19 health deficiencies
Top issue: Quality of Life and Care (8 deficiencies)
2 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Fullerton, CA
5-star overall rating with 3-star inspections with 19 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
2525 Brea Blvd., Fullerton, CA
(714) 256-1000
Overall
5 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Beds
99
Certified beds
Average residents
54
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Continuing Life
Operator or chain grouping
Approved since
1992-08-04
CMS approved date
Coverage
Medicare
Participation flags
Chain footprint
6 facilities
Chain averages 5 overall / 4 health / 5 staffing / 5 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
RN hours / resident day
0.66
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.37
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
3.11
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
5.14
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
2.03
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
4.76
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.51
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.19
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.60
CMS adjusted RN staffing hours
Adjusted total hours
4.65
CMS adjusted total nurse staffing hours
Case-mix index
1.51
Higher values indicate more complex resident acuity
RN turnover
13%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
29%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Program rank
641
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
66.13
Composite VBP score used to determine payment impact.
Payment multiplier
1.0201
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
4.12
Baseline 17.62% · Performance 19.52% · Measure score 4.12 · Achievement 4.12 · Improvement 0
Healthcare-associated infections
9.35
Baseline 4.95% · Performance 5.04% · Measure score 9.35 · Achievement 9.35 · Improvement 0
Total nurse turnover
8.59
Baseline 24.62% · Performance 28.57% · Measure score 8.59 · Achievement 8.59 · Improvement 0
Adjusted total nurse staffing
4.39
Baseline 4.34 hours · Performance 4.33 hours · Measure score 4.39 · Achievement 4.39 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.6% |
10.72%
1.1 pts better
|
No Different than the National Rate · Eligible stays 311 · Observed rate 7.72% · Lower 95% interval 7.07% |
| Discharge to community | 63.24% |
50.57%
12.7 pts better
|
Better than the National Rate · Eligible stays 293 · Observed rate 59.73% · Lower 95% interval 58.14% |
| Medicare spending per beneficiary | 1.02 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 227 · Denominator 227 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 227 |
| Discharge self-care score | 57.32% |
53.69%
3.6 pts better
|
Numerator 94 · Denominator 164 |
| Discharge mobility score | 55.49% |
50.94%
4.6 pts better
|
Numerator 91 · Denominator 164 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 227 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 5.04% |
7.12%
2.1 pts better
|
No Different than the National Rate · Eligible stays 213 · Observed rate 2.82% · Lower 95% interval 3.04% |
| Staff COVID-19 vaccination coverage | 2.11% |
8.2%
6.1 pts worse
|
Numerator 3 · Denominator 142 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 48.17% |
56.45%
8.3 pts worse
|
Numerator 79 · Denominator 164 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 133 · Denominator 133 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 57 · Denominator 57 |
| Resident COVID-19 vaccinations up to date | 10.09% |
25.2%
15.1 pts worse
|
Numerator 11 · Denominator 109 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.0 |
2.3
0.3 pts better
|
1.9
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 2.5 · Expected 2.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.8 |
1.6
0.8 pts better
|
1.8
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.8 · Expected 1.7 · 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 | 0.0% |
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 | 0.0% |
6.8%
6.8 pts better
|
11.4%
11.4 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 who lose too much weight | 16.2% |
4.1%
12.1 pts worse
|
5.4%
10.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 11.5% · Q3 25.0% · Q4 21.4% · 4Q avg 16.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 21.5% |
13.7%
7.8 pts worse
|
19.6%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 19.2% · Q3 32.1% · Q4 27.6% · 4Q avg 21.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 2.9% |
14.2%
11.3 pts better
|
16.7%
13.8 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 2.9% · 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 | 7.1% |
11.0%
3.9 pts better
|
16.3%
9.2 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 7.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.6% |
10.7%
5.1 pts better
|
14.9%
9.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 0.0% · Q3 4.3% · Q4 11.5% · 4Q avg 5.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.9% |
1.0%
0.1 pts better
|
1.0%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.7% |
1.2%
0.5 pts better
|
1.7%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.9% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 11.2% |
10.9%
0.3 pts worse
|
19.8%
8.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.3% · Q2 13.1% · Q3 9.4% · Q4 3.3% · 4Q avg 11.2% |
| Percentage of long-stay residents with pressure ulcers | 1.0% |
4.7%
3.7 pts better
|
5.1%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 2.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.6% |
94.0%
5.6 pts better
|
81.7%
17.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.4% · Q2 99.2% · Q3 100.0% · Q4 100.0% · 4Q avg 99.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 15.8% |
11.2%
4.6 pts worse
|
12.0%
3.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 15.8% · Observed 14.2% · Expected 10.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.8% |
1.5%
0.7 pts better
|
1.6%
0.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 97.8% |
93.2%
4.6 pts better
|
79.7%
18.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 97.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.0% |
23.2%
3.2 pts better
|
23.9%
3.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.0% · Observed 19.1% · Expected 22.8% · Used in QM five-star |
Survey summary
Top issue: Quality of Life and Care (8 deficiencies)
2 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Top issue: Resident Rights (4 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Top issue: Pharmacy Service (2 deficiencies)
3 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Fire safety
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-12-10
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-12-10
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-12-24
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-12-24
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-12-24
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-12-24
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-12-24
Fire Safety
Use approved construction type or materials.
Corrected 2023-05-05
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-05-05
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-05-05
Inspection history
Health
Provide and implement an infection prevention and control program.
Corrected 2025-12-23
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-12-23
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 2025-12-23
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 2025-12-23
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2025-12-23
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-12-23
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 2025-12-23
Health
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Corrected 2025-12-23
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-12-23
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2026-01-05
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-12-23
Health
Keep residents' personal and medical records private and confidential.
Corrected 2025-12-23
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-12-23
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-12-23
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-10-28
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-10-28
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-10-28
Health
Provide and implement an infection prevention and control program.
Corrected 2025-10-28
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-10-28
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-12-23
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-12-23
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-12-23
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-12-23
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-12-23
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 2024-12-23
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 2024-12-23
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
Health
Provide and implement an infection prevention and control program.
Corrected 2024-12-23
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-12-23
Health
Keep all essential equipment working safely.
Corrected 2024-12-23
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 2024-12-23
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-12-23
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-12-23
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 2024-12-23
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2024-12-23
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2024-12-23
Health
Dispose of garbage and refuse properly.
Corrected 2024-12-23
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-03-28
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-05-09
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-05-09
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 2023-05-09
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-05-09
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 2023-05-09
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-05-09
Health
Keep all essential equipment working safely.
Corrected 2023-05-09
Penalties and ownership
5% Or Greater Direct Ownership Interest · Organization
Operational/Managerial Control · Individual
Operational/Managerial Control · Organization
Limited Partnership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
Operational/Managerial Control · Individual
General Partnership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Individual
Corporate Officer · Individual
5% Or Greater Indirect Ownership Interest · Individual
Corporate Officer · Individual
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