Medicare flags this nursing home for abuse. Medicare adds this flag when a home was cited for abuse that harmed a resident, or for potential abuse more than once. Ask the home what changed.
Inspection citations
37’23
16’24
26’25
25’26
104 shown
| Date | Severity | What inspectors found | Visit |
|---|---|---|---|
| Jul 31, 2026 | D · potential | Ensure that residents are fully informed and understand their health status, care and treatments. | Routine |
| Jul 31, 2026 | E · potential | 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. | Routine |
| Jul 31, 2026 | E · potential | 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. | Routine |
| Jul 31, 2026 | D · potential | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| Jul 31, 2026 | D · potential | Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. | Routine |
| Jul 31, 2026 | D · potential | Ensure each resident receives an accurate assessment. | Routine |
| Jul 31, 2026 | D · potential | Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Routine |
| Jul 31, 2026 | D · potential | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Routine |
| Jul 31, 2026 | D · potential | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Routine |
| Jul 31, 2026 | D · potential | Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Routine |
| Jul 31, 2026 | D · potential | 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. | Routine |
| Jul 31, 2026 | D · potential | Provide safe and appropriate respiratory care for a resident when needed. | Routine |
| Jul 31, 2026 | E · potential | Provide safe, appropriate pain management for a resident who requires such services. | Routine |
| Jul 31, 2026 | D · potential | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Routine |
| Jul 31, 2026 | D · potential | 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. | Routine |
| Jul 31, 2026 | E · potential | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Routine |
| Jul 31, 2026 | E · potential | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Routine |
| Jul 31, 2026 | E · potential | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Routine |
| Jul 31, 2026 | E · potential | Provide and implement an infection prevention and control program. | Routine |
| Jul 31, 2026 | D · potential | Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Routine |
| Jul 31, 2026 | D · potential | Keep all essential equipment working safely. | Routine |
| Jun 17, 2026 | D · potential | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| Jun 10, 2026 | D · potential | Provide and implement an infection prevention and control program. | Complaint |
| Jun 4, 2026 | D · potential | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| Jun 4, 2026 | D · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Complaint |
| Oct 29, 2025 | D · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Complaint |
| Sep 24, 2025 | D · potential | Respond appropriately to all alleged violations. | Complaint |
| Aug 7, 2025 | D · potential | Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge. | Complaint |
| Aug 7, 2025 | B · minimal | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Complaint |
| Jul 15, 2025 | D · potential | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| Jul 15, 2025 | B · minimal | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Complaint |
| Jun 6, 2025 | D · potential | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| Jun 6, 2025 | D · potential | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Complaint |
| Jun 6, 2025 | D · potential | Respond appropriately to all alleged violations. | Complaint |
| Jun 6, 2025 | D · potential | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Complaint |
| Jun 6, 2025 | D · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| Feb 28, 2025 | D · potential | Ensure that residents are fully informed and understand their health status, care and treatments. | Routine |
| Feb 28, 2025 | D · potential | 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. | Routine |
| Feb 28, 2025 | D · potential | PASARR screening for Mental disorders or Intellectual Disabilities | Routine |
| Feb 28, 2025 | D · potential | Provide activities to meet all resident's needs. | Routine |
| Feb 28, 2025 | D · potential | 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. | Routine |
| Feb 28, 2025 | E · potential | Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Routine |
| Feb 28, 2025 | D · potential | Provide safe and appropriate respiratory care for a resident when needed. | Routine |
| Feb 28, 2025 | D · potential | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Routine |
| Feb 28, 2025 | D · potential | 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. | Routine |
| Feb 28, 2025 | D · potential | Ensure medication error rates are not 5 percent or greater. | Routine |
| Feb 28, 2025 | D · potential | 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. | Routine |
| Feb 28, 2025 | E · potential | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Complaint |
| Feb 28, 2025 | D · potential | Dispose of garbage and refuse properly. | Routine |
| Feb 28, 2025 | B · minimal | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Routine |
| Feb 28, 2025 | D · potential | Provide and implement an infection prevention and control program. | Routine |
| Dec 18, 2024 | D · potential | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| Nov 5, 2024 | D · potential | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Complaint |
| Jul 24, 2024 | B · minimal | Provide and implement an infection prevention and control program. | Complaint |
| Jun 26, 2024 | B · minimal | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Complaint |
| Jun 26, 2024 | D · potential | Provide enough food/fluids to maintain a resident's health. | Complaint |
| Jun 26, 2024 | D · potential | Provide and implement an infection prevention and control program. | Complaint |
| May 21, 2024 | D · potential | Reasonably accommodate the needs and preferences of each resident. | Complaint |
| Apr 19, 2024 | B · minimal | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Complaint |
| Apr 19, 2024 | D · potential | Reasonably accommodate the needs and preferences of each resident. | Complaint |
| Apr 19, 2024 | D · potential | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Complaint |
| Apr 19, 2024 | D · potential | 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. | Complaint |
| Mar 27, 2024 | D · potential | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| Feb 20, 2024 | B · minimal | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Complaint |
| Feb 20, 2024 | D · potential | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Complaint |
| Jan 25, 2024 | D · potential | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Complaint |
| Jan 25, 2024 | D · potential | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Complaint |
| Dec 21, 2023 | D · potential | Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Routine |
| Dec 21, 2023 | D · potential | Allow residents to self-administer drugs if determined clinically appropriate. | Routine |
| Dec 21, 2023 | D · potential | 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. | Routine |
| Dec 21, 2023 | B · minimal | Keep residents' personal and medical records private and confidential. | Routine |
| Dec 21, 2023 | D · potential | Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Routine |
| Dec 21, 2023 | B · minimal | Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Routine |
| Dec 21, 2023 | B · minimal | Assure that each resident’s assessment is updated at least once every 3 months. | Routine |
| Dec 21, 2023 | B · minimal | Ensure each resident receives an accurate assessment. | Routine |
| Dec 21, 2023 | D · potential | Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Routine |
| Dec 21, 2023 | D · potential | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Routine |
| Dec 21, 2023 | B · minimal | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Routine |
| Dec 21, 2023 | D · potential | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Routine |
| Dec 21, 2023 | D · potential | Provide care and assistance to perform activities of daily living for any resident who is unable. | Routine |
| Dec 21, 2023 | D · potential | Provide activities to meet all resident's needs. | Routine |
| Dec 21, 2023 | D · potential | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Routine |
| Dec 21, 2023 | B · minimal | Provide safe and appropriate respiratory care for a resident when needed. | Routine |
| Dec 21, 2023 | D · potential | 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. | Routine |
| Dec 21, 2023 | B · minimal | Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Routine |
| Dec 21, 2023 | D · potential | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Routine |
| Dec 21, 2023 | E · potential | 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. | Routine |
| Dec 21, 2023 | D · potential | Ensure medication error rates are not 5 percent or greater. | Routine |
| Dec 21, 2023 | E · potential | 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. | Routine |
| Dec 21, 2023 | D · potential | Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Routine |
| Dec 21, 2023 | D · potential | 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. | Routine |
| Dec 21, 2023 | D · potential | Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Routine |
| Dec 21, 2023 | E · potential | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Routine |
| Dec 21, 2023 | D · potential | Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Routine |
| Dec 21, 2023 | B · minimal | Dispose of garbage and refuse properly. | Routine |
| Dec 21, 2023 | B · minimal | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Routine |
| Dec 21, 2023 | B · minimal | 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. | Routine |
| Dec 21, 2023 | D · potential | Provide and implement an infection prevention and control program. | Routine |
| Dec 21, 2023 | D · potential | Implement a program that monitors antibiotic use. | Routine |
| Dec 21, 2023 | E · potential | 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. | Routine |
| Nov 16, 2023 | D · potential | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Complaint |
| Oct 26, 2023 | D · potential | Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Complaint |
| Oct 26, 2023 | D · potential | 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. | Complaint |
| Oct 26, 2023 | E · potential | Provide timely, quality laboratory services/tests to meet the needs of residents. | Complaint |
Medicare's severity letters: A–C minimal harm, D–F potential for more than minimal harm, G–L actual harm or immediate danger. Source: CMS health deficiencies file, processed October 1, 2026.
Questions to ask on a visit
South Coast Post Acute
1030 W Warner Ave, Santa Ana, CA 92707 · (714) 546-6450
Visit date: ____________ Spoke with: ______________________
Record on file
- Certification
- Medicare and Medi-Cal certified skilled nursing facility
- Medicare number (CCN)
- 055653
- Certified beds
- 255
- Legal owner
- 1030 Warner Avenue I Opco LLC
- Part of
- Windsor
Full profile on Medicare's Care Compare. Source: CMS, processed October 1, 2026.
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