Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
SOUTH COAST POST ACUTE
SANTA ANA, CA · 255 certified beds · Last Life Safety survey February 28, 2025
CMS Certification Number 055653 · first certified June 1974
Ownership
Operated by WINDSOR · For profit - Limited Liability company
- Ownership changed March 24, 2023 (change of ownership)from ROYALE HEALTH CARE CENTER INC.
Position within CA
20 citations — more than 51% of the 1,165 certified nursing homes in CA. Compared within CA rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 5 citations; the earlier surveys in the window averaged 7.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
Past the typical window (March 2026 to August 2026). Most CA facilities have been surveyed by July 2027. This facility’s last Life Safety survey was February 2025. Facilities in CA are typically surveyed 12–18 months after the last one (median 14), measured over 1,766 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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4 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Physical environment (health survey)
9 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 20 Life Safety citations above. The Physical Environment Index
- F-0880 Provide and implement an infection prevention and control program.
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F-0909 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.
How that compares
Compared with the median facility in CA, and nationally. Surveyors differ markedly between states, so the CA figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 20 |
| Median facility in CA | 19 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| April 19, 2022 | 5 |
| December 21, 2023 | 10 |
| February 28, 2025 | 5 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0363 | Install corridor and hallway doors that block smoke. | 3 | 2025-02-28 |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 2 | 2025-02-28 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 2 | 2025-02-28 |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 2 | 2025-02-28 |
| K-0919 | Meet requirements for the use of electrical equipment. | 1 | 2022-04-19 |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | 1 | 2023-12-21 |
| K-0324 | Provide properly protected cooking facilities. | 1 | 2023-12-21 |
| K-0912 | Have power receptacles that are properly grounded. | 1 | 2023-12-21 |
What the citations cover
- Smoke Deficiencies 10
- Gas, Vacuum, and Electrical Systems Deficiencies 6
- Services Deficiencies 2
- Miscellaneous Deficiencies 1
- Other 1
| Category | Citations |
|---|---|
| Smoke Deficiencies | 10 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 6 |
| Services Deficiencies | 2 |
| Miscellaneous Deficiencies | 1 |
| Egress Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
February 28, 2025 — 5 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (March 12, 2025) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (March 12, 2025) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (March 12, 2025) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (March 12, 2025) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (March 12, 2025) |
December 21, 2023 — 10 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (February 2, 2024) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (February 2, 2024) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (February 2, 2024) |
| K-0351 | Install an approved automatic sprinkler system. | Deficient, Provider has date of correction (February 2, 2024) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (February 2, 2024) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (February 2, 2024) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (February 2, 2024) |
| K-0912 | Have power receptacles that are properly grounded. | Deficient, Provider has date of correction (February 2, 2024) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (February 2, 2024) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (February 2, 2024) |
April 19, 2022 — 5 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (April 28, 2022) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (April 28, 2022) |
| K-0500 | Meet other general requirements that are deficient. | Deficient, Provider has date of correction (April 28, 2022) |
| K-0919 | Meet requirements for the use of electrical equipment. | Deficient, Provider has date of correction (April 28, 2022) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (April 28, 2022) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.