Cycle 1
Health 2025-07-23 · Fire 2025-07-23
12 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
3 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Costa Mesa, CA
Victoria Healthcare And Rehabilitation Center
5-star overall rating with 5-star inspections with 12 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
340 Victoria Street, Costa Mesa, CA
(949) 642-0387
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
79
Certified beds
Average residents
72
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
1971-12-31
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
Hours and turnover
RN hours / resident day
0.54
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.18
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
2.83
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
4.54
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
1.72
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
4.02
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.34
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.17
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.46
CMS adjusted RN staffing hours
Adjusted total hours
3.84
CMS adjusted total nurse staffing hours
Case-mix index
1.62
Higher values indicate more complex resident acuity
RN turnover
14%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
24%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,680
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
43.15
Composite VBP score used to determine payment impact.
Payment multiplier
0.9961
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.12
Baseline 19.97% · Performance 19.06% · Measure score 5.12 · Achievement 5.12 · Improvement 2.59
Healthcare-associated infections
0
Baseline 7.01% · Performance 8.22% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
10
Baseline 33.33% · Performance 16.67% · Measure score 10 · Achievement 10 · Improvement 9
Adjusted total nurse staffing
2.14
Baseline 3.87 hours · Performance 3.69 hours · Measure score 2.14 · Achievement 2.14 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.93% |
10.72%
0.8 pts better
|
No Different than the National Rate · Eligible stays 293 · Observed rate 8.19% · Lower 95% interval 7.15% |
| Discharge to community | 57.67% |
50.57%
7.1 pts better
|
No Different than the National Rate · Eligible stays 283 · Observed rate 54.42% · Lower 95% interval 50.25% |
| Medicare spending per beneficiary | 1.27 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 239 · Denominator 239 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 239 |
| Discharge self-care score | 50% |
53.69%
3.7 pts worse
|
Numerator 33 · Denominator 66 |
| Discharge mobility score | 46.97% |
50.94%
4 pts worse
|
Numerator 31 · Denominator 66 |
| Pressure ulcers or injuries, new or worsened | 2.09% |
2.29%
0.2 pts better
|
Numerator 5 · Denominator 239 · Adjusted rate 2.14% |
| Healthcare-associated infections requiring hospitalization | 8.22% |
7.12%
1.1 pts worse
|
No Different than the National Rate · Eligible stays 197 · Observed rate 8.12% · Lower 95% interval 5.17% |
| Staff COVID-19 vaccination coverage | 17.57% |
8.2%
9.4 pts better
|
Numerator 26 · Denominator 148 |
| Staff flu vaccination coverage | 62.65% |
42%
20.6 pts better
|
Numerator 104 · Denominator 166 |
| Discharge function score | 40.91% |
56.45%
15.5 pts worse
|
Numerator 27 · Denominator 66 |
| Transfer of health information to provider | 98.54% |
95.95%
2.6 pts better
|
Numerator 135 · Denominator 137 |
| Transfer of health information to patient | 97.56% |
96.28%
1.3 pts better
|
Numerator 80 · Denominator 82 |
| Resident COVID-19 vaccinations up to date | 34.04% |
25.2%
8.8 pts better
|
Numerator 48 · Denominator 141 |
Quality measures
Resident outcomes and process scores
| 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 · Adjusted 1.4 · Observed 1.8 · Expected 2.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.1 |
1.6
0.5 pts better
|
1.8
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.0 · 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 | 1.5% |
1.6%
0.1 pts better
|
3.3%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 2.7% · Q3 0.0% · Q4 0.0% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.8% |
6.8%
2 pts better
|
11.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 9.7% · Q3 4.2% · Q4 0.0% · 4Q avg 4.8% |
| Percentage of long-stay residents who lose too much weight | 8.3% |
4.1%
4.2 pts worse
|
5.4%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 6.2% · Q3 3.6% · Q4 10.7% · 4Q avg 8.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 4.0% |
13.7%
9.7 pts better
|
19.6%
15.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 5.9% · Q3 3.3% · Q4 0.0% · 4Q avg 4.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 5.5% |
14.2%
8.7 pts better
|
16.7%
11.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.5% · Q2 5.0% · Q3 4.2% · Q4 0.0% · 4Q avg 5.5% · 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 | 24.3% |
11.0%
13.3 pts worse
|
16.3%
8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 24.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 20.6% |
10.7%
9.9 pts worse
|
14.9%
5.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.1% · Q2 20.7% · Q3 16.0% · Q4 22.7% · 4Q avg 20.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.4% |
1.0%
1.4 pts worse
|
1.0%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 3.1% · Q3 0.0% · Q4 0.0% · 4Q avg 2.4% · 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 | 24.3% |
10.9%
13.4 pts worse
|
19.8%
4.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 37.2% · Q2 24.1% · Q3 23.7% · Q4 10.8% · 4Q avg 24.3% |
| Percentage of long-stay residents with pressure ulcers | 5.9% |
4.7%
1.2 pts worse
|
5.1%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 6.9% · Q3 8.9% · Q4 5.7% · 4Q avg 5.9% · 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 | 12.6% |
11.2%
1.4 pts worse
|
12.0%
0.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.6% · Observed 12.3% · Expected 10.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.4% |
1.5%
0.1 pts better
|
1.6%
0.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 1.4% · Q3 1.4% · Q4 1.4% · 4Q avg 1.4% · Used in QM five-star |
| 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 · 4Q avg 99.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.4% |
23.2%
3.2 pts worse
|
23.9%
2.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.4% · Observed 25.8% · Expected 23.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-10-31 · Fire 2023-10-31
3 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2021-07-09 · Fire 2021-07-09
15 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
6 fire-safety deficiencies
Top issue: Emergency Preparedness (5 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-07-23
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-07-22
D · Potential for more than minimal harm
2025-07-23
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-08-01
D · Potential for more than minimal harm
2025-07-23
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-08-01
D · Potential for more than minimal harm
2023-10-31
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-12-05
D · Potential for more than minimal harm
2023-10-31
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2023-12-05
D · Potential for more than minimal harm
2023-10-31
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2023-12-05
D · Potential for more than minimal harm
2023-10-31
K361 · Smoke Deficiencies
Fire Safety
Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.
Corrected 2023-12-05
D · Potential for more than minimal harm
2023-10-31
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2023-12-05
D · Potential for more than minimal harm
2023-10-31
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-12-05
D · Potential for more than minimal harm
2021-07-09
E18 · Emergency Preparedness Deficiencies
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2021-07-26
D · Potential for more than minimal harm
2021-07-09
E23 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for medical documentation.
Corrected 2021-07-26
D · Potential for more than minimal harm
2021-07-09
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2021-07-26
D · Potential for more than minimal harm
2021-07-09
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2021-07-26
D · Potential for more than minimal harm
2021-07-09
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2021-07-26
D · Potential for more than minimal harm
2021-07-09
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 2021-07-26
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-09-04
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 2025-09-18
E · Potential for more than minimal harm
2025-07-23
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 2025-08-08
D · Potential for more than minimal harm
2025-07-23
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-08-08
D · Potential for more than minimal harm
2025-07-23
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 2025-08-08
D · Potential for more than minimal harm
2025-07-23
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-08-08
D · Potential for more than minimal harm
2025-07-23
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-08-08
D · Potential for more than minimal harm
2025-07-23
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 2025-08-08
D · Potential for more than minimal harm
2025-07-23
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 2025-08-08
B · Minimal harm
2025-07-23
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-08-08
B · Minimal harm
2025-07-23
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2025-08-08
B · Minimal harm
2025-07-23
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-08-08
B · Minimal harm
2025-07-23
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2025-08-08
B · Minimal harm
2024-04-29
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 2024-05-16
D · Potential for more than minimal harm
2023-10-31
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-11-19
D · Potential for more than minimal harm
2023-10-31
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2023-11-19
D · Potential for more than minimal harm
2023-10-23
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-11-10
D · Potential for more than minimal harm
2023-06-28
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-07-28
D · Potential for more than minimal harm
2023-03-28
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 2023-04-15
D · Potential for more than minimal harm
2023-03-28
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 2023-04-15
D · Potential for more than minimal harm
2021-07-09
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2021-08-09
D · Potential for more than minimal harm
2021-07-09
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2021-08-09
D · Potential for more than minimal harm
2021-07-09
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 2021-08-09
D · Potential for more than minimal harm
2021-07-09
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 2021-08-09
D · Potential for more than minimal harm
2021-07-09
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2021-08-09
D · Potential for more than minimal harm
2021-07-09
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 2021-08-09
D · Potential for more than minimal harm
2021-07-09
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 2021-08-09
D · Potential for more than minimal harm
2021-07-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-08-09
D · Potential for more than minimal harm
2021-07-09
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2021-08-09
B · Minimal harm
2021-07-09
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2021-08-09
B · Minimal harm
2021-07-09
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2021-08-09
Penalties and ownership
What sits behind the stars
Ownership
Flagstone Healthcare South LLC
5% Or Greater Direct Ownership Interest · Organization
The Ensign Group Inc
5% Or Greater Indirect Ownership Interest · Organization
Burnam, Soon
Corporate Officer · Individual
Willits, Adam
Corporate Director · Individual
Yuhas, Michael
Operational/Managerial Control · Individual
Yuhas, Michael
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Newport Subacute Healthcare Center
Costa Mesa, CA
1-star overall rating with 1-star inspections with 48 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Mesa Verde Post Acute Care Center
Costa Mesa, CA
4-star overall rating with 3-star inspections with $4,558 in total fines with 21 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Newport Nursing And Rehabilitation Center
Newport Beach, CA
4-star overall rating with 4-star inspections with 16 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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