Alamitos West Health & Rehabilitation
Los Alamitos, California
Skilled nursing facility in Los Alamitos, CA with 150 certified beds and a 2-star CMS overall rating.
Alamitos West Health & Rehabilitation is a skilled nursing facility in Los Alamitos, California (Orange County), with 150 Medicare/Medicaid-certified beds.
Address: 3902 Katella Avenue, Los Alamitos, CA 90720. Phone: (562) 596-5561.
Ownership: For profit - Individual. Certified for Medicare and Medicaid. Automatic sprinkler systems in all required areas. Has a resident council. Part of the The Ensign Group chain.
CMS Five-Star ratings (source: Medicare Care Compare): overall 2 of 5, health inspections 2, staffing 2, quality measures 4.
Levels of care
- Skilled nursing
Facility details
- Street address
- 3902 Katella Avenue
- City
- Los Alamitos
- State
- California
- ZIP code
- 90720
- Phone
- (562) 596-5561
- Levels of care
- Skilled nursing
- Payment options accepted
- Medicare, Medicaid
- Cms Ccn
- 056169
- County
- Orange
- Ownership Type
- For profit - Individual
- Provider Type
- Medicare and Medicaid
- Certified Beds
- 150
- Avg Daily Residents
- 138.3
- Continuing Care Community
- No
- Resident Family Council
- Resident
- Sprinklers All Areas
- Yes
- Medicare Medicaid Approved Date
- 1978-05-01
- Chain Name
- The Ensign Group
- Overall Rating
- 2
- Health Inspection Rating
- 2
- Staffing Rating
- 2
- Quality Measure Rating
- 4
- Total Nurse Hours Per Resident Day
- 4.2042
- Rn Hours Per Resident Day
- 0.3466
- Latitude
- 33.803
- Longitude
- -118.07
Medicare & Medicaid quality data
Published by the Centers for Medicare & Medicaid Services (CMS) [1] , data as of October 1, 2026. CMS ID 056169. Ratings compare this home with other nursing homes; they are not a pass or fail.
How does it compare in Los Alamitos? · Lowest-rated in California
CMS overall rating
3 / 5
Average- Certified beds
- 150
- Residents per day
- 128
- Ownership
- For profit - Individual
- Health citations (latest)
- 33
- Fines
- 0
Star ratings
CMS rates every certified nursing home from 1 to 5 stars in three areas and combines them into an overall rating. The ratings compare homes with each other: 5 is much above average, 3 is average, 1 is much below average.
Overall rating
AverageThe headline score, from 1 to 5 stars.
✗ Worse than the state average. State 3.2 · National 3.0
How is this scored?
Three steps: start with the health inspection stars; add one star if staffing is 5 stars (subtract one if it is 1 star); then add one star if quality measures are 5 stars (subtract one if 1 star). It never goes above 5 or below 1, and a home with 1 health inspection star can gain at most one star from the other two. It compares homes with each other; it is not a pass/fail grade. [11]
Health inspections
Below averageHow the home did in recent state inspections and complaint investigations.
✗ Worse than the state average. State 2.8 · National 2.8
How is this scored?
Based on the two most recent annual inspections plus 36 months of complaint and infection-control inspections, and on how many revisits were needed to confirm fixes. Each citation is weighted by scope and severity. Homes are then ranked within their own state: the best 10% (lowest scores) earn 5 stars, the middle 70% earn 2, 3 or 4 stars in equal shares, and the worst 20% earn 1 star. [11]
Staffing
AverageHow many nurses care for each resident, and how stable the nursing team is.
✗ Worse than the state average. State 3.3 · National 3.0
How is this scored?
Six measures: three of staffing level (total nurse, registered nurse and weekend nurse hours per resident per day, adjusted for how much care residents need) and three of turnover (nursing staff, RNs and administrators). The hours come from payroll records submitted to CMS each quarter; turnover uses six quarters of that data. [11]
Quality measures
Much above averageHow residents are actually doing.
✓ Better than the state average. State 4.2 · National 3.7
How is this scored?
Scores 15 quality measures drawn from resident assessments (the Minimum Data Set) and Medicare claims, such as falls with major injury, pressure ulcers, rehospitalizations and medication use. Long-stay and short-stay residents are rated separately and combined. [11]
This home State average National average
- Long-stay quality
- Residents who live in the home: outcomes such as falls, pressure ulcers and medication use.
- Short-stay quality
- Residents staying for rehab or recovery: outcomes such as rehospitalization and regaining function.
How to read the numbers on this page
- Star ratings — 1 to 5 (no stars = not rated)
- 5 is much above average and 1 is much below average, compared with other nursing homes. A home with too little data may have no rating.
- Health inspection score — 0 and up, lower is better
- Points added up from citations (see the scope and severity grid) and revisits. 0 means a clean record; the state table shows which scores earn which stars.
- Quality measure percentages — 0 to 100%
- The share of residents with an outcome, such as a fall with major injury. For most measures a lower percentage is better; for vaccination measures a higher percentage is better.
- Nurse hours per resident per day — Hours, higher is better
- Paid nursing time divided by residents. For example 4.0 means each resident gets about four hours of nursing care a day, shared across all shifts.
- Staff turnover — 0 to 100%, lower is better
- The share of nursing staff who left during the year. High turnover can mean less continuity of care.
- Case-mix index — Around 1.0 is typical
- How much care the residents need. Above 1 means sicker or more dependent residents who need more staff time.
- Fines — Dollars; payment denials in days
- Penalties CMS imposed for serious or repeated problems. A payment denial stops Medicare/Medicaid payment for new admissions.
Sources: Nursing Home Provider Information [1] ; Nursing Home State & National Averages [9] ; Design for Care Compare Nursing Home Five-Star Quality Rating System: Technical Users' Guide [11]
Staffing & turnover
More nursing time per resident and a steadier team are both signs of better care. Hours come from payroll records the home submits to CMS each quarter.
Nurse hours per resident per day, by role
A resident's day is 24 hours; this is how much paid nursing time each resident gets, shared across all shifts.
RN 0.39 · LPN 1.34 · Nurse aide 2.59. What the home's payroll records show.
RN 0.70 · LPN 0.87 · Nurse aide 2.38. What CMS predicts a home with these residents' needs would staff.
RN 0.38 · LPN 1.31 · Nurse aide 2.53. The reported hours rescaled so homes with sicker or healthier residents can be compared fairly.
Compared with CA and the nation
This home State average National average
- Total nurse hours (hrs/resident/day, higher is better)
- 4.32
✗ Worse than the state average. State 4.54 · National 3.90
- Registered nurse (RN) hours (hrs/resident/day, higher is better)
- 0.39
✗ Worse than the state average. State 0.68 · National 0.69
- Licensed nurse hours (RN + LPN) (hrs/resident/day, higher is better)
- 1.73
✗ Worse than the state average. State 1.88 · National 1.55
- Nurse aide hours (hrs/resident/day, higher is better)
- 2.59
✗ Worse than the state average. State 2.66 · National 2.35
- Weekend total nurse hours (hrs/resident/day, higher is better)
- 3.86
✗ Worse than the state average. State 4.10 · National 3.43
- Weekend RN hours (hrs/resident/day, higher is better)
- 0.21
✗ Worse than the state average. State 0.52 · National 0.48
- Physical therapist hours (hrs/resident/day, higher is better)
- 0.11
✓ Better than the state average. State 0.10 · National 0.07
- Nursing staff turnover (%, lower is better)
- 46.6%
✗ Worse than the state average. State 36.6% · National 45.3%
- RN turnover (%, lower is better)
- 30.8%
✓ Better than the state average. State 37.8% · National 42.5%
- Administrators who left (people, lower is better)
- 1
✗ Worse than the state average. State 0 · National 1
- Nursing case-mix index (index)
- 1.43
State 1.51 · National 1.41
Turnover is the share of nursing staff who left over the year. The case-mix index shows how much care residents need: about 1.0 is typical, higher means more dependent residents.
Sources: Nursing Home Provider Information [1] ; Nursing Home State & National Averages [9] ; Design for Care Compare Nursing Home Five-Star Quality Rating System: Technical Users' Guide [11]
Inspections
State inspectors visit each home about once a year and investigate complaints. Every problem they cite is a deficiency, lettered A to L by how serious and how widespread it was.
Health inspection score
104.0 points — in CA that earns (Below average).
Lower is better. The score adds up points for every citation (more for serious, widespread problems) and for revisits needed to confirm fixes, then weights recent inspections most. [11]
Score needed for each star in CA [10]
- 5 ★
- 0.000-33.000
- 4 ★
- 33.001-66.000
- 3 ★
- 66.001-96.000
- 2 ★ (this home)
- 96.001-146.000
- 1 ★
- >146.000
| Period | Inspection | Citations (complaint) | Citation points | Revisits | Revisit points | Total |
|---|---|---|---|---|---|---|
| Most recent cycle | Nov 19, 2025 | 33 (12) | 100 | 1 | 0 | 100 |
| Prior cycles (2 and 3) | Sep 27, 2024 | 42 (23) | 116 | 1 | 0 | 116 |
Health citations per inspection
Nov 19, 2025
Sep 27, 2024
Feb 22, 2022
State average for that cycle. Fewer is better.
Fire-safety citations per inspection
Nov 19, 2025
Sep 27, 2024
Feb 22, 2022
State average for that cycle. Fewer is better.
What the latest health inspection cited
- Quality of Life and Care 8
- Resident Rights 6
- Pharmacy Service 5
- Resident Assessment and Care Planning 4
- Freedom from Abuse and Neglect and Exploitation 3
- Nutrition and Dietary 3
- Infection Control 2
- Nursing and Physician Services 1
- Administration 1
What the latest fire-safety inspection cited
- Smoke 2
- Construction 1
- Services 1
How serious were the citations?
Each health citation gets a letter. The number in each cell is how many of this home's citations got that letter; the points show what each letter adds to the health inspection score. Citations where care was substandard score higher than shown. [11]
| Isolated (a few residents) | Pattern (some residents) | Widespread (many residents) | |
|---|---|---|---|
| Immediate jeopardy to resident health or safety | J · 50 pts 0 | K · 100 pts 0 | L · 150 pts 0 |
| Actual harm, not immediate jeopardy | G · 20 pts 0 | H · 35 pts 0 | I · 45 pts 0 |
| No actual harm, potential for more than minimal harm | D · 4 pts 57 | E · 8 pts 4 | F · 16 pts 0 |
| No actual harm, potential for minimal harm only | A · 0 pts 0 | B · 0 pts 23 | C · 0 pts 1 |
Darker cells mean more citations. Counts cover every health citation CMS lists for this home.
All health citations (85) [2]
Inspection on Aug 4, 2026 · 1 citation
-
D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
F0755 · Pharmacy Service Deficiencies · Deficient, Provider has date of correction (Aug 17, 2026) · From a complaint
Inspection on Jul 23, 2026 · 2 citations
-
D
Ensure that residents are fully informed and understand their health status, care and treatments.
F0552 · Resident Rights Deficiencies · Deficient, Provider has date of correction (Aug 10, 2026) · From a complaint
-
D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F0684 · Quality of Life and Care Deficiencies · Deficient, Provider has date of correction (Aug 10, 2026) · From a complaint
Inspection on Jun 10, 2026 · 4 citations
-
D
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
F0607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction (Jun 26, 2026) · From a complaint
-
D
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
F0710 · Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction (Jun 26, 2026) · From a complaint
-
D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
F0580 · Resident Rights Deficiencies · Deficient, Provider has date of correction (Jun 26, 2026) · From a complaint
-
D
Provide or obtain dental services for each resident.
F0791 · Quality of Life and Care Deficiencies · Deficient, Provider has date of correction (Jun 26, 2026) · From a complaint
Inspection on May 21, 2026 · 1 citation
-
D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
F0609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction (Jun 10, 2026) · From a complaint
Inspection on Apr 30, 2026 · 1 citation
-
D
Provide and implement an infection prevention and control program.
F0880 · Infection Control Deficiencies · Deficient, Provider has date of correction (May 10, 2026) · From a complaint
Inspection on Mar 20, 2026 · 1 citation
-
D
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
F0628 · Resident Rights Deficiencies · Deficient, Provider has date of correction (Apr 10, 2026) · From a complaint
Inspection on Feb 3, 2026 · 2 citations
-
D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F0689 · Quality of Life and Care Deficiencies · Deficient, Provider has date of correction (Feb 13, 2026) · From a complaint
-
B
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
F0842 · Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction (Feb 13, 2026) · From a complaint
Inspection on Nov 19, 2025 · 21 citations
-
B
Provide safe and appropriate respiratory care for a resident when needed.
F0695 · Quality of Life and Care Deficiencies · Deficient, Provider has date of correction (Dec 10, 2025)
-
D
Reasonably accommodate the needs and preferences of each resident.
F0558 · Resident Rights Deficiencies · Deficient, Provider has date of correction (Dec 10, 2025)
-
B
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
F0842 · Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction (Dec 10, 2025)
-
D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
F0686 · Quality of Life and Care Deficiencies · Deficient, Provider has date of correction (Dec 10, 2025)
-
D
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
F0605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction (Dec 10, 2025)
-
D
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F0812 · Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction (Dec 10, 2025)
-
D
Provide and implement an infection prevention and control program.
F0880 · Infection Control Deficiencies · Deficient, Provider has date of correction (Dec 10, 2025)
-
B
PASARR screening for Mental disorders or Intellectual Disabilities
F0645 · Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction (Dec 10, 2025)
-
B
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
F0557 · Resident Rights Deficiencies · Deficient, Provider has date of correction (Dec 10, 2025)
-
D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F0689 · Quality of Life and Care Deficiencies · Deficient, Provider has date of correction (Dec 10, 2025)
-
B
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
F0847 · Administration Deficiencies · Deficient, Provider has date of correction (Dec 10, 2025)
-
B
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.
F0578 · Resident Rights Deficiencies · Deficient, Provider has date of correction (Dec 10, 2025)
-
D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F0684 · Quality of Life and Care Deficiencies · Deficient, Provider has date of correction (Dec 10, 2025)
-
D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
F0755 · Pharmacy Service Deficiencies · Deficient, Provider has date of correction (Dec 10, 2025)
-
B
Ensure each resident receives an accurate assessment.
F0641 · Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction (Dec 10, 2025)
-
D
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.
F0803 · Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction (Dec 10, 2025)
-
D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
F0757 · Pharmacy Service Deficiencies · Deficient, Provider has date of correction (Dec 10, 2025)
-
D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
F0698 · Quality of Life and Care Deficiencies · Deficient, Provider has date of correction (Dec 10, 2025)
-
D
Ensure medication error rates are not 5 percent or greater.
F0759 · Pharmacy Service Deficiencies · Deficient, Provider has date of correction (Dec 10, 2025)
-
D
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
F0813 · Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction (Dec 10, 2025)
-
D
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.
F0761 · Pharmacy Service Deficiencies · Deficient, Provider has date of correction (Dec 10, 2025)
Inspection on Aug 22, 2025 · 4 citations
-
B
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F0684 · Quality of Life and Care Deficiencies · Deficient, Provider has no plan of correction · From a complaint
-
B
Provide and implement an infection prevention and control program.
F0880 · Infection Control Deficiencies · Deficient, Provider has no plan of correction · From a complaint
-
B
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
F0842 · Resident Assessment and Care Planning Deficiencies · Deficient, Provider has no plan of correction · From a complaint
-
B
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
F0921 · Environmental Deficiencies · Deficient, Provider has no plan of correction · From a complaint
Inspection on Jul 9, 2025 · 2 citations
-
D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
F0686 · Quality of Life and Care Deficiencies · Deficient, Provider has date of correction (Jul 31, 2025) · From a complaint
-
D
Provide and implement an infection prevention and control program.
F0880 · Infection Control Deficiencies · Deficient, Provider has date of correction (Jul 31, 2025) · From a complaint
Inspection on Apr 3, 2025 · 3 citations
-
B
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
F0557 · Resident Rights Deficiencies · Deficient, Provider has date of correction (Apr 16, 2025) · From a complaint
-
B
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.
F0803 · Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction (Apr 16, 2025) · From a complaint
-
D
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.
F0909 · Environmental Deficiencies · Deficient, Provider has date of correction (Apr 16, 2025) · From a complaint
Inspection on Jan 24, 2025 · 3 citations
-
D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
F0580 · Resident Rights Deficiencies · Deficient, Provider has date of correction (Feb 19, 2025) · From a complaint
-
B
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
F0550 · Resident Rights Deficiencies · Deficient, Provider has date of correction (Feb 19, 2025) · From a complaint
-
D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F0689 · Quality of Life and Care Deficiencies · Deficient, Provider has date of correction (Feb 19, 2025) · From a complaint
Inspection on Dec 12, 2024 · 6 citations
-
D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
F0757 · Pharmacy Service Deficiencies · Deficient, Provider has date of correction (Jan 8, 2025) · From a complaint
-
B
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F0656 · Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction (Jan 8, 2025) · From a complaint
-
D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
F0690 · Quality of Life and Care Deficiencies · Deficient, Provider has date of correction (Jan 8, 2025) · From a complaint
-
B
Reasonably accommodate the needs and preferences of each resident.
F0558 · Resident Rights Deficiencies · Deficient, Provider has date of correction (Jan 8, 2025) · From a complaint
-
B
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
F0755 · Pharmacy Service Deficiencies · Deficient, Provider has date of correction (Jan 8, 2025) · From a complaint
-
B
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
F0842 · Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction (Jan 8, 2025) · From a complaint
Inspection on Nov 6, 2024 · 2 citations
-
B
Reasonably accommodate the needs and preferences of each resident.
F0558 · Resident Rights Deficiencies · Deficient, Provider has date of correction (Nov 29, 2024) · From a complaint
-
D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F0684 · Quality of Life and Care Deficiencies · Deficient, Provider has date of correction (Nov 29, 2024) · From a complaint
Inspection on Sep 27, 2024 · 22 citations
-
D
Keep all essential equipment working safely.
F0908 · Environmental Deficiencies · Deficient, Provider has date of correction (Oct 27, 2024)
-
D
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
F0756 · Pharmacy Service Deficiencies · Deficient, Provider has date of correction (Oct 27, 2024)
-
B
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
F0842 · Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction (Oct 27, 2024)
-
D
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.
F0761 · Pharmacy Service Deficiencies · Deficient, Provider has date of correction (Oct 27, 2024)
-
D
Ensure medication error rates are not 5 percent or greater.
F0759 · Pharmacy Service Deficiencies · Deficient, Provider has date of correction (Oct 27, 2024)
-
C
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
F0806 · Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction (Oct 27, 2024) · From a complaint
-
D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
F0883 · Infection Control Deficiencies · Deficient, Provider has date of correction (Oct 27, 2024)
-
D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
F0757 · Pharmacy Service Deficiencies · Deficient, Provider has date of correction (Oct 27, 2024)
-
D
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
F0849 · Administration Deficiencies · Deficient, Provider has date of correction (Oct 27, 2024)
-
E
Provide and implement an infection prevention and control program.
F0880 · Infection Control Deficiencies · Deficient, Provider has date of correction (Oct 27, 2024)
-
D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F0656 · Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction (Oct 27, 2024)
-
D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
F0698 · Quality of Life and Care Deficiencies · Deficient, Provider has date of correction (Oct 27, 2024)
-
D
Reasonably accommodate the needs and preferences of each resident.
F0558 · Resident Rights Deficiencies · Deficient, Provider has date of correction (Oct 27, 2024) · From a complaint
-
D
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
F0813 · Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction (Oct 27, 2024)
-
D
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.
F0803 · Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction (Oct 27, 2024)
-
D
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.
F0758 · Pharmacy Service Deficiencies · Deficient, Provider has date of correction (Oct 27, 2024)
-
D
Provide safe and appropriate respiratory care for a resident when needed.
F0695 · Quality of Life and Care Deficiencies · Deficient, Provider has date of correction (Oct 27, 2024)
-
B
Dispose of garbage and refuse properly.
F0814 · Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction (Oct 27, 2024) · From a complaint
-
D
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.
F0578 · Resident Rights Deficiencies · Deficient, Provider has date of correction (Oct 27, 2024)
-
D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
F0755 · Pharmacy Service Deficiencies · Deficient, Provider has date of correction (Oct 27, 2024)
-
E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F0812 · Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction (Oct 27, 2024)
-
D
Implement a program that monitors antibiotic use.
F0881 · Infection Control Deficiencies · Deficient, Provider has date of correction (Oct 27, 2024)
Inspection on Feb 22, 2022 · 10 citations
-
E
Provide and implement an infection prevention and control program.
F0880 · Infection Control Deficiencies · Deficient, Provider has date of correction (Mar 17, 2022)
-
D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F0689 · Quality of Life and Care Deficiencies · Deficient, Provider has date of correction (Mar 17, 2022)
-
D
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.
F0578 · Resident Rights Deficiencies · Deficient, Provider has date of correction (Mar 17, 2022)
-
D
Provide appropriate foot care.
F0687 · Quality of Life and Care Deficiencies · Deficient, Provider has date of correction (Mar 17, 2022)
-
D
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.
F0761 · Pharmacy Service Deficiencies · Deficient, Provider has date of correction (Mar 17, 2022)
-
D
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F0812 · Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction (Mar 17, 2022)
-
E
Implement a program that monitors antibiotic use.
F0881 · Infection Control Deficiencies · Deficient, Provider has date of correction (Mar 17, 2022)
-
B
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
F0842 · Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction (Mar 17, 2022)
-
D
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
F0849 · Administration Deficiencies · Deficient, Provider has date of correction (Mar 17, 2022)
-
D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
F0690 · Quality of Life and Care Deficiencies · Deficient, Provider has date of correction (Mar 17, 2022)
All fire-safety citations (12) [3]
Inspection on Nov 19, 2025 · 4 citations
-
D
Properly select, install, inspect, or maintain portable fire extinguishes.
K0355 · Smoke Deficiencies · Deficient, Provider has date of correction (Nov 19, 2025)
-
D
Meet other general requirements that are deficient.
K0500 · Services Deficiencies · Deficient, Provider has date of correction (Nov 19, 2025)
-
D
Inspect, test, and maintain automatic sprinkler systems.
K0353 · Smoke Deficiencies · Deficient, Provider has date of correction (Nov 19, 2025)
-
D
Use approved construction type or materials.
K0161 · Construction Deficiencies · Deficient, Provider has date of correction (Nov 19, 2025)
Inspection on Sep 27, 2024 · 3 citations
-
D
Ensure proper usage of power strips and extension cords.
K0920 · Gas, Vacuum, and Electrical Systems Deficiencies · Deficient, Provider has date of correction (Oct 27, 2024)
-
F
Conduct testing and exercise requirements.
E0039 · Emergency Preparedness Deficiencies · Deficient, Provider has date of correction (Oct 27, 2024)
-
D
Have proper medical gas storage and administration areas.
K0923 · Gas, Vacuum, and Electrical Systems Deficiencies · Deficient, Provider has date of correction (Oct 27, 2024)
Inspection on Feb 22, 2022 · 5 citations
-
D
Install corridor and hallway doors that block smoke.
K0363 · Smoke Deficiencies · Deficient, Provider has date of correction (Mar 18, 2022)
-
D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K0211 · Egress Deficiencies · Deficient, Provider has date of correction (Mar 18, 2022)
-
D
Meet other general requirements that are deficient.
K0500 · Services Deficiencies · Deficient, Provider has date of correction (Mar 18, 2022)
-
D
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K0321 · Smoke Deficiencies · Deficient, Provider has date of correction (Mar 18, 2022)
-
D
Conduct risk assessment and an All-Hazards approach.
E0006 · Emergency Preparedness Deficiencies · Deficient, Provider has date of correction (Mar 18, 2022)
Sources: Nursing Home Provider Information [1] ; Nursing Home Survey Summary [4] ; Nursing Home Health Deficiencies [2] ; Nursing Home Fire Safety Deficiencies [3] ; Nursing Home Health Inspection Cut Points [10] ; Design for Care Compare Nursing Home Five-Star Quality Rating System: Technical Users' Guide [11]
Fines & penalties
CMS can fine a home or stop Medicare and Medicaid payments for new admissions when problems are serious or keep recurring. Most homes have none.
- Fines
- 0 State avg 0.8 · National 0.9
- Total fined
- $0 State avg 23,366 · National 30,351
- Payment denials
- 0 Periods with no Medicare/Medicaid payment for new admissions
Sources: Nursing Home Provider Information [1] ; Nursing Home Penalties [5] ; Nursing Home State & National Averages [9]
Resident quality measures
These measure what actually happens to residents, as a percentage from 0 to 100 (or events per 1,000 resident days). For almost all of them a lower number is better; the vaccination measures are the exception and are marked. A star means the measure counts toward the quality star rating.
This home State average National average
Long-stay residents (14) [7]
Residents who live in the home. From their regular health assessments (the Minimum Data Set), averaged over four quarters. Period: 2025Q3-2026Q2.
- Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine Higher is better
- 95.7
✗ Worse than the state average. State 98.7 · National 93.7
- Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine Higher is better
- 91.2
✗ Worse than the state average. State 97.9 · National 95.3
- Percentage of long-stay residents experiencing one or more falls with major injury ★ Lower is better
- 2.6
✗ Worse than the state average. State 1.6 · National 3.2
- Percentage of long-stay residents who have depressive symptoms Lower is better
- 11.4
✗ Worse than the state average. State 7.6 · National 13.5
- Percentage of long-stay residents who lose too much weight Lower is better
- 9.6
✗ Worse than the state average. State 4.1 · National 5.1
- Percentage of long-stay residents who received an antianxiety or hypnotic medication Lower is better
- 4.6
✓ Better than the state average. State 13.7 · National 19.5
- Percentage of long-stay residents who received an antipsychotic medication ★ Lower is better
- 11.6
✓ Better than the state average. State 12.3 · National 15.4
- Percentage of long-stay residents who were physically restrained Lower is better
- 0.0
✓ Better than the state average. State 0.3 · National 0.1
- Percentage of long-stay residents whose ability to walk independently worsened ★ Lower is better
- 12.9
✗ Worse than the state average. State 8.9 · National 12.7
- Percentage of long-stay residents whose need for help with daily activities has increased ★ Lower is better
- 22.3
✗ Worse than the state average. State 10.2 · National 13.5
- Percentage of long-stay residents with a catheter inserted and left in their bladder ★ Lower is better
- 0.8
✗ Worse than the state average. State 0.7 · National 0.7
- Percentage of long-stay residents with a urinary tract infection ★ Lower is better
- 2.4
✗ Worse than the state average. State 1.2 · National 1.5
- Percentage of long-stay residents with new or worsened bowel or bladder incontinence Lower is better
- 28.8
✗ Worse than the state average. State 9.8 · National 18.3
- Percentage of long-stay residents with pressure ulcers ★ Lower is better
- 3.8
✓ Better than the state average. State 4.3 · National 4.5
Short-stay residents (3) [7]
Residents staying for rehab or recovery. From their health assessments, averaged over four quarters. Period: 2025Q3-2026Q2.
- Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine Higher is better
- 84.3
✗ Worse than the state average. State 94.6 · National 82.3
- Percentage of short-stay residents who newly received an antipsychotic medication ★ Lower is better
- 0.9
✓ Better than the state average. State 1.3 · National 1.5
- Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine Higher is better
- 68.0
✗ Worse than the state average. State 93.1 · National 80.1
Long-stay residents: hospital use (2) [8]
Hospital stays and emergency visits found in Medicare claims, adjusted for how sick residents were. Period: 20250401-20260331.
- Number of hospitalizations per 1000 long-stay resident days ★ Lower is better · Expected for these residents: 2.5
- 2.1
✓ Better than the state average. State 2.2 · National 1.8
- Number of outpatient emergency department visits per 1000 long-stay resident days ★ Lower is better · Expected for these residents: 1.8
- 0.5
✓ Better than the state average. State 1.5 · National 1.7
Short-stay residents: hospital use (2) [8]
Rehospitalizations and emergency visits after admission, found in Medicare claims and adjusted for how sick residents were. Period: 20250401-20260331.
- Percentage of short-stay residents who had an outpatient emergency department visit ★ Lower is better · Expected for these residents: 10.9
- 2.9
✓ Better than the state average. State 11.1 · National 11.8
- Percentage of short-stay residents who were rehospitalized after a nursing home admission ★ Lower is better · Expected for these residents: 25.6
- 19.1
✓ Better than the state average. State 22.6 · National 23.4
Sources: Nursing Home MDS Quality Measures [7] ; Nursing Home Medicare Claims Quality Measures [8] ; Nursing Home State & National Averages [9] ; Design for Care Compare Nursing Home Five-Star Quality Rating System: Technical Users' Guide [11]
Ownership & operator
Who owns and runs a home can matter: for-profit, non-profit and chain-owned homes tend to differ on staffing and inspection results.
- Ownership type
- For profit - Individual
- Legal business name
- MALCOLM HEALTHCARE, INC.
- Certified for
- Medicare and Medicaid
- Certified beds
- 150
- Residents per day (average)
- 127.6
- In Medicare/Medicaid since
- May 1, 1978
- Resident and family council
- Resident
- Sprinklers in all required areas
- Yes
- County
- Orange
- Located in a hospital
- No
Company profiles: The Ensign Group (347 homes, average 3.3 stars)
Part of THE ENSIGN GROUP
One of 347 homes in this chain. Average star ratings across the chain (1 to 5):
- Overall
- 3.3
- Health inspections
- 2.8
- Staffing
- 2.8
- Quality
- 4.4
Owners, officers and managers (10) [6]
Operational/Managerial Control
- AYELE, ETSEGENET (individual, NOT APPLICABLE, since 04/01/2025)
- CLUFF, CASEY (individual, NOT APPLICABLE, since 04/01/2025)
Adp Of The Snf
- AYELE, ETSEGENET (individual, NOT APPLICABLE, since 04/01/2025)
- CLUFF, CASEY (individual, NOT APPLICABLE, since 04/01/2025)
Corporate Officer
- BURNAM, SOON (individual, NOT APPLICABLE, since 04/25/2024)
- LOOPER, WILLIAM (individual, NOT APPLICABLE, since 04/25/2024)
- SATO, AMI (individual, NOT APPLICABLE, since 09/09/2024)
- WILLITS, ADAM (individual, NOT APPLICABLE, since 04/25/2024)
Managing Control - Governing Body
- CLUFF, CASEY (individual, NOT APPLICABLE, since 04/01/2025)
Corporate Director
- WILLITS, ADAM (individual, NOT APPLICABLE, since 04/25/2024)
Sources: Nursing Home Provider Information [1] ; Nursing Home Ownership [6]
Sources
All figures on this page come from the U.S. government's published nursing home data, as of October 1, 2026. We reproduce them without change except for rounding and layout; ratings, scores and flags are CMS's, not ours. Averages and comparisons use the state and national figures CMS publishes in the same release.
- 1. Centers for Medicare & Medicaid Services, Provider Data Catalog. Nursing Home Provider Information. Star ratings, staffing, turnover, inspection scores, fines, chain and flag data. https://data.cms.gov/provider-data/dataset/4pq5-n9py
- 2. Centers for Medicare & Medicaid Services, Provider Data Catalog. Nursing Home Health Deficiencies. Each health deficiency cited, with scope and severity. https://data.cms.gov/provider-data/dataset/r5ix-sfxw
- 3. Centers for Medicare & Medicaid Services, Provider Data Catalog. Nursing Home Fire Safety Deficiencies. Each fire-safety deficiency cited. https://data.cms.gov/provider-data/dataset/ifjz-ge4w
- 4. Centers for Medicare & Medicaid Services, Provider Data Catalog. Nursing Home Survey Summary. Deficiency totals by inspection cycle and category. https://data.cms.gov/provider-data/dataset/tbry-pc2d
- 5. Centers for Medicare & Medicaid Services, Provider Data Catalog. Nursing Home Penalties. Fines and payment denials. https://data.cms.gov/provider-data/dataset/g6vv-u9sr
- 6. Centers for Medicare & Medicaid Services, Provider Data Catalog. Nursing Home Ownership. Owners, officers, directors and managers. https://data.cms.gov/provider-data/dataset/y2hd-n93e
- 7. Centers for Medicare & Medicaid Services, Provider Data Catalog. Nursing Home MDS Quality Measures. Quarterly quality measure scores from resident assessments. https://data.cms.gov/provider-data/dataset/djen-97ju
- 8. Centers for Medicare & Medicaid Services, Provider Data Catalog. Nursing Home Medicare Claims Quality Measures. Risk-adjusted quality measures from Medicare claims. https://data.cms.gov/provider-data/dataset/ijh5-nb2v
- 9. Centers for Medicare & Medicaid Services, Provider Data Catalog. Nursing Home State & National Averages. State and national averages used for comparison. https://data.cms.gov/provider-data/dataset/xcdc-v8bm
- 10. Centers for Medicare & Medicaid Services, Provider Data Catalog. Nursing Home Health Inspection Cut Points. Score ranges that earn each health inspection star in a state. https://data.cms.gov/provider-data/dataset/hicp-9999
- 11. Centers for Medicare & Medicaid Services. Design for Care Compare Nursing Home Five-Star Quality Rating System: Technical Users' Guide. How the star ratings, scope and severity points, and abuse and Special Focus flags are defined. https://www.cms.gov/medicare/provider-enrollment-and-certification/certificationandcomplianc/downloads/usersguide.pdf
- 12. Centers for Medicare & Medicaid Services. Medicare Care Compare. CMS's own consumer site, with the latest figures. https://www.medicare.gov/care-compare/
Attendant Homes is not affiliated with or endorsed by CMS. The data describes past inspections and reported figures and can be out of date or contain errors; it is not a recommendation. Confirm current information with the facility and on Medicare Care Compare [12] .
Written by Attendant Homes
Have a question or some feedback? Send Attendant Homes a message.
See more from Attendant Homes →
Reviews (0)
Sign in to write a review.
No reviews yet. Be the first to write one.