12 health deficiencies
Top issue: Infection Control (4 deficiencies)
5 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Pacific Grove, CA
3-star overall rating with 3-star inspections with $9,440 in total fines with 12 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
200 Lighthouse Avenue, Pacific Grove, CA
(831) 375-2695
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Beds
51
Certified beds
Average residents
44
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Bvhc, LLC
Operator or chain grouping
Approved since
1971-08-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
RN hours / resident day
0.66
Registered nurse staffing
LPN hours / resident day
0.87
Licensed practical nurse staffing
Aide hours / resident day
2.50
Nurse aide staffing
Weekend hours
3.47
Weekend nurse staffing
RN turnover
33%
Annual RN turnover
Total nurse turnover
41%
Annual nurse turnover
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.4 |
2.3
0.9 pts better
|
1.9
0.5 pts better
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.2 |
1.6
0.4 pts better
|
1.8
0.6 pts better
|
Long Stay · 20240701-20250630 |
| 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 |
| 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 |
| 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 |
| Percentage of long-stay residents who have depressive symptoms | 8.8% |
6.8%
2 pts worse
|
11.4%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 4.7% |
4.1%
0.6 pts worse
|
5.4%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 29.0% |
13.7%
15.3 pts worse
|
19.6%
9.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 27.5% |
14.2%
13.3 pts worse
|
16.7%
10.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents whose ability to walk independently worsened | 9.3% |
11.0%
1.7 pts better
|
16.3%
7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 6.9% |
10.7%
3.8 pts better
|
14.9%
8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents with a urinary tract infection | 1.3% |
1.2%
0.1 pts worse
|
1.7%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 15.5% |
10.9%
4.6 pts worse
|
19.8%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 6.3% |
4.7%
1.6 pts worse
|
5.1%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 88.9% |
94.0%
5.1 pts worse
|
81.7%
7.2 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.9% |
11.2%
4.3 pts better
|
12.0%
5.1 pts better
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.0% |
1.5%
0.5 pts better
|
1.6%
0.6 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
93.2%
6.8 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.6% |
23.2%
0.6 pts better
|
23.9%
1.3 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Top issue: Infection Control (4 deficiencies)
5 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Top issue: Quality of Life and Care (5 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Top issue: Quality of Life and Care (5 deficiencies)
9 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Fire safety
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-12-30
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-12-17
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-12-23
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2025-12-17
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-12-17
Fire Safety
Use approved construction type or materials.
Corrected 2025-03-03
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-06-13
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2024-06-13
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-06-13
Fire Safety
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
Corrected 2024-06-13
Fire Safety
Provide emergency officials' contact information.
Corrected 2024-06-13
Fire Safety
Use approved construction type or materials.
Corrected 2024-06-13
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-06-13
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-06-13
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2024-06-13
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2022-07-27
Fire Safety
Provide emergency officials' contact information.
Corrected 2022-07-27
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2022-07-27
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2022-07-27
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2022-07-27
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-07-27
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2022-07-27
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-07-27
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-07-27
Inspection history
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2025-12-17
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-12-17
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-12-17
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2025-12-17
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2025-12-17
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-12-17
Health
Provide and implement an infection prevention and control program.
Corrected 2025-12-17
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-12-17
Health
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Not marked corrected
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-10-06
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2025-04-25
Health
Keep residents' personal and medical records private and confidential.
Corrected 2025-04-11
Health
Honor the resident's right to manage his or her financial affairs.
Corrected 2024-10-07
Health
Provide appropriate foot care.
Corrected 2024-10-11
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2024-09-13
Health
Provide and implement an infection prevention and control program.
Corrected 2024-09-13
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2024-09-04
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-09-04
Health
Provide activities to meet all resident's needs.
Corrected 2024-08-21
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-06-10
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-06-10
Health
Dispose of garbage and refuse properly.
Corrected 2024-06-10
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-06-10
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-06-10
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 2024-06-10
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-06-10
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 2024-06-10
Health
Provide and implement an infection prevention and control program.
Corrected 2024-06-10
Health
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Corrected 2024-06-10
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-04-26
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-07-01
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-04-17
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-04-17
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 2022-07-09
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2022-07-09
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-07-09
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-07-09
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2022-07-09
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2022-07-09
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2022-07-09
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-07-09
Health
Provide appropriate foot care.
Corrected 2022-07-09
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-07-09
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2022-07-09
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2022-07-09
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 2022-07-09
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 2022-07-09
Health
Dispose of garbage and refuse properly.
Corrected 2022-07-09
Health
Provide and implement an infection prevention and control program.
Corrected 2022-07-09
Health
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Corrected 2022-07-09
Penalties and ownership
Payment Denial · denial start 2024-04-18 · 8 days
8 day denial
Fine · fine $3,147
Fine
Fine · fine $6,293
Fine
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
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