed 31.2% · Expected 28.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-03-25 · Fire 2022-03-25
15 health deficiencies
Top issue: Nutrition and Dietary (4 deficiencies)
11 fire-safety deficiencies
Top issue: Emergency Preparedness (4 deficiencies)
Cycle 3
Health 2019-05-13 · Fire 2019-05-13
28 health deficiencies
Top issue: Quality of Life and Care (10 deficiencies)
12 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-10-24
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-11-14
D · Potential for more than minimal harm
2024-10-24
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-11-14
C · Minimal harm
2024-10-24
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-11-14
D · Potential for more than minimal harm
2022-03-25
E23 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for medical documentation.
Corrected 2022-04-28
D · Potential for more than minimal harm
2022-03-25
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2022-04-28
D · Potential for more than minimal harm
2022-03-25
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2022-04-28
D · Potential for more than minimal harm
2022-03-25
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2022-04-28
D · Potential for more than minimal harm
2022-03-25
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2022-04-28
D · Potential for more than minimal harm
2022-03-25
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-04-28
D · Potential for more than minimal harm
2022-03-25
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-04-28
D · Potential for more than minimal harm
2022-03-25
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-04-28
D · Potential for more than minimal harm
2022-03-25
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2022-04-28
D · Potential for more than minimal harm
2022-03-25
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-04-28
D · Potential for more than minimal harm
2022-03-25
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-04-28
F · Potential for more than minimal harm
2019-05-13
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2019-07-05
E · Potential for more than minimal harm
2019-05-13
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2019-07-05
E · Potential for more than minimal harm
2019-05-13
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2019-07-05
D · Potential for more than minimal harm
2019-05-13
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2019-07-05
D · Potential for more than minimal harm
2019-05-13
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2019-07-05
D · Potential for more than minimal harm
2019-05-13
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2019-07-05
D · Potential for more than minimal harm
2019-05-13
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-07-05
D · Potential for more than minimal harm
2019-05-13
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2019-07-05
D · Potential for more than minimal harm
2019-05-13
K900 · Miscellaneous Deficiencies
Fire Safety
Meet Health Care Facilities Code mechanical requirements.
Corrected 2019-07-05
D · Potential for more than minimal harm
2019-05-13
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2019-07-05
D · Potential for more than minimal harm
2019-05-13
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2019-07-05
D · Potential for more than minimal harm
2019-05-13
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2019-07-05
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-01
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-12-14
D · Potential for more than minimal harm
2025-12-01
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-12-14
D · Potential for more than minimal harm
2025-04-07
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-04-30
D · Potential for more than minimal harm
2024-12-18
F567 · Resident Rights Deficiencies
Health
Honor the resident's right to manage his or her financial affairs.
Corrected 2024-12-23
D · Potential for more than minimal harm
2024-12-18
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-12-23
E · Potential for more than minimal harm
2024-10-24
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-11-15
E · Potential for more than minimal harm
2024-10-24
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2024-11-15
E · Potential for more than minimal harm
2024-10-24
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-11-15
E · Potential for more than minimal harm
2024-10-24
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-11-15
E · Potential for more than minimal harm
2024-10-24
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2024-11-15
D · Potential for more than minimal harm
2024-10-24
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-11-15
D · Potential for more than minimal harm
2024-10-24
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-11-15
D · Potential for more than minimal harm
2024-10-24
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-11-15
D · Potential for more than minimal harm
2024-10-24
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-11-15
D · Potential for more than minimal harm
2024-10-24
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-11-15
D · Potential for more than minimal harm
2024-10-24
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2024-11-15
D · Potential for more than minimal harm
2024-10-24
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-11-15
D · Potential for more than minimal harm
2024-10-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-15
D · Potential for more than minimal harm
2024-10-24
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-11-15
B · Minimal harm
2024-10-24
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-11-15
B · Minimal harm
2024-10-24
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-11-15
B · Minimal harm
2024-10-24
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2024-11-15
B · Minimal harm
2024-10-24
F907 · Environmental Deficiencies
Health
Provide enough space and equipment to meet each resident's needs
Corrected 2024-11-15
B · Minimal harm
2024-08-08
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-08-12
D · Potential for more than minimal harm
2024-05-03
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2024-05-24
D · Potential for more than minimal harm
2024-05-03
F773 · Administration Deficiencies
Health
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Corrected 2024-05-24
D · Potential for more than minimal harm
2024-03-29
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2024-04-02
D · Potential for more than minimal harm
2024-01-16
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-02-07
D · Potential for more than minimal harm
2024-01-16
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-02-07
D · Potential for more than minimal harm
2024-01-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-02-07
B · Minimal harm
2024-01-16
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-02-07
B · Minimal harm
2023-12-20
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2023-12-27
B · Minimal harm
2023-09-13
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2023-10-03
D · Potential for more than minimal harm
2023-07-20
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2023-07-28
D · Potential for more than minimal harm
2023-04-28
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-05-12
F · Potential for more than minimal harm
2022-03-25
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-05-17
D · Potential for more than minimal harm
2022-03-25
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2022-05-17
D · Potential for more than minimal harm
2022-03-25
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-05-17
D · Potential for more than minimal harm
2022-03-25
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-05-17
D · Potential for more than minimal harm
2022-03-25
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2022-05-17
D · Potential for more than minimal harm
2022-03-25
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-05-17
D · Potential for more than minimal harm
2022-03-25
F813 · Nutrition and Dietary Deficiencies
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2022-05-17
B · Minimal harm
2022-03-25
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2022-05-17
B · Minimal harm
2022-03-25
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2022-05-17
F · Potential for more than minimal harm
2019-05-13
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2019-06-03
E · Potential for more than minimal harm
2019-05-13
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2019-06-03
E · Potential for more than minimal harm
2019-05-13
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2019-06-03
D · Potential for more than minimal harm
2019-05-13
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2019-06-03
D · Potential for more than minimal harm
2019-05-13
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2019-06-03
D · Potential for more than minimal harm
2019-05-13
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2019-06-03
D · Potential for more than minimal harm
2019-05-13
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2019-06-03
D · Potential for more than minimal harm
2019-05-13
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2019-06-03
D · Potential for more than minimal harm
2019-05-13
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2019-06-03
D · Potential for more than minimal harm
2019-05-13
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2019-06-03
D · Potential for more than minimal harm
2019-05-13
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2019-06-03
D · Potential for more than minimal harm
2019-05-13
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2019-06-03
D · Potential for more than minimal harm
2019-05-13
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2019-06-03
D · Potential for more than minimal harm
2019-05-13
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2019-06-03
D · Potential for more than minimal harm
2019-05-13
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2019-06-03
D · Potential for more than minimal harm
2019-05-13
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2019-06-03
D · Potential for more than minimal harm
2019-05-13
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2019-06-03
D · Potential for more than minimal harm
2019-05-13
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2019-06-03
D · Potential for more than minimal harm
2019-05-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-06-03
B · Minimal harm
2019-05-13
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2019-06-03
Penalties and ownership
What sits behind the stars
Ownership
Flagstone Healthcare South LLC
5% Or Greater Direct Ownership Interest · Organization
The Ensign Group Inc
5% Or Greater Indirect Ownership Interest · Organization
Burnam, Soon
Corporate Officer · Individual
Keetch, Chad
Corporate Officer · Individual
Looper, William
Corporate Officer · Individual
Ruggles, Marc
Operational/Managerial Control · Individual
Sato, Ami
Corporate Officer · Individual
Talebi Dolouei, Reza
Operational/Managerial Control · Individual
Willits, Adam
Corporate Director · Individual
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4-star overall rating with 3-star inspections with 21 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
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5-star overall rating with 3-star inspections with 25 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Healthbridge Children's Hospital - Orange D/P SNF
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4-star overall rating with 4-star inspections with $3,846 in total fines with 13 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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