Cycle 1
Health 2024-10-11 · Fire 2024-10-11
42 health deficiencies
Top issue: Quality of Life and Care (11 deficiencies)
15 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (5 deficiencies)
Lake Forest, CA
Trabuco Hills Post Acute
2-star overall rating with 2-star inspections with 42 recent health deficiencies with 15 fire-safety deficiencies in the latest cycle
25652 Old Trabuco Road, Lake Forest, CA
(949) 380-9380
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
175
Certified beds
Average residents
167
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
David & Frank Johnson
Operator or chain grouping
Approved since
1988-06-28
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
45 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
0.36
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.24
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
2.54
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
4.14
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
1.60
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
3.75
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.26
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
0.28
CMS adjusted RN staffing hours
Adjusted total hours
3.23
CMS adjusted total nurse staffing hours
Case-mix index
1.76
Higher values indicate more complex resident acuity
RN turnover
41%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
37%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,254
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
17.51
Composite VBP score used to determine payment impact.
Payment multiplier
0.9818
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 18.64% · Performance 23.42% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 5.65% · Performance 10.33% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
6.3
Baseline 38.71% · Performance 37.93% · Measure score 6.3 · Achievement 6.3 · Improvement 0.06
Adjusted total nurse staffing
0.70
Baseline 3.04 hours · Performance 3.28 hours · Measure score 0.70 · Achievement 0.70 · Improvement 0.38
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.16% |
10.72%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 211 · Observed rate 11.85% · Lower 95% interval 8.73% |
| Discharge to community | 53.44% |
50.57%
2.9 pts better
|
No Different than the National Rate · Eligible stays 222 · Observed rate 46.85% · Lower 95% interval 46.87% |
| Medicare spending per beneficiary | 1.36 |
1.02
0.3 pts worse
|
|
| Drug regimen review with follow-up | 97.83% |
95.27%
2.6 pts better
|
Numerator 270 · Denominator 276 |
| Falls with major injury | 0.36% |
0.77%
0.4 pts better
|
Numerator 1 · Denominator 276 |
| Discharge self-care score | 52.56% |
53.69%
1.1 pts worse
|
Numerator 82 · Denominator 156 |
| Discharge mobility score | 47.44% |
50.94%
3.5 pts worse
|
Numerator 74 · Denominator 156 |
| Pressure ulcers or injuries, new or worsened | 1.45% |
2.29%
0.8 pts better
|
Numerator 4 · Denominator 276 · Adjusted rate 0.99% |
| Healthcare-associated infections requiring hospitalization | 10.33% |
7.12%
3.2 pts worse
|
No Different than the National Rate · Eligible stays 184 · Observed rate 14.13% · Lower 95% interval 7.1% |
| Staff COVID-19 vaccination coverage | 7.97% |
8.2%
0.2 pts worse
|
Numerator 20 · Denominator 251 |
| Staff flu vaccination coverage | 61.01% |
42%
19 pts better
|
Numerator 133 · Denominator 218 |
| Discharge function score | 50% |
56.45%
6.5 pts worse
|
Numerator 78 · Denominator 156 |
| Transfer of health information to provider | 99.41% |
95.95%
3.5 pts better
|
Numerator 168 · Denominator 169 |
| Transfer of health information to patient | 93.33% |
96.28%
3 pts worse
|
Numerator 42 · Denominator 45 |
| Resident COVID-19 vaccinations up to date | 14.69% |
25.2%
10.5 pts worse
|
Numerator 21 · Denominator 143 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.4 |
2.3
0.1 pts worse
|
1.9
0.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.4 · Observed 2.6 · Expected 2.1 · 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 1.1 · Expected 1.5 · 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 | 2.8% |
1.6%
1.2 pts worse
|
3.3%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 2.2% · Q3 3.5% · Q4 3.3% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.6% |
6.8%
2.2 pts better
|
11.4%
6.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.2% · Q2 4.8% · Q3 2.4% · Q4 6.0% · 4Q avg 4.6% |
| Percentage of long-stay residents who lose too much weight | 5.7% |
4.1%
1.6 pts worse
|
5.4%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 5.8% · Q3 5.3% · Q4 6.0% · 4Q avg 5.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.0% |
13.7%
4.3 pts worse
|
19.6%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.4% · Q2 16.7% · Q3 15.8% · Q4 19.8% · 4Q avg 18.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.1% |
14.2%
2.1 pts better
|
16.7%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.8% · Q2 15.1% · Q3 10.9% · Q4 12.5% · 4Q avg 12.1% · 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 | 8.4% |
11.0%
2.6 pts better
|
16.3%
7.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.5% · Q2 23.9% · Q3 4.0% · Q4 0.0% · 4Q avg 8.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.7% |
10.7%
1 pts better
|
14.9%
5.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.8% · Q2 6.9% · Q3 6.5% · Q4 11.4% · 4Q avg 9.7% · 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 | 0.6% |
1.2%
0.6 pts better
|
1.7%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.2% · Q3 0.0% · Q4 1.1% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 13.3% |
10.9%
2.4 pts worse
|
19.8%
6.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 21.5% · Q2 15.2% · Q3 4.8% · Q4 12.1% · 4Q avg 13.3% |
| Percentage of long-stay residents with pressure ulcers | 4.3% |
4.7%
0.4 pts better
|
5.1%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 3.4% · Q3 4.8% · Q4 6.6% · 4Q avg 4.3% · 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 | 7.0% |
11.2%
4.2 pts better
|
12.0%
5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.0% · Observed 6.2% · Expected 9.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.5% |
1.5%
1 pts better
|
1.6%
1.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.7% · Q2 0.7% · Q3 0.3% · Q4 0.3% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 99.5% |
93.2%
6.3 pts better
|
79.7%
19.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 99.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 33.4% |
23.2%
10.2 pts worse
|
23.9%
9.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 33.4% · Observed 34.5% · Expected 24.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-04-08 · Fire 2022-04-08
24 health deficiencies
Top issue: Nutrition and Dietary (6 deficiencies)
13 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (4 deficiencies)
Cycle 3
Health 2019-04-29 · Fire 2019-04-29
24 health deficiencies
Top issue: Quality of Life and Care (9 deficiencies)
11 fire-safety deficiencies
Top issue: Emergency Preparedness (6 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-10-11
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2024-11-15
F · Potential for more than minimal harm
2024-10-11
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2024-11-15
F · Potential for more than minimal harm
2024-10-11
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-11-15
F · Potential for more than minimal harm
2024-10-11
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2024-11-15
F · Potential for more than minimal harm
2024-10-11
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-11-15
E · Potential for more than minimal harm
2024-10-11
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2024-11-15
E · Potential for more than minimal harm
2024-10-11
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-11-15
E · Potential for more than minimal harm
2024-10-11
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2024-11-15
E · Potential for more than minimal harm
2024-10-11
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-11-15
D · Potential for more than minimal harm
2024-10-11
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2024-11-15
D · Potential for more than minimal harm
2024-10-11
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-11-15
C · Minimal harm
2024-10-11
K342 · Smoke Deficiencies
Fire Safety
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
Corrected 2024-11-15
C · Minimal harm
2024-10-11
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-11-15
C · Minimal harm
2024-10-11
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2024-11-15
B · Minimal harm
2024-10-11
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 2024-11-15
F · Potential for more than minimal harm
2022-04-08
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-05-03
D · Potential for more than minimal harm
2022-04-08
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2022-05-03
D · Potential for more than minimal harm
2022-04-08
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2022-05-03
D · Potential for more than minimal harm
2022-04-08
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-05-03
D · Potential for more than minimal harm
2022-04-08
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2022-05-03
D · Potential for more than minimal harm
2022-04-08
K321 · Smoke Deficiencies
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 2022-05-03
D · Potential for more than minimal harm
2022-04-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-05-03
D · Potential for more than minimal harm
2022-04-08
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-05-03
D · Potential for more than minimal harm
2022-04-08
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-05-03
D · Potential for more than minimal harm
2022-04-08
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-05-03
D · Potential for more than minimal harm
2022-04-08
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2022-05-03
D · Potential for more than minimal harm
2022-04-08
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-05-03
D · Potential for more than minimal harm
2022-04-08
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-05-03
E · Potential for more than minimal harm
2019-04-29
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-07-01
D · Potential for more than minimal harm
2019-04-29
E34 · Emergency Preparedness Deficiencies
Fire Safety
Provide a means of sharing information on occupancy/needs.
Corrected 2019-07-01
D · Potential for more than minimal harm
2019-04-29
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2019-07-01
D · Potential for more than minimal harm
2019-04-29
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2019-07-01
D · Potential for more than minimal harm
2019-04-29
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2019-07-01
D · Potential for more than minimal harm
2019-04-29
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2019-07-01
D · Potential for more than minimal harm
2019-04-29
E9 · Emergency Preparedness Deficiencies
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2019-07-01
D · Potential for more than minimal harm
2019-04-29
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2019-07-01
D · Potential for more than minimal harm
2019-04-29
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2019-07-01
D · Potential for more than minimal harm
2019-04-29
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2019-07-01
D · Potential for more than minimal harm
2019-04-29
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2019-07-01
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-23
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2026-02-22
B · Minimal harm
2026-01-23
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2026-02-22
B · Minimal harm
2026-01-23
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2026-02-22
B · Minimal harm
2026-01-23
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2026-02-22
B · Minimal harm
2026-01-23
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 2026-02-22
B · Minimal harm
2026-01-23
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 2026-02-22
D · Potential for more than minimal harm
2025-09-09
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-10-09
D · Potential for more than minimal harm
2025-09-09
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 2025-10-09
D · Potential for more than minimal harm
2025-08-21
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-09-21
B · Minimal harm
2025-08-21
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 2025-09-21
B · Minimal harm
2025-08-21
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2025-09-21
D · Potential for more than minimal harm
2025-08-08
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 2025-09-08
B · Minimal harm
2025-08-08
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-09-08
D · Potential for more than minimal harm
2025-04-24
F825 · Quality of Life and Care Deficiencies
Health
Provide or get specialized rehabilitative services as required for a resident.
Corrected 2025-05-24
D · Potential for more than minimal harm
2025-02-19
F825 · Quality of Life and Care Deficiencies
Health
Provide or get specialized rehabilitative services as required for a resident.
Corrected 2025-03-10
B · 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 2024-12-15
E · Potential for more than minimal harm
2024-10-11
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 2024-11-11
E · Potential for more than minimal harm
2024-10-11
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 2024-11-11
E · Potential for more than minimal harm
2024-10-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-11
E · Potential for more than minimal harm
2024-10-11
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 2024-11-11
D · Potential for more than minimal harm
2024-10-11
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-11-11
D · Potential for more than minimal harm
2024-10-11
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-11-11
D · Potential for more than minimal harm
2024-10-11
F578 · Resident Rights Deficiencies
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 2024-11-11
D · Potential for more than minimal harm
2024-10-11
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 2024-11-11
D · Potential for more than minimal harm
2024-10-11
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-11-11
D · Potential for more than minimal harm
2024-10-11
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-11-11
D · Potential for more than minimal harm
2024-10-11
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2024-11-11
D · Potential for more than minimal harm
2024-10-11
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-11-11
D · Potential for more than minimal harm
2024-10-11
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 2024-11-11
D · Potential for more than minimal harm
2024-10-11
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 2024-11-11
D · Potential for more than minimal harm
2024-10-11
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-11-11
D · Potential for more than minimal harm
2024-10-11
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-11-11
D · Potential for more than minimal harm
2024-10-11
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 2024-11-11
D · Potential for more than minimal harm
2024-10-11
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2024-11-11
D · Potential for more than minimal harm
2024-10-11
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 2024-11-11
D · Potential for more than minimal harm
2024-10-11
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-11-11
D · Potential for more than minimal harm
2024-10-11
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 2024-11-11
D · Potential for more than minimal harm
2024-10-11
F803 · Nutrition and Dietary Deficiencies
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 2024-11-11
D · Potential for more than minimal harm
2024-10-11
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2024-11-11
D · Potential for more than minimal harm
2024-10-11
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2024-11-11
B · Minimal harm
2024-10-11
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 2024-11-11
B · Minimal harm
2024-10-11
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 2024-11-11
B · Minimal harm
2024-10-11
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2024-11-11
B · Minimal harm
2024-10-11
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-11-11
B · Minimal harm
2024-10-11
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 2024-11-11
B · Minimal harm
2024-10-11
F914 · Environmental Deficiencies
Health
Provide bedrooms that don't allow residents to see each other when privacy is needed.
Corrected 2024-11-11
B · Minimal harm
2024-08-01
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 2024-09-01
D · Potential for more than minimal harm
2024-06-20
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-07-20
B · Minimal harm
2024-05-16
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-06-16
B · Minimal harm
2024-04-30
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2024-05-30
B · Minimal harm
2024-03-20
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 2024-04-20
B · Minimal harm
2024-03-07
F809 · Nutrition and Dietary Deficiencies
Health
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Corrected 2024-04-06
D · Potential for more than minimal harm
2023-04-27
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-05-26
D · Potential for more than minimal harm
2023-04-06
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-05-06
D · Potential for more than minimal harm
2023-04-04
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-04-14
E · Potential for more than minimal harm
2022-04-08
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 2022-05-08
D · Potential for more than minimal harm
2022-04-08
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2022-05-08
D · Potential for more than minimal harm
2022-04-08
F578 · Resident Rights Deficiencies
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 2022-05-08
D · Potential for more than minimal harm
2022-04-08
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 2022-05-08
D · Potential for more than minimal harm
2022-04-08
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 2022-05-08
D · Potential for more than minimal harm
2022-04-08
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-05-08
D · Potential for more than minimal harm
2022-04-08
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 2022-05-08
D · Potential for more than minimal harm
2022-04-08
F813 · Nutrition and Dietary Deficiencies
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2022-05-08
D · Potential for more than minimal harm
2022-04-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-05-08
B · Minimal harm
2022-04-08
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 2022-05-08
B · Minimal harm
2022-04-08
F803 · Nutrition and Dietary Deficiencies
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 2022-05-08
B · Minimal harm
2022-04-08
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2022-05-08
B · Minimal harm
2022-04-08
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2022-05-08
B · Minimal harm
2022-04-08
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 2022-05-08
E · Potential for more than minimal harm
2019-04-29
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2019-05-22
D · Potential for more than minimal harm
2019-04-29
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 2019-05-22
D · Potential for more than minimal harm
2019-04-29
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2019-05-22
D · Potential for more than minimal harm
2019-04-29
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2019-05-22
D · Potential for more than minimal harm
2019-04-29
F578 · Resident Rights Deficiencies
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 2019-05-22
D · Potential for more than minimal harm
2019-04-29
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2019-05-22
D · Potential for more than minimal harm
2019-04-29
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2019-05-22
D · Potential for more than minimal harm
2019-04-29
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2019-05-22
D · Potential for more than minimal harm
2019-04-29
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 2019-05-22
D · Potential for more than minimal harm
2019-04-29
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 2019-05-22
D · Potential for more than minimal harm
2019-04-29
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2019-05-22
D · Potential for more than minimal harm
2019-04-29
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2019-05-22
D · Potential for more than minimal harm
2019-04-29
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2019-05-22
D · Potential for more than minimal harm
2019-04-29
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2019-05-22
D · Potential for more than minimal harm
2019-04-29
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2019-05-22
D · Potential for more than minimal harm
2019-04-29
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2019-05-22
D · Potential for more than minimal harm
2019-04-29
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 2019-05-22
D · Potential for more than minimal harm
2019-04-29
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 2019-05-22
D · Potential for more than minimal harm
2019-04-29
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2019-05-22
D · Potential for more than minimal harm
2019-04-29
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 2019-05-22
D · Potential for more than minimal harm
2019-04-29
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2019-05-22
Penalties and ownership
What sits behind the stars
Ownership
Johnson, David
5% Or Greater Direct Ownership Interest · Individual
Johnson, Frank
5% Or Greater Direct Ownership Interest · Individual
Cline, Talmadge
Operational/Managerial Control · Individual
Dehghanmanesh, Adrian
Corporate Officer · Individual
Farrales, Mary
Corporate Officer · Individual
Johnson, David
Operational/Managerial Control · Individual
Kochek, Joshua
Operational/Managerial Control · Individual
Kochek, Joshua
Corporate Officer · Individual
Lake Forest Post Acute LLC
Operational/Managerial Control · Organization
Oxford, Micheal
Operational/Managerial Control · Individual
Oxford, Micheal
Corporate Officer · Individual
Nearby options
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3-star overall rating with 3-star inspections with 17 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Laguna Hills Health And Rehabilitation Center
Laguna Hills, CA
1-star overall rating with 1-star inspections with 36 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Villa Valencia Healthcare Center
Laguna Hills, CA
3-star overall rating with 3-star inspections with 22 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
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