Cycle 1
Health 2024-11-15 · Fire 2024-11-15
30 health deficiencies
Top issue: Quality of Life and Care (12 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Orange, CA
New Orange Hills
2-star overall rating with 2-star inspections with 30 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
5017 E. Chapman Avenue, Orange, CA
(714) 997-7090
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
145
Certified beds
Average residents
135
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
1987-12-07
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
0.50
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
2.12
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
2.39
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
5.01
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
2.62
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
4.51
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.37
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.12
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.31
CMS adjusted RN staffing hours
Adjusted total hours
3.10
CMS adjusted total nurse staffing hours
Case-mix index
2.21
Higher values indicate more complex resident acuity
RN turnover
18%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
33%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,788
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
28.77
Composite VBP score used to determine payment impact.
Payment multiplier
0.9851
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.24
Baseline 24.52% · Performance 21.72% · Measure score 3.24 · Achievement 0 · Improvement 3.24
Healthcare-associated infections
3.30
Baseline 11.66% · Performance 9.13% · Measure score 3.30 · Achievement 0 · Improvement 3.30
Total nurse turnover
4.97
Baseline 76.36% · Performance 48.19% · Measure score 4.97 · Achievement 3.79 · Improvement 4.97
Adjusted total nurse staffing
0
Baseline 3.18 hours · Performance 3.06 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.89% |
10.72%
2.2 pts worse
|
No Different than the National Rate · Eligible stays 79 · Observed rate 17.72% · Lower 95% interval 9.78% |
| Discharge to community | 42.77% |
50.57%
7.8 pts worse
|
No Different than the National Rate · Eligible stays 87 · Observed rate 36.78% · Lower 95% interval 34.65% |
| Medicare spending per beneficiary | 1.4 |
1.02
0.4 pts worse
|
|
| Drug regimen review with follow-up | 98.92% |
95.27%
3.7 pts better
|
Numerator 92 · Denominator 93 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 93 |
| Discharge self-care score | 34.04% |
53.69%
19.6 pts worse
|
Numerator 16 · Denominator 47 |
| Discharge mobility score | 36.17% |
50.94%
14.8 pts worse
|
Numerator 17 · Denominator 47 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 93 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 9.13% |
7.12%
2 pts worse
|
No Different than the National Rate · Eligible stays 69 · Observed rate 14.49% · Lower 95% interval 5.83% |
| Staff COVID-19 vaccination coverage | 8.81% |
8.2%
0.6 pts better
|
Numerator 20 · Denominator 227 |
| Staff flu vaccination coverage | 89.64% |
42%
47.6 pts better
|
Numerator 251 · Denominator 280 |
| Discharge function score | 34.04% |
56.45%
22.4 pts worse
|
Numerator 16 · Denominator 47 |
| Transfer of health information to provider | 97.83% |
95.95%
1.9 pts better
|
Numerator 45 · Denominator 46 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 21 · Denominator 21 |
| Resident COVID-19 vaccinations up to date | 19.61% |
25.2%
5.6 pts worse
|
Numerator 10 · Denominator 51 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.1 |
2.3
0.2 pts better
|
1.9
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 3.5 · Expected 3.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.0 |
1.6
0.6 pts better
|
1.8
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 1.3 · Expected 2.2 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.8% |
98.5%
1.3 pts better
|
93.4%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 99.2% · Q3 100.0% · Q4 100.0% · 4Q avg 99.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.6% |
98.2%
0.6 pts worse
|
95.5%
2.1 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
1.6%
1.6 pts better
|
3.3%
3.3 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 who have depressive symptoms | 23.0% |
6.8%
16.2 pts worse
|
11.4%
11.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.3% · Q2 25.3% · Q3 19.3% · Q4 14.1% · 4Q avg 23.0% |
| Percentage of long-stay residents who lose too much weight | 1.6% |
4.1%
2.5 pts better
|
5.4%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.5% · Q2 0.9% · Q3 2.0% · Q4 0.0% · 4Q avg 1.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 24.7% |
13.7%
11 pts worse
|
19.6%
5.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.1% · Q2 26.3% · Q3 26.7% · Q4 19.4% · 4Q avg 24.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 19.2% |
14.2%
5 pts worse
|
16.7%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.3% · Q2 24.0% · Q3 15.4% · Q4 7.5% · 4Q avg 19.2% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 5.1% |
0.4%
4.7 pts worse
|
0.1%
5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 5.0% · Q3 2.8% · Q4 4.5% · 4Q avg 5.1% |
| Percentage of long-stay residents whose ability to walk independently worsened | 11.6% |
11.0%
0.6 pts worse
|
16.3%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 11.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 6.6% |
10.7%
4.1 pts better
|
14.9%
8.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.6% · Q2 4.3% · Q3 0.0% · Q4 7.0% · 4Q avg 6.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.5% |
1.0%
0.5 pts better
|
1.0%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.0% · Q3 0.0% · Q4 1.1% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.2%
1.2 pts better
|
1.7%
1.7 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 new or worsened bowel or bladder incontinence | 18.3% |
10.9%
7.4 pts worse
|
19.8%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.3% · Q2 23.1% · Q3 20.5% · Q4 10.7% · 4Q avg 18.3% |
| Percentage of long-stay residents with pressure ulcers | 5.3% |
4.7%
0.6 pts worse
|
5.1%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.3% · Q2 5.0% · Q3 4.3% · Q4 4.6% · 4Q avg 5.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.8% |
94.0%
5.8 pts better
|
81.7%
18.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.5% · Q2 100.0% · Q3 100.0% · Q4 99.6% · 4Q avg 99.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.0% |
11.2%
1.2 pts better
|
12.0%
2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.0% · Observed 11.8% · Expected 13.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.2% |
1.5%
1.3 pts better
|
1.6%
1.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.9% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 88.1% |
93.2%
5.1 pts worse
|
79.7%
8.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 88.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.3% |
23.2%
1.1 pts worse
|
23.9%
0.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.3% · Observed 31.8% · Expected 31.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-05-16 · Fire 2022-05-16
22 health deficiencies
Top issue: Quality of Life and Care (9 deficiencies)
22 fire-safety deficiencies
Top issue: Emergency Preparedness (14 deficiencies)
Cycle 3
Health 2020-02-26 · Fire 2020-02-26
37 health deficiencies
Top issue: Quality of Life and Care (12 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-11-15
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-11-20
F · Potential for more than minimal harm
2024-11-15
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-11-21
F · Potential for more than minimal harm
2024-11-15
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-11-21
F · Potential for more than minimal harm
2024-11-15
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-11-21
D · Potential for more than minimal harm
2024-11-15
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-11-21
D · Potential for more than minimal harm
2024-11-15
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-11-21
C · Minimal harm
2024-11-15
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-11-18
F · Potential for more than minimal harm
2022-05-16
E29 · Emergency Preparedness Deficiencies
Fire Safety
Develop a communication plan.
Corrected 2022-06-14
F · Potential for more than minimal harm
2022-05-16
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2022-06-14
E · Potential for more than minimal harm
2022-05-16
E20 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures including evacuation.
Corrected 2022-06-14
E · Potential for more than minimal harm
2022-05-16
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2022-06-14
D · Potential for more than minimal harm
2022-05-16
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2022-06-14
D · Potential for more than minimal harm
2022-05-16
E18 · Emergency Preparedness Deficiencies
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2022-06-14
D · Potential for more than minimal harm
2022-05-16
E22 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for sheltering.
Corrected 2022-06-14
D · Potential for more than minimal harm
2022-05-16
E23 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for medical documentation.
Corrected 2022-06-14
D · Potential for more than minimal harm
2022-05-16
E24 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2022-06-14
D · Potential for more than minimal harm
2022-05-16
E25 · Emergency Preparedness Deficiencies
Fire Safety
Create arrangements with other facilities to receive patients.
Corrected 2022-06-14
D · Potential for more than minimal harm
2022-05-16
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2022-06-14
D · Potential for more than minimal harm
2022-05-16
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2022-06-14
D · Potential for more than minimal harm
2022-05-16
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2022-06-14
D · Potential for more than minimal harm
2022-05-16
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2022-06-14
D · Potential for more than minimal harm
2022-05-16
E9 · Emergency Preparedness Deficiencies
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2022-06-14
D · Potential for more than minimal harm
2022-05-16
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-06-14
D · Potential for more than minimal harm
2022-05-16
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2022-06-14
D · Potential for more than minimal harm
2022-05-16
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-06-14
D · Potential for more than minimal harm
2022-05-16
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-06-14
D · Potential for more than minimal harm
2022-05-16
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2022-06-14
D · Potential for more than minimal harm
2022-05-16
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2022-06-14
D · Potential for more than minimal harm
2022-05-16
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-06-14
D · Potential for more than minimal harm
2020-02-26
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2020-08-13
D · Potential for more than minimal harm
2020-02-26
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2020-08-13
D · Potential for more than minimal harm
2020-02-26
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2020-08-13
D · Potential for more than minimal harm
2020-02-26
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2020-08-13
D · Potential for more than minimal harm
2020-02-26
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2020-08-13
D · Potential for more than minimal harm
2020-02-26
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2020-08-13
D · Potential for more than minimal harm
2020-02-26
K907 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure medical gas and vacuum systems have documented maintenance programs.
Corrected 2020-08-13
D · Potential for more than minimal harm
2020-02-26
K908 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure gas and vacuum systems are inspected and tested as part of a maintenance program.
Corrected 2020-08-13
D · Potential for more than minimal harm
2020-02-26
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2020-08-13
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-11-26
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-12-08
B · Minimal harm
2025-11-26
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 2025-12-08
G · Actual harm
2025-11-10
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 2025-12-23
D · Potential for more than minimal harm
2025-09-18
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-10-10
D · Potential for more than minimal harm
2025-08-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-08-13
D · Potential for more than minimal harm
2025-07-10
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2025-07-30
D · Potential for more than minimal harm
2025-05-14
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-06-04
D · Potential for more than minimal harm
2025-05-14
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-06-04
D · Potential for more than minimal harm
2025-05-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-04
B · Minimal harm
2025-05-14
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 2025-06-04
D · Potential for more than minimal harm
2025-02-28
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-03-20
D · Potential for more than minimal harm
2025-02-28
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 2025-03-20
B · Minimal harm
2025-01-07
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-01-28
E · Potential for more than minimal harm
2024-11-15
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 2024-12-14
D · Potential for more than minimal harm
2024-11-15
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-12-14
D · Potential for more than minimal harm
2024-11-15
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-12-14
D · Potential for more than minimal harm
2024-11-15
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 2024-12-14
D · Potential for more than minimal harm
2024-11-15
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-12-14
D · Potential for more than minimal harm
2024-11-15
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-12-14
D · Potential for more than minimal harm
2024-11-15
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 2024-12-14
D · Potential for more than minimal harm
2024-11-15
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-12-14
D · Potential for more than minimal harm
2024-11-15
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2024-12-14
D · Potential for more than minimal harm
2024-11-15
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-12-14
D · Potential for more than minimal harm
2024-11-15
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2024-12-14
D · Potential for more than minimal harm
2024-11-15
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 2024-12-14
D · Potential for more than minimal harm
2024-11-15
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 2024-12-14
D · Potential for more than minimal harm
2024-11-15
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-12-14
D · Potential for more than minimal harm
2024-11-15
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 2024-12-14
D · Potential for more than minimal harm
2024-11-15
F773 · Administration Deficiencies
Health
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Corrected 2024-12-14
D · Potential for more than minimal harm
2024-11-15
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 2024-12-14
D · Potential for more than minimal harm
2024-11-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-12-14
D · Potential for more than minimal harm
2024-11-15
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2024-12-14
B · Minimal harm
2024-11-15
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 2024-12-14
B · Minimal harm
2024-08-01
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-08-12
B · Minimal harm
2024-05-30
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-06-14
D · Potential for more than minimal harm
2024-03-21
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 2024-04-13
D · Potential for more than minimal harm
2024-03-21
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-04-13
D · Potential for more than minimal harm
2024-03-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-04-12
D · Potential for more than minimal harm
2024-03-12
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 2024-03-27
D · Potential for more than minimal harm
2024-01-24
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-02-15
D · Potential for more than minimal harm
2024-01-24
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 2024-02-15
D · Potential for more than minimal harm
2024-01-24
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 2024-02-15
D · Potential for more than minimal harm
2023-12-13
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 2023-12-29
D · Potential for more than minimal harm
2023-12-13
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 2023-12-29
D · Potential for more than minimal harm
2023-11-17
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-12-05
D · Potential for more than minimal harm
2023-10-23
F661 · Resident Assessment and Care Planning Deficiencies
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2023-11-07
D · Potential for more than minimal harm
2023-08-30
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-09-12
D · Potential for more than minimal harm
2023-08-30
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-09-12
D · Potential for more than minimal harm
2023-08-30
F909 · Environmental Deficiencies
Health
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
Corrected 2023-09-12
D · Potential for more than minimal harm
2023-05-16
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 2023-05-16
D · Potential for more than minimal harm
2023-05-16
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-05-16
D · Potential for more than minimal harm
2023-05-16
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-05-16
D · Potential for more than minimal harm
2023-05-16
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2023-05-16
D · Potential for more than minimal harm
2023-04-04
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2023-05-04
D · Potential for more than minimal harm
2023-04-04
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 2023-05-04
D · Potential for more than minimal harm
2022-05-16
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2022-06-16
D · Potential for more than minimal harm
2022-05-16
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2022-06-16
D · Potential for more than minimal harm
2022-05-16
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 2022-06-16
D · Potential for more than minimal harm
2022-05-16
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-06-16
D · Potential for more than minimal harm
2022-05-16
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-06-16
D · Potential for more than minimal harm
2022-05-16
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 2022-06-16
D · Potential for more than minimal harm
2022-05-16
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2022-06-16
D · Potential for more than minimal harm
2022-05-16
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2022-06-16
D · Potential for more than minimal harm
2022-05-16
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 2022-06-16
D · Potential for more than minimal harm
2022-05-16
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 2022-06-16
D · Potential for more than minimal harm
2022-05-16
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 2022-06-16
D · Potential for more than minimal harm
2022-05-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-06-16
D · Potential for more than minimal harm
2022-05-16
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2022-06-16
E · Potential for more than minimal harm
2020-02-26
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 2020-03-26
E · Potential for more than minimal harm
2020-02-26
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2020-03-26
E · Potential for more than minimal harm
2020-02-26
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2020-03-26
E · Potential for more than minimal harm
2020-02-26
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2020-03-26
E · Potential for more than minimal harm
2020-02-26
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 2020-03-26
E · Potential for more than minimal harm
2020-02-26
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 2020-03-26
E · Potential for more than minimal harm
2020-02-26
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 2020-03-26
E · Potential for more than minimal harm
2020-02-26
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 2020-03-26
D · Potential for more than minimal harm
2020-02-26
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 2020-03-26
D · Potential for more than minimal harm
2020-02-26
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2020-03-26
D · Potential for more than minimal harm
2020-02-26
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 2020-03-26
D · Potential for more than minimal harm
2020-02-26
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2020-03-26
D · Potential for more than minimal harm
2020-02-26
F687 · Quality of Life and Care Deficiencies
Health
Provide appropriate foot care.
Corrected 2020-03-26
D · Potential for more than minimal harm
2020-02-26
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2020-03-26
D · Potential for more than minimal harm
2020-02-26
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2020-03-26
D · Potential for more than minimal harm
2020-02-26
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2020-03-26
D · Potential for more than minimal harm
2020-02-26
F808 · Nutrition and Dietary Deficiencies
Health
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Corrected 2020-03-26
D · Potential for more than minimal harm
2020-02-26
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2020-03-26
D · Potential for more than minimal harm
2020-02-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2020-03-26
B · Minimal harm
2020-02-26
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 2020-03-26
B · Minimal harm
2020-02-26
F914 · Environmental Deficiencies
Health
Provide bedrooms that don't allow residents to see each other when privacy is needed.
Corrected 2020-03-26
Penalties and ownership
What sits behind the stars
$0
2025-11-10
Payment Denial
Payment Denial · denial start 2025-12-10 · 13 days
13 day denial
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
Fitch, Craig
Corporate Officer · Individual
Looper, William
Corporate Officer · Individual
Villafania, James
Operational/Managerial Control · Individual
Villafania, James
W-2 Managing Employee · Individual
Willits, Adam
Corporate Director · Individual
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4-star overall rating with 4-star inspections with $4,194 in total fines with 18 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
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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
#3
The Hills Post Acute
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2-star overall rating with 2-star inspections with $4,893 in total fines with 15 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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