13 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
3 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Pomona, CA
4-star overall rating with 3-star inspections with 13 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
219 E. Foothill Blvd, Pomona, CA
(909) 593-1391
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Beds
99
Certified beds
Average residents
89
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
1980-11-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
329 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
RN hours / resident day
0.36
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.18
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
2.54
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
4.08
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
1.54
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
3.68
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.19
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.12
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.35
CMS adjusted RN staffing hours
Adjusted total hours
3.94
CMS adjusted total nurse staffing hours
Case-mix index
1.42
Higher values indicate more complex resident acuity
RN turnover
25%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
37%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Program rank
6,331
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
33.27
Composite VBP score used to determine payment impact.
Payment multiplier
0.9876
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
3.40
Baseline 17.98% · Performance 19.85% · Measure score 3.40 · Achievement 3.40 · Improvement 0
Healthcare-associated infections
0
Baseline 6.37% · Performance 8.50% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
7.34
Baseline 48.25% · Performance 33.68% · Measure score 7.34 · Achievement 7.34 · Improvement 5.72
Adjusted total nurse staffing
2.56
Baseline 4.06 hours · Performance 3.81 hours · Measure score 2.56 · Achievement 2.56 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.52% |
10.72%
0.2 pts better
|
No Different than the National Rate · Eligible stays 180 · Observed rate 11.11% · Lower 95% interval 8.23% |
| Discharge to community | 51.53% |
50.57%
1 pts better
|
No Different than the National Rate · Eligible stays 180 · Observed rate 42.78% · Lower 95% interval 43.21% |
| Medicare spending per beneficiary | 1.13 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 173 · Denominator 173 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 173 |
| Discharge self-care score | 61.18% |
53.69%
7.5 pts better
|
Numerator 52 · Denominator 85 |
| Discharge mobility score | 56.47% |
50.94%
5.5 pts better
|
Numerator 48 · Denominator 85 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 173 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 8.5% |
7.12%
1.4 pts worse
|
No Different than the National Rate · Eligible stays 116 · Observed rate 11.21% · Lower 95% interval 5.13% |
| Staff COVID-19 vaccination coverage | 10.14% |
8.2%
1.9 pts better
|
Numerator 15 · Denominator 148 |
| Staff flu vaccination coverage | 23.9% |
42%
18.1 pts worse
|
Numerator 38 · Denominator 159 |
| Discharge function score | 56.47% |
56.45%
About the same
|
Numerator 48 · Denominator 85 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 49 · Denominator 49 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 81 · Denominator 81 |
| Resident COVID-19 vaccinations up to date | 12.24% |
25.2%
13 pts worse
|
Numerator 12 · Denominator 98 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 5.2 |
2.3
2.9 pts worse
|
1.9
3.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 5.2 · Observed 5.2 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.5 |
1.6
0.1 pts better
|
1.8
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.4 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
98.5%
1.5 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
98.2%
1.8 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
1.6%
1.6 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 7.3% |
6.8%
0.5 pts worse
|
11.4%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 10.6% · Q3 7.0% · Q4 7.0% · 4Q avg 7.3% |
| Percentage of long-stay residents who lose too much weight | 3.1% |
4.1%
1 pts better
|
5.4%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 2.6% · Q3 2.7% · Q4 2.6% · 4Q avg 3.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.3% |
13.7%
4.4 pts better
|
19.6%
10.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.6% · Q2 10.9% · Q3 9.5% · Q4 7.0% · 4Q avg 9.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 8.0% |
14.2%
6.2 pts better
|
16.7%
8.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.5% · Q2 8.8% · Q3 5.9% · Q4 6.2% · 4Q avg 8.0% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.4%
0.4 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 4.0% |
11.0%
7 pts better
|
16.3%
12.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · 4Q avg 4.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.5% |
10.7%
1.8 pts worse
|
14.9%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.8% · Q2 9.5% · Q3 12.5% · Q4 15.4% · 4Q avg 12.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.4% |
1.0%
0.6 pts better
|
1.0%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.7% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.1% |
1.2%
0.1 pts better
|
1.7%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 0.0% · Q3 0.0% · Q4 2.1% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 13.1% |
10.9%
2.2 pts worse
|
19.8%
6.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.3% · Q2 16.1% · Q3 7.4% · Q4 19.0% · 4Q avg 13.1% |
| Percentage of long-stay residents with pressure ulcers | 5.4% |
4.7%
0.7 pts worse
|
5.1%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.5% · Q2 3.5% · Q3 7.0% · Q4 1.4% · 4Q avg 5.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
94.0%
6 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.6% |
11.2%
5.6 pts better
|
12.0%
6.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.6% · Observed 6.0% · Expected 12.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.3% |
1.5%
0.2 pts better
|
1.6%
0.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.5% · Q2 1.6% · Q3 1.7% · Q4 1.2% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
93.2%
6.8 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.5% |
23.2%
2.3 pts worse
|
23.9%
1.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.5% · Observed 27.6% · Expected 25.8% · Used in QM five-star |
Survey summary
Top issue: Quality of Life and Care (4 deficiencies)
3 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Top issue: Quality of Life and Care (5 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Top issue: Quality of Life and Care (10 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-12-23
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-12-21
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-12-20
Fire Safety
Meet other general requirements that are deficient.
Corrected 2023-12-26
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-12-26
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2021-08-16
Fire Safety
Ensure that sources of ignition are removed from patients receiving respiratory therapy.
Corrected 2021-08-16
Inspection history
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-11-25
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-09-15
Health
Help the resident with transportation to and from laboratory services outside of the facility.
Corrected 2025-07-24
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-05-20
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-05-20
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-05-20
Health
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.
Corrected 2024-12-20
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-12-13
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-12-17
Health
Provide and implement an infection prevention and control program.
Corrected 2024-12-12
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-12-16
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2024-12-13
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-12-13
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-11-15
Health
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.
Corrected 2024-01-05
Health
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.
Corrected 2024-01-05
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-01-05
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-01-05
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-01-05
Health
Provide and implement an infection prevention and control program.
Corrected 2024-01-05
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-01-05
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-01-05
Health
Provide activities to meet all resident's needs.
Corrected 2024-01-05
Health
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.
Corrected 2024-01-05
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2024-01-05
Health
Provide a neutral and fair arbitration process and agree to arbitrator and venue.
Corrected 2024-01-05
Health
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.
Corrected 2024-01-05
Health
Implement a program that monitors antibiotic use.
Corrected 2024-01-05
Health
Provide and implement an infection prevention and control program.
Corrected 2023-10-13
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-07-10
Health
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.
Corrected 2021-08-28
Health
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.
Corrected 2021-08-28
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2021-08-28
Health
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.
Corrected 2021-08-28
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2021-08-28
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2021-08-28
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2021-08-28
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2021-08-28
Health
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.
Corrected 2021-08-28
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2021-08-28
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2021-08-28
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2021-08-28
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2021-08-28
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2021-08-28
Health
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.
Corrected 2021-08-28
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2021-08-28
Health
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Corrected 2021-08-28
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2021-08-28
Health
Provide and implement an infection prevention and control program.
Corrected 2021-08-28
Penalties and ownership
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
Operational/Managerial Control · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
Operational/Managerial Control · Organization
Corporate Director · Individual
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