10 health deficiencies
Top issue: Pharmacy Service (4 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Laguna Hills, CA
4-star overall rating with 4-star inspections with 10 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
24962 Calle Aragon, Laguna Hills, CA
(949) 587-9000
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Beds
99
Certified beds
Average residents
92
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
1987-04-09
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
RN hours / resident day
0.34
Registered nurse staffing
LPN hours / resident day
1.57
Licensed practical nurse staffing
Aide hours / resident day
2.43
Nurse aide staffing
Weekend hours
3.73
Weekend nurse staffing
RN turnover
73%
Annual RN turnover
Total nurse turnover
53%
Annual nurse turnover
Quality measures
| 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 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.7 |
1.6
0.9 pts better
|
1.8
1.1 pts better
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.5% |
98.5%
1 pts better
|
93.4%
6.1 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 | 3.8% |
1.6%
2.2 pts worse
|
3.3%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 3.0% |
6.8%
3.8 pts better
|
11.4%
8.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 0.6% |
4.1%
3.5 pts better
|
5.4%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 20.1% |
13.7%
6.4 pts worse
|
19.6%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 3.7% |
14.2%
10.5 pts better
|
16.7%
13 pts better
|
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 | 7.3% |
11.0%
3.7 pts better
|
16.3%
9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 7.4% |
10.7%
3.3 pts better
|
14.9%
7.5 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 | 0.6% |
1.2%
0.6 pts better
|
1.7%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 10.3% |
10.9%
0.6 pts better
|
19.8%
9.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 2.9% |
4.7%
1.8 pts better
|
5.1%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.7% |
11.2%
1.5 pts worse
|
12.0%
0.7 pts worse
|
Short Stay · 20240701-20250630 |
| 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 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 99.7% |
93.2%
6.5 pts better
|
79.7%
20 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 28.5% |
23.2%
5.3 pts worse
|
23.9%
4.6 pts worse
|
Short Stay · 20240701-20250630 |
Survey summary
Top issue: Pharmacy Service (4 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Top issue: Nutrition and Dietary (4 deficiencies)
6 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Top issue: Quality of Life and Care (14 deficiencies)
12 fire-safety deficiencies
Top issue: Emergency Preparedness (6 deficiencies)
Fire safety
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2025-02-07
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-02-08
Fire Safety
Provide emergency officials' contact information.
Corrected 2022-06-14
Fire Safety
Provide family notifications of emergency plan.
Corrected 2022-06-14
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 2022-06-14
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2022-06-14
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2022-06-14
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-06-14
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-12-30
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2019-12-30
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2019-12-30
Fire Safety
Establish policies and procedures for sheltering.
Corrected 2019-12-30
Fire Safety
List the names and contact information of those in the facility.
Corrected 2019-12-30
Fire Safety
Provide emergency officials' contact information.
Corrected 2019-12-30
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2019-12-30
Fire Safety
Use approved construction type or materials.
Corrected 2019-12-30
Fire Safety
Meet other general requirements that are deficient.
Corrected 2019-12-30
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2019-12-30
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2019-12-30
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2019-12-30
Inspection history
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-08-27
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2025-02-21
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-02-21
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-02-21
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2025-02-21
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-02-21
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2025-02-21
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-02-21
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 2025-02-21
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-02-21
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-11-09
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-09-18
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-09-18
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-12-30
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-12-30
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-09-22
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-07-22
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-06-02
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-06-02
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-06-02
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-06-02
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-04-15
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-04-15
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-04-15
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 2023-04-15
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-04-15
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2023-04-15
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-06-24
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2022-06-24
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2022-06-24
Health
Provide activities to meet all resident's needs.
Corrected 2022-06-24
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-06-24
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2022-06-24
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 2022-06-24
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 2022-06-24
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2022-06-24
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2022-06-24
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2022-06-24
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2019-12-01
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2019-12-01
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2019-12-01
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2019-12-01
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2019-12-01
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2019-12-01
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2019-12-01
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2019-12-01
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2019-12-01
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2019-12-01
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 2019-12-01
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2019-12-01
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 2019-12-01
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2019-12-01
Health
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Corrected 2019-12-01
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2019-12-01
Penalties and ownership
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
Corporate Officer · Individual
Operational/Managerial Control · Individual
W-2 Managing Employee · Individual
Corporate Officer · Individual
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