SNF

KINDRED HOSPITAL BREA D/P SNF

CCN: 555859 · BREA, CA 92821 · Orange County

ℹ Hospital-based

Overview

Address
875 N BREA BLVD, BREA, CA 92821
Phone
7145296842
Certified beds
38
Avg daily residents
36 (95% of beds filled)
Ownership
For-profit corporation
Provider type
Medicare and Medicaid
Medicare/Medicaid since
2009-07-14
Setting
Urban
5 /5
★★★★★
CMS Overall Rating

CMS 5-Star Ratings

CMS rates every Medicare/Medicaid-certified nursing home on four domains. The Overall rating is driven primarily by Health Inspection results, then adjusted up or down by Staffing and Quality Measures.

Overall Rating
Composite of Health Inspection, Staffing, and Quality Measures.
★★★★★ 5/5
Health Inspection
Based on the three most recent standard surveys, with more weight on recent results.
★★★★★ 4/5
Staffing
Weighted combination of RN and total nurse staffing hours per resident per day, case-mix adjusted.
★★★★★ 4/5
Quality Measures
15 resident-level quality measures split between long-stay and short-stay (post-acute) residents.
★★★★★ 5/5
Quality Measures breakdown
Long-Stay Quality Measures ★★★★★ 5/5
Short-Stay Quality Measures ★★★★★ 5/5

Staffing & Workforce

Direct-care staffing is the strongest operational driver of quality in nursing homes. Values are hours per resident per day, derived from payroll-based journal (PBJ) submissions. "Case-mix" adjusts for resident acuity; "Adjusted" is the CMS rating-input value.

Role Reported Case-mix expected Adjusted Federal floor
Total nurse
All nursing staff combined: RN + LPN + Aide
 7.09 7.74 3.54 ≥ 3.48
Registered Nurse (RN)
Licensed RN hours. Strongest driver of clinical outcomes.
 2.45 1.35 1.22 ≥ 0.55
Licensed Practical Nurse (LPN)
LPN/LVN hours. Often handles medication administration.
 1.61 1.72 0.80 —
Nurse aide
CNA hours. Bulk of direct resident care — bathing, feeding, mobility.
 3.04 4.67 1.52 —
Licensed (RN + LPN)
Combined licensed nurse coverage.
 4.05 — — —
Physical therapist
Rehabilitation therapist hours — important for post-acute / rehab admissions.
 0.15 — — —

Federal minimums (phasing in under the CMS 2024 minimum staffing rule) shown for reference. RN: 0.55 hrs/resident/day. Total nurse: 3.48 hrs/resident/day.

Weekend staffing

Total nurse (weekend)
6.68
hrs / resident / day
RN (weekend)
1.83
hrs / resident / day
Total nurse (adjusted, weekend)
3.33
hrs / resident / day

Weekend under-staffing is a common quality-of-care concern — adverse events are more frequent when licensed coverage drops.

Staff turnover

Total nursing staff turnover
15.5%
annual
RN turnover
11.8%
annual
Administrators departed
0
last 12 months

Resident acuity

Nursing Case-Mix Index
2.74
higher acuity than avg
Case-Mix Index Ratio
1.99
facility / state ratio

Health Inspections

CMS weights three inspection cycles to compute the Health Inspection rating: the most recent (50%), the second most recent (33%), and the oldest (17%). Each standard-survey deficiency is assigned a score based on scope and severity; complaint-survey findings and revisit scores are added to produce the cycle total.

Cycle Date Total defs. Standard Complaint Deficiency score Revisits Total score
Cycle 1 (most recent) 2024-11-22 13 10 4 56 1 56
Cycle 2/3 (prior) 2023-12-01 15 8 7 52 1 52
Total weighted health score
55.0
lower is better

Deficiencies (45)

Individual survey findings. Scope/severity uses the CMS A–L matrix: letters further down the alphabet indicate greater harm and wider scope, up through J–L (immediate jeopardy).

6 A/B/C No actual harm — minor
39 D/E/F Actual harm — potential for minor
Tag Description Scope/Severity Survey date Corrected
0658 Ensure services provided by the nursing facility meet professional standards of quality. D 2025-09-17 2025-10-15
0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. D 2025-09-17 2025-10-15
0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. D 2025-09-17 2025-10-15
0550 Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. B 2024-11-22 2024-12-21
0693 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. D 2024-11-22 2024-12-21
0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed. D 2024-11-22 2024-12-21
0695 Provide safe and appropriate respiratory care for a resident when needed. D 2024-11-22 2024-12-21
0700 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. E 2024-11-22 2024-12-21
0803 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. D 2024-11-22 2024-12-21
0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. E 2024-11-22 2024-12-21
0814 Dispose of garbage and refuse properly. B 2024-11-22 2024-12-21
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. E 2024-11-22 2024-12-21
0761 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. D 2024-11-22 2024-12-21
0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. D 2024-10-15 2024-10-30
0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. D 2024-10-15 2024-10-30
0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. B 2023-12-01 2023-12-26
0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. D 2023-12-01 2023-12-26
0693 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. D 2023-12-01 2023-12-26
0759 Ensure medication error rates are not 5 percent or greater. D 2023-12-01 2023-12-26
0761 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. D 2023-12-01 2023-12-26
0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. E 2023-12-01 2023-12-26
0814 Dispose of garbage and refuse properly. B 2023-12-01 2023-12-26
0882 Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. D 2023-12-01 2023-12-26
0880 Provide and implement an infection prevention and control program. D 2023-11-30 2023-12-26
0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. D 2023-10-26 2023-11-26
0814 Dispose of garbage and refuse properly. B 2023-10-26 2023-11-26
0880 Provide and implement an infection prevention and control program. D 2023-08-01 2023-09-08
0700 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. D 2023-06-06 2023-06-27
0558 Reasonably accommodate the needs and preferences of each resident. D 2023-01-23 2023-02-14
0578 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. D 2023-01-23 2023-02-14
0641 Ensure each resident receives an accurate assessment. B 2023-01-23 2023-02-14
0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. D 2023-01-23 2023-02-14
0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. D 2023-01-23 2023-02-14
0693 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. D 2023-01-23 2023-02-14
0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed. D 2023-01-23 2023-02-14
0695 Provide safe and appropriate respiratory care for a resident when needed. D 2023-01-23 2023-02-14
0700 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. D 2023-01-23 2023-02-14
0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. D 2023-01-23 2023-02-14
0759 Ensure medication error rates are not 5 percent or greater. D 2023-01-23 2023-02-14
0761 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. D 2023-01-23 2023-02-14
0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. D 2023-01-23 2023-02-14
0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. D 2023-01-23 2023-02-14
0880 Provide and implement an infection prevention and control program. E 2023-01-23 2023-02-14
0881 Implement a program that monitors antibiotic use. D 2023-01-23 2023-02-14
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. E 2023-01-23 2023-02-14

Ownership & Corporate Structure

Chain: KINDRED HEALTHCARE

Chain ID
300
Facilities in chain
4
Legal business name
THC - ORANGE COUNTY LLC
Chain-average star ratings (for peer context)
Overall
3.5
Health
3.0
Staffing
3.3
QM
4.3

Owner / manager individuals (3)

Name Role Association
ROCK, DANA OPERATIONAL/MANAGERIAL CONTROL since 12/09/2024
TRAYLOR, JOHNETTA OPERATIONAL/MANAGERIAL CONTROL since 12/09/2024
VADECHA, JAINAM OPERATIONAL/MANAGERIAL CONTROL since 02/07/2022

Source: CMS Nursing Home Ownership. Percent ownership is rarely disclosed — CMS only requires it for specific roles.

Facility Features

CCRC
No
Hospital-based
Yes
Resident / family council
None
Sprinkler systems
Yes
Abuse citation flag
No
Methodology & sources

Full methodology →

All Data

Every labeled field shipped for this facility by CMS. No national median or percentile context is available for SNFs in the current release.

Download CSV

Show 99 rows
Source Metric Value Raw key
Provider Information Abuse Icon N Abuse Icon
Provider Information Adjusted LPN Staffing Hours per Resident per Day 0.80176 Adjusted LPN Staffing Hours per Resident per Day
Provider Information Adjusted Nurse Aide Staffing Hours per Resident per Day 1.51682 Adjusted Nurse Aide Staffing Hours per Resident per Day
Provider Information Adjusted RN Staffing Hours per Resident per Day 1.22118 Adjusted RN Staffing Hours per Resident per Day
Provider Information Adjusted Total Nurse Staffing Hours per Resident per Day 3.53975 Adjusted Total Nurse Staffing Hours per Resident per Day
Provider Information Adjusted Weekend Total Nurse Staffing Hours per Resident per Day 3.33336 Adjusted Weekend Total Nurse Staffing Hours per Resident per Day
Provider Information Administrator turnover footnote — Administrator turnover footnote
Provider Information Automatic Sprinkler Systems in All Required Areas Yes Automatic Sprinkler Systems in All Required Areas
Provider Information Average Number of Residents per Day 36.0 Average Number of Residents per Day
Provider Information Average Number of Residents per Day Footnote — Average Number of Residents per Day Footnote
Provider Information Case-Mix LPN Staffing Hours per Resident per Day 1.71688 Case-Mix LPN Staffing Hours per Resident per Day
Provider Information Case-Mix Nurse Aide Staffing Hours per Resident per Day 4.66610 Case-Mix Nurse Aide Staffing Hours per Resident per Day
Provider Information Case-Mix RN Staffing Hours per Resident per Day 1.35328 Case-Mix RN Staffing Hours per Resident per Day
Provider Information Case-Mix Total Nurse Staffing Hours per Resident per Day 7.73626 Case-Mix Total Nurse Staffing Hours per Resident per Day
Provider Information Case-Mix Weekend Total Nurse Staffing Hours per Resident per Day 6.81870 Case-Mix Weekend Total Nurse Staffing Hours per Resident per Day
Provider Information Chain Average Health Inspection Rating 3.0 Chain Average Health Inspection Rating
Provider Information Chain Average Overall 5-star Rating 3.5 Chain Average Overall 5-star Rating
Provider Information Chain Average QM Rating 4.3 Chain Average QM Rating
Provider Information Chain Average Staffing Rating 3.3 Chain Average Staffing Rating
Provider Information Chain ID 300 Chain ID
Provider Information Chain Name KINDRED HEALTHCARE Chain Name
Provider Information City/Town BREA City/Town
Provider Information CMS Certification Number (CCN) 555859 CMS Certification Number (CCN)
Provider Information Continuing Care Retirement Community N Continuing Care Retirement Community
Provider Information County/Parish Orange County/Parish
Provider Information Date First Approved to Provide Medicare and Medicaid Services 2009-07-14 Date First Approved to Provide Medicare and Medicaid Services
Provider Information Geocoding Footnote — Geocoding Footnote
Provider Information Health Inspection Rating 4 Health Inspection Rating
Provider Information Health Inspection Rating Footnote — Health Inspection Rating Footnote
Provider Information Latitude 33.9337 Latitude
Provider Information Legal Business Name THC - ORANGE COUNTY LLC Legal Business Name
Provider Information Location 875 N BREA BLVD,BREA,CA,92821 Location
Provider Information Long-Stay QM Rating 5 Long-Stay QM Rating
Provider Information Long-Stay QM Rating Footnote — Long-Stay QM Rating Footnote
Provider Information Longitude -117.89 Longitude
Provider Information Most Recent Health Inspection More Than 2 Years Ago N Most Recent Health Inspection More Than 2 Years Ago
Provider Information Number of administrators who have left the nursing home 0 Number of administrators who have left the nursing home
Provider Information Number of Certified Beds 38 Number of Certified Beds
Provider Information Number of Citations from Infection Control Inspections — Number of Citations from Infection Control Inspections
Provider Information Number of Facilities in Chain 4 Number of Facilities in Chain
Provider Information Number of Fines 0 Number of Fines
Provider Information Number of Payment Denials 0 Number of Payment Denials
Provider Information Nursing Case-Mix Index 2.74061 Nursing Case-Mix Index
Provider Information Nursing Case-Mix Index Ratio 1.98934 Nursing Case-Mix Index Ratio
Provider Information Overall Rating 5 Overall Rating
Provider Information Overall Rating Footnote — Overall Rating Footnote
Provider Information Ownership Type For profit - Corporation Ownership Type
Provider Information Physical Therapist Staffing Footnote — Physical Therapist Staffing Footnote
Provider Information Processing Date 2026-03-01 Processing Date
Provider Information Provider Address 875 N BREA BLVD Provider Address
Provider Information Provider Changed Ownership in Last 12 Months N Provider Changed Ownership in Last 12 Months
Provider Information Provider Name KINDRED HOSPITAL BREA D/P SNF Provider Name
Provider Information Provider Resides in Hospital Y Provider Resides in Hospital
Provider Information Provider SSA County Code 400 Provider SSA County Code
Provider Information Provider Type Medicare and Medicaid Provider Type
Provider Information QM Rating 5 QM Rating
Provider Information QM Rating Footnote — QM Rating Footnote
Provider Information Rating Cycle 1 Health Deficiency Score 56 Rating Cycle 1 Health Deficiency Score
Provider Information Rating Cycle 1 Health Revisit Score 0 Rating Cycle 1 Health Revisit Score
Provider Information Rating Cycle 1 Number of Complaint Health Deficiencies 4 Rating Cycle 1 Number of Complaint Health Deficiencies
Provider Information Rating Cycle 1 Number of Health Revisits 1 Rating Cycle 1 Number of Health Revisits
Provider Information Rating Cycle 1 Number of Standard Health Deficiencies 10 Rating Cycle 1 Number of Standard Health Deficiencies
Provider Information Rating Cycle 1 Standard Survey Health Date 2024-11-22 Rating Cycle 1 Standard Survey Health Date
Provider Information Rating Cycle 1 Total Health Score 56 Rating Cycle 1 Total Health Score
Provider Information Rating Cycle 1 Total Number of Health Deficiencies 13 Rating Cycle 1 Total Number of Health Deficiencies
Provider Information Rating Cycle 2 Number of Standard Health Deficiencies 8 Rating Cycle 2 Number of Standard Health Deficiencies
Provider Information Rating Cycle 2 Standard Health Survey Date 2023-12-01 Rating Cycle 2 Standard Health Survey Date
Provider Information Rating Cycle 2/3 Health Deficiency Score 52 Rating Cycle 2/3 Health Deficiency Score
Provider Information Rating Cycle 2/3 Health Revisit Score 0 Rating Cycle 2/3 Health Revisit Score
Provider Information Rating Cycle 2/3 Number of Complaint Health Deficiencies 7 Rating Cycle 2/3 Number of Complaint Health Deficiencies
Provider Information Rating Cycle 2/3 Number of Health Revisits 1 Rating Cycle 2/3 Number of Health Revisits
Provider Information Rating Cycle 2/3 Total Health Score 52 Rating Cycle 2/3 Total Health Score
Provider Information Rating Cycle 2/3 Total Number of Health Deficiencies 15 Rating Cycle 2/3 Total Number of Health Deficiencies
Provider Information Registered Nurse hours per resident per day on the weekend 1.82803 Registered Nurse hours per resident per day on the weekend
Provider Information Registered Nurse turnover 11.8 Registered Nurse turnover
Provider Information Registered Nurse turnover footnote — Registered Nurse turnover footnote
Provider Information Reported Licensed Staffing Hours per Resident per Day 4.05341 Reported Licensed Staffing Hours per Resident per Day
Provider Information Reported LPN Staffing Hours per Resident per Day 1.60650 Reported LPN Staffing Hours per Resident per Day
Provider Information Reported Nurse Aide Staffing Hours per Resident per Day 3.03930 Reported Nurse Aide Staffing Hours per Resident per Day
Provider Information Reported Physical Therapist Staffing Hours per Resident Per Day 0.14912 Reported Physical Therapist Staffing Hours per Resident Per Day
Provider Information Reported RN Staffing Hours per Resident per Day 2.44691 Reported RN Staffing Hours per Resident per Day
Provider Information Reported Staffing Footnote — Reported Staffing Footnote
Provider Information Reported Total Nurse Staffing Hours per Resident per Day 7.09271 Reported Total Nurse Staffing Hours per Resident per Day
Provider Information Short-Stay QM Rating 5 Short-Stay QM Rating
Provider Information Short-Stay QM Rating Footnote — Short-Stay QM Rating Footnote
Provider Information Special Focus Status — Special Focus Status
Provider Information Staffing Rating 4 Staffing Rating
Provider Information Staffing Rating Footnote — Staffing Rating Footnote
Provider Information State CA State
Provider Information Telephone Number 7145296842 Telephone Number
Provider Information Total Amount of Fines in Dollars 0.00 Total Amount of Fines in Dollars
Provider Information Total number of nurse staff hours per resident per day on the weekend 6.67915 Total number of nurse staff hours per resident per day on the weekend
Provider Information Total Number of Penalties 0 Total Number of Penalties
Provider Information Total nursing staff turnover 15.5 Total nursing staff turnover
Provider Information Total nursing staff turnover footnote — Total nursing staff turnover footnote
Provider Information Total Weighted Health Survey Score 55.000 Total Weighted Health Survey Score
Provider Information Urban Y Urban
Provider Information With a Resident and Family Council None With a Resident and Family Council
Provider Information ZIP Code 92821 ZIP Code