20 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fullerton, CA
3-star overall rating with 3-star inspections with 20 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
245 E Wilshire Avenue, Fullerton, CA
(714) 871-6020
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Beds
99
Certified beds
Average residents
91
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
1969-09-03
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
RN hours / resident day
0.37
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.11
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
2.45
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
3.93
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
1.48
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
3.62
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.31
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.15
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.35
CMS adjusted RN staffing hours
Adjusted total hours
3.78
CMS adjusted total nurse staffing hours
Case-mix index
1.42
Higher values indicate more complex resident acuity
RN turnover
17%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
18%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Program rank
6,586
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
32.32
Composite VBP score used to determine payment impact.
Payment multiplier
0.9870
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
1.56
Baseline 17.16% · Performance 20.71% · Measure score 1.56 · Achievement 1.56 · Improvement 0
Healthcare-associated infections
0
Baseline 8.84% · Performance 10.88% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
10
Baseline 26.19% · Performance 21.18% · Measure score 10 · Achievement 10 · Improvement 9
Adjusted total nurse staffing
1.37
Baseline 3.42 hours · Performance 3.47 hours · Measure score 1.37 · Achievement 1.37 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.84% |
10.72%
1.1 pts worse
|
No Different than the National Rate · Eligible stays 297 · Observed rate 11.78% · Lower 95% interval 8.72% |
| Discharge to community | 54% |
50.57%
3.4 pts better
|
No Different than the National Rate · Eligible stays 285 · Observed rate 47.02% · Lower 95% interval 48.56% |
| Medicare spending per beneficiary | 1.37 |
1.02
0.4 pts worse
|
|
| Drug regimen review with follow-up | 99.31% |
95.27%
4 pts better
|
Numerator 289 · Denominator 291 |
| Falls with major injury | 0.34% |
0.77%
0.4 pts better
|
Numerator 1 · Denominator 291 |
| Discharge self-care score | 46.9% |
53.69%
6.8 pts worse
|
Numerator 68 · Denominator 145 |
| Discharge mobility score | 38.62% |
50.94%
12.3 pts worse
|
Numerator 56 · Denominator 145 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 291 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 10.88% |
7.12%
3.8 pts worse
|
Worse than the National Rate · Eligible stays 213 · Observed rate 15.49% · Lower 95% interval 8.34% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 150 |
| Staff flu vaccination coverage | 76.02% |
42%
34 pts better
|
Numerator 130 · Denominator 171 |
| Discharge function score | 51.03% |
56.45%
5.4 pts worse
|
Numerator 74 · Denominator 145 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 130 · Denominator 130 |
| Transfer of health information to patient | 98.81% |
96.28%
2.5 pts better
|
Numerator 83 · Denominator 84 |
| Resident COVID-19 vaccinations up to date | 13.48% |
25.2%
11.7 pts worse
|
Numerator 19 · Denominator 141 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.2 |
2.3
0.1 pts better
|
1.9
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 3.8 · Expected 3.3 · Used in QM five-star |
| 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 · Adjusted 1.2 · Observed 1.5 · Expected 2.2 · 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 | 97.5% |
98.2%
0.7 pts worse
|
95.5%
2 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.4% |
1.6%
1.2 pts better
|
3.3%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 10.3% |
6.8%
3.5 pts worse
|
11.4%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.3% · Q2 15.3% · Q3 3.4% · Q4 6.9% · 4Q avg 10.3% |
| Percentage of long-stay residents who lose too much weight | 0.0% |
4.1%
4.1 pts better
|
5.4%
5.4 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 received an antianxiety or hypnotic medication | 21.2% |
13.7%
7.5 pts worse
|
19.6%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.6% · Q2 23.2% · Q3 14.8% · Q4 17.7% · 4Q avg 21.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 22.3% |
14.2%
8.1 pts worse
|
16.7%
5.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.1% · Q2 26.8% · Q3 20.6% · Q4 20.0% · 4Q avg 22.3% · 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 | 4.0% |
11.0%
7 pts better
|
16.3%
12.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.8% · Q4 10.9% · 4Q avg 4.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.9% |
10.7%
1.2 pts worse
|
14.9%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.9% · Q2 12.1% · Q3 10.0% · Q4 16.7% · 4Q avg 11.9% · 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 | 0.0% |
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 | 22.0% |
10.9%
11.1 pts worse
|
19.8%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.7% · Q2 19.0% · Q3 26.6% · Q4 23.4% · 4Q avg 22.0% |
| Percentage of long-stay residents with pressure ulcers | 3.6% |
4.7%
1.1 pts better
|
5.1%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 5.9% · Q3 3.2% · Q4 2.1% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
94.0%
6 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.5% |
11.2%
3.7 pts better
|
12.0%
4.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.5% · Observed 8.0% · Expected 12.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.0% |
1.5%
1.5 pts worse
|
1.6%
1.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 2.8% · Q3 2.6% · Q4 2.4% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 91.1% |
93.2%
2.1 pts worse
|
79.7%
11.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 91.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.9% |
23.2%
0.7 pts worse
|
23.9%
About the same
|
Short Stay · 20240701-20250630 · Adjusted 23.9% · Observed 23.6% · Expected 23.5% · Used in QM five-star |
Survey summary
Top issue: Quality of Life and Care (6 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Top issue: Quality of Life and Care (8 deficiencies)
6 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Top issue: Nutrition and Dietary (2 deficiencies)
8 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Fire safety
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-10-13
Fire Safety
Establish policies and procedures for medical documentation.
Corrected 2022-01-03
Fire Safety
Provide family notifications of emergency plan.
Corrected 2022-01-03
Fire Safety
Establish staff and initial training requirements.
Corrected 2022-01-03
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2022-01-03
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-01-03
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-01-03
Fire Safety
Provide emergency officials' contact information.
Corrected 2019-08-16
Fire Safety
Use approved construction type or materials.
Corrected 2019-08-16
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2019-08-16
Fire Safety
Meet other general requirements that are deficient.
Corrected 2019-08-16
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2019-08-16
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2019-08-16
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2019-08-16
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2019-08-16
Inspection history
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2025-10-03
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2025-10-03
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-10-03
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-07-15
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-12-31
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-12-31
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-12-31
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-10-22
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-22
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-10-22
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2024-10-22
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 2024-10-22
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2024-10-22
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-10-22
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 2024-10-22
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-10-22
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 2024-10-22
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 2024-10-22
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2024-10-22
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2024-10-22
Health
Implement a program that monitors antibiotic use.
Corrected 2024-10-22
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2024-10-22
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 2024-10-22
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-06-14
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-06-14
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-01-07
Health
Provide and implement an infection prevention and control program.
Corrected 2022-01-07
Health
Implement a program that monitors antibiotic use.
Corrected 2022-01-07
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2022-01-07
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-01-07
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 2022-01-07
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-01-07
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2022-01-07
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 2022-01-07
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2022-01-07
Health
Dispose of garbage and refuse properly.
Corrected 2022-01-07
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2019-07-27
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2019-07-27
Health
Provide or obtain dental services for each resident.
Corrected 2019-07-27
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 2019-07-27
Health
Provide and implement an infection prevention and control program.
Corrected 2019-07-27
Health
Keep all essential equipment working safely.
Corrected 2019-07-27
Penalties and ownership
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
Corporate Officer · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
Corporate Officer · Individual
Corporate Officer · Individual
Corporate Director · Individual
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