Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Irvine Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to serve food at safe and appetizing temperatures, affecting five residents who reported receiving cold meals. Observations revealed that hot foods were below 135°F and cold foods were above 41°F, contrary to facility policy. Despite staff education, the facility did not effectively monitor food temperatures.
A facility failed to maintain the confidentiality of a resident's medical records when an RN reported a resident's chest pain to a physician's daughter, who is not a medical professional. The facility's policy requires that only medical professionals be informed of significant changes in a resident's condition. Interviews confirmed the breach, with the DON and Administrator acknowledging it as a HIPAA violation. The physician confirmed receiving the information through his daughter, leading to the resident being sent to the ER.
A registered nurse failed to follow infection control protocols while caring for a resident with cerebral infarction and atrial fibrillation. The nurse did not wash hands before or after obtaining vital signs and a glucometer check, and improperly used gloves, violating the facility's infection control policy.
The facility failed to ensure residents could access call lights, with several found out of reach during observations. Residents reported that staff hid call lights or instructed them not to use them. Staff interviews confirmed the issue, and records showed ongoing grievances about call lights not being answered promptly.
A resident was inaccurately diagnosed with paraphilia upon admission, despite no evidence of such behavior in hospital records or staff observations. The MDS Nurse admitted the diagnosis was entered incorrectly, and interviews with staff, including the PCP and DON, revealed concerns about the impact of incorrect diagnoses on care and treatment. The facility lacked a system to ensure accurate entry of diagnoses, leading to potential mismanagement of the resident's care.
A resident with severe cognitive impairment and behaviors of touching other residents was admitted to the facility. Despite staff observations and the resident's known diagnoses, the care plan lacked individualized interventions and documentation of outcomes. Interviews revealed inconsistent awareness and reporting of the resident's behaviors, contributing to the deficiency in care planning.
A discolored area under a stairwell in a non-resident area was noted, with no certified inspection conducted to identify potential mold. The Maintenance Director and RPOD performed informal tests, concluding it was not mold, but no outside lab was consulted. The facility's policy requires mold identification and mitigation, but the discoloration remained unverified, leading to a deficiency in maintaining a safe and clean environment.
Failure to Serve Food at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to provide food at safe and appetizing temperatures, affecting five residents who attended a Resident Group Meeting. These residents expressed concerns about receiving cold food, with one resident stating they relied on snacks from family due to the cold meals. The facility's policies require hot foods to be served at temperatures above 135 degrees Fahrenheit and cold foods below 41 degrees Fahrenheit. However, during a test tray observation, the Dietary Manager found that hot foods were below the required temperature, and cold foods were above the required temperature. The State Survey Agent observed a lunch tray pass where the food temperatures did not meet the facility's policy standards. The cheese pizza was recorded at 112.9 degrees Fahrenheit, the fruit cocktail at 45 degrees Fahrenheit, and the salad at 62.5 degrees Fahrenheit. The District Dietary Manager acknowledged the need for meals to be served at appropriate temperatures for palatability, satisfaction, and safety. The Administrator was aware of the complaints but admitted that the facility failed to monitor food temperatures effectively, despite previous staff education on meal service.
Breach of Medical Record Confidentiality
Penalty
Summary
The facility failed to ensure the confidentiality of medical records for one of the sampled residents, identified as Resident 4 (R4). On February 12, 2025, at 11:55 PM, a Registered Nurse (RN1) called the home phone number of Physician 1 to report R4's complaint of chest pain. During this call, RN1 spoke with Physician 1's daughter, who is not a medical professional, and relayed R4's medical information to her. This action was contrary to the facility's policy, which mandates that only a physician, nurse practitioner, or physician assistant should be notified of a significant change in a resident's condition. The facility's policy aims to ensure that all interested parties are informed of a resident's change in health status to develop an appropriate treatment plan. Interviews conducted with RN1, the Director of Nursing (DON), the Administrator, and Physician 1 confirmed the breach of confidentiality. RN1 acknowledged that she should not have given the report to Physician 1's daughter, as she was not a trained medical professional. The DON and the Administrator both stated that relaying a resident's medical information to a physician's family member is a violation of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Physician 1 confirmed that his daughter, who had previously worked for him but is not currently employed as a medical professional, relayed the information to him, leading to his decision to order R4 to be sent to the emergency room for further evaluation.
Infection Control Breach by RN During Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of a registered nurse (RN1) during a routine check on a resident (R4). On the night of February 12, 2025, RN1 was observed obtaining vital signs and performing a glucometer check on R4 without washing her hands before or after the procedures. Additionally, RN1 exited R4's room wearing gloves, accessed a treatment cart drawer in the hallway with the same soiled gloves, and then re-entered R4's room without changing them. This sequence of actions violated the facility's infection control policy, which aims to prevent the transmission of communicable diseases and infections. Resident 4, who was admitted to the facility on October 24, 2023, has medical conditions including cerebral infarction, transient cerebral ischemic attack, and atrial fibrillation. During interviews, RN1 acknowledged the importance of proper handwashing and glove use to prevent the spread of infections and admitted to not following these protocols. The Director of Nursing and the Administrator both confirmed that staff are expected to adhere to the facility's infection control policies to ensure resident safety.
Deficiency in Call Light Accessibility and Response
Penalty
Summary
The facility failed to ensure that residents could call for staff assistance through a communication system that relays the call directly to a staff member from each resident's bedside. During observations on the night shift, call lights for several residents were found to be out of reach, including one under the bed, another behind a chair on the floor, and one clipped to a privacy curtain. Interviews with residents revealed concerns about the accessibility of call lights, with some residents stating that staff hid their call lights at night or instructed them not to use them. Observations confirmed that call lights were not within reach, and residents had to call out for help. Interviews with staff members acknowledged that call lights should be within reach and that failing to do so increases the risk of residents getting hurt. The facility's Educator admitted that the call light issue had been an ongoing problem. A review of the facility's records showed multiple grievances filed by residents and family members about call lights not being answered promptly. Despite the Administrator's awareness and efforts to educate staff, the facility continued to receive complaints about the issue.
Inaccurate Resident Assessment and Misdiagnosis
Penalty
Summary
The facility failed to ensure that each resident received an accurate assessment that reflected their status, specifically concerning a resident diagnosed with paraphilia. The resident, who was admitted with diagnoses including Alzheimer's disease, depression, paraphilia, and dementia, did not have paraphilia listed in the hospital discharge History and Physical (H&P) or the facility's admission H&P. Observations and interviews with staff and the resident's family indicated no evidence of inappropriate sexual behavior, contradicting the diagnosis of paraphilia. The Minimum Data Set (MDS) assessments for the resident showed severe cognitive impairment, with no inappropriate sexual behaviors recorded. Interviews with various State Registered Nurse Aides (SRNAs) and Licensed Practical Nurses (LPNs) revealed that none had observed any inappropriate behavior from the resident. The MDS Nurse admitted that the diagnosis of paraphilia was incorrectly entered during the admission process, and there was uncertainty about whether a system was in place to ensure accurate entry of diagnoses. Interviews with the facility's staff, including the MDS Coordinator, Director of Nursing (DON), and the Primary Care Provider (PCP), highlighted concerns about the impact of incorrect diagnoses on care and treatment. The PCP was unaware of the paraphilia diagnosis and expressed concern about potential polypharmacy. The facility Administrator and other staff members were unsure of the implications of a wrong diagnosis on care planning, indicating a lack of awareness and oversight in ensuring accurate resident assessments.
Failure to Implement Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident, identified as R6, who displayed behaviors of touching and patting the hands, arms, shoulders, and backs of female residents shortly after admission. Despite these behaviors being observed by staff, the comprehensive care plan did not address these behaviors with individualized person-centered interventions. The care plan included a general intervention to redirect R6 as needed, but there was no review or outcome documented for this intervention. R6 was admitted to the facility with diagnoses including Alzheimer's disease, depression, paraphilia, and dementia, and had a Brief Interview for Mental Status (BIMS) score indicating severe cognitive impairment. The care plan noted R6's desire for affection from peers and included interventions for monitoring and redirecting inappropriate behaviors. However, there was no documentation of the effectiveness or outcomes of these interventions, and staff interviews revealed inconsistent awareness and reporting of R6's behaviors. Interviews with various staff members, including SRNAs, LPNs, the Social Service Director, and the Director of Nursing, indicated that R6's behaviors were known but not consistently documented or addressed in the care plan. The MDS Coordinator expressed uncertainty about whether staff nurses updated care plans with new interventions, and there was a lack of clarity on how nurse aides were informed of residents' care needs. This lack of a systematic approach to updating and reviewing the care plan contributed to the deficiency in providing adequate supervision and monitoring for R6.
Unverified Discoloration Under Stairwell Raises Concerns
Penalty
Summary
A dark discolored area was observed under the stairwell of a non-resident area in the facility, where the wall meets the floor. The facility's policy on Water Intrusion and Mold Remediation requires identification and mitigation of mold, which can appear as discoloration. However, there was no documentation of an inspection by an outside certified entity or lab to identify the discoloration. The Maintenance Director stated that a friend performed a moisture test, which showed no moisture, and concluded there was no mold. The Regional Plant Operations Director (RPOD) also performed a moisture test and scrapings, concluding the area was not mold but a dirty wall, and recommended priming and painting the wall. The RPOD's inspection did not involve any formal certification for identifying mold, and the facility did not contact an outside lab for testing. The Maintenance Director reported receiving complaints about the discoloration in July and followed the RPOD's recommendation to bleach and paint the wall, although the area close to the floor remained discolored. Housekeeping reported the issue to maintenance months ago, but no further action was taken to confirm the presence of mold. The Health Department Environmentalist stated that only an outside lab could confirm mold presence, and bleaching and painting were not recommended if mold was present. The Director of Nursing reported no increase in respiratory illnesses among staff or residents since the discoloration was first noted. The Administrator, who oversees facility operations, stated that maintenance did not report any concerns about the discolored area. The facility's failure to have the discoloration inspected by a certified entity or lab and reliance on informal assessments led to the deficiency in ensuring a safe, clean, and comfortable environment as per the facility's policy on resident rights.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 18 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Irvine
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Stanton Nursing And Rehabilitation Center | 11.9 mi | ★★★★★ | 0 | 0 |
| Lee County Care & Rehabilitation Center | 17.3 mi | ★★★★★ | 0 | 0 |
| Telford Terrace | 18.4 mi | ★★★★★ | 3 | 0 |
| Berea Health And Rehabilitation | 18.7 mi | ★★★★★ | 0 | 0 |
| Kenwood Health And Rehabilitation Center | 18.8 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.