Cycle 1
Health 2026-02-12 · Fire 2026-02-12
11 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
San Bernardino, CA
Del Rosa Villa
2-star overall rating with 2-star inspections with abuse icon flag with $43,930 in total fines with 11 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
2018 N Del Rosa Ave, San Bernardino, CA
(909) 885-3261
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
104
Certified beds
Average residents
94
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Pacs Group
Operator or chain grouping
Approved since
1984-09-10
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
264 facilities
Chain averages 3 overall / 3 health / 2 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
Hours and turnover
RN hours / resident day
0.19
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.21
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
2.51
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
3.91
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
1.40
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
3.58
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.13
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.16
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.16
CMS adjusted RN staffing hours
Adjusted total hours
3.30
CMS adjusted total nurse staffing hours
Case-mix index
1.62
Higher values indicate more complex resident acuity
RN turnover
40%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
52%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,050
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
30.92
Composite VBP score used to determine payment impact.
Payment multiplier
0.9862
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
8.34
Baseline 23.00% · Performance 17.72% · Measure score 8.34 · Achievement 8 · Improvement 8.34
Healthcare-associated infections
1.86
Baseline 7.21% · Performance 7.28% · Measure score 1.86 · Achievement 1.86 · Improvement 0
Total nurse turnover
1.51
Baseline 51.26% · Performance 57.50% · Measure score 1.51 · Achievement 1.51 · Improvement 0
Adjusted total nurse staffing
0.66
Baseline 3.42 hours · Performance 3.27 hours · Measure score 0.66 · Achievement 0.66 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.99% |
10.72%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 163 · Observed rate 11.66% · Lower 95% interval 8.19% |
| Discharge to community | 36.47% |
50.57%
14.1 pts worse
|
Worse than the National Rate · Eligible stays 116 · Observed rate 27.59% · Lower 95% interval 27.48% |
| Medicare spending per beneficiary | 1.56 |
1.02
0.5 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 149 · Denominator 149 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 149 |
| Discharge self-care score | 54% |
53.69%
0.3 pts better
|
Numerator 54 · Denominator 100 |
| Discharge mobility score | 34% |
50.94%
16.9 pts worse
|
Numerator 34 · Denominator 100 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 149 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.28% |
7.12%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 98 · Observed rate 8.16% · Lower 95% interval 5.01% |
| Staff COVID-19 vaccination coverage | 4.2% |
8.2%
4 pts worse
|
Numerator 6 · Denominator 143 |
| Staff flu vaccination coverage | 43.75% |
42%
1.8 pts better
|
Numerator 70 · Denominator 160 |
| Discharge function score | 44% |
56.45%
12.5 pts worse
|
Numerator 44 · Denominator 100 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 40 · Denominator 40 |
| Transfer of health information to patient | 61.29% |
96.28%
35 pts worse
|
Numerator 19 · Denominator 31 |
| Resident COVID-19 vaccinations up to date | 1.28% |
25.2%
23.9 pts worse
|
Numerator 1 · Denominator 78 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.2 |
2.3
0.1 pts better
|
1.9
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 4.8 · Expected 4.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.3 |
1.6
0.3 pts better
|
1.8
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 2.2 · Expected 2.9 · 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 | 28.3% |
6.8%
21.5 pts worse
|
11.4%
16.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 41.9% · Q2 31.7% · Q3 19.0% · Q4 20.6% · 4Q avg 28.3% |
| Percentage of long-stay residents who lose too much weight | 5.4% |
4.1%
1.3 pts worse
|
5.4%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 6.3% · Q3 0.0% · Q4 6.5% · 4Q avg 5.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 20.1% |
13.7%
6.4 pts worse
|
19.6%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.2% · Q2 21.6% · Q3 21.1% · Q4 19.4% · 4Q avg 20.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 8.5% |
14.2%
5.7 pts better
|
16.7%
8.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.1% · Q2 13.9% · Q3 10.8% · Q4 2.3% · 4Q avg 8.5% · 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 | 7.3% |
11.0%
3.7 pts better
|
16.3%
9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.4% · Q2 0.0% · Q4 8.8% · 4Q avg 7.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.0% |
10.7%
4.3 pts worse
|
14.9%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.8% · Q2 16.4% · Q3 12.1% · Q4 20.0% · 4Q avg 15.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.0%
1 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.2%
1.2 pts better
|
1.7%
1.7 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 with new or worsened bowel or bladder incontinence | 2.6% |
10.9%
8.3 pts better
|
19.8%
17.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.5% · Q2 5.3% · Q3 1.7% · Q4 0.0% · 4Q avg 2.6% |
| Percentage of long-stay residents with pressure ulcers | 4.5% |
4.7%
0.2 pts better
|
5.1%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 2.1% · Q3 7.0% · Q4 3.9% · 4Q avg 4.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.5% |
94.0%
5.5 pts better
|
81.7%
17.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.3% · Q2 99.3% · Q3 100.0% · Q4 99.3% · 4Q avg 99.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.8% |
11.2%
0.6 pts worse
|
12.0%
0.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.8% · Observed 12.4% · Expected 11.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short 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 short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 99.4% |
93.2%
6.2 pts better
|
79.7%
19.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 99.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.7% |
23.2%
3.5 pts better
|
23.9%
4.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 19.7% · Observed 19.0% · Expected 23.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2025-01-24 · Fire 2025-01-24
9 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-12-13 · Fire 2023-12-13
14 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2026-02-12
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Not marked corrected
D · Potential for more than minimal harm
2026-02-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Not marked corrected
D · Potential for more than minimal harm
2026-02-12
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Not marked corrected
D · Potential for more than minimal harm
2026-02-12
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Not marked corrected
D · Potential for more than minimal harm
2025-01-24
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2025-02-19
D · Potential for more than minimal harm
2025-01-24
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2025-02-19
D · Potential for more than minimal harm
2025-01-24
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-02-17
C · Minimal harm
2025-01-24
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-02-19
E · Potential for more than minimal harm
2023-12-13
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-02-05
E · Potential for more than minimal harm
2023-12-13
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-02-05
D · Potential for more than minimal harm
2023-12-13
E34 · Emergency Preparedness Deficiencies
Fire Safety
Provide a means of sharing information on occupancy/needs.
Corrected 2024-02-05
D · Potential for more than minimal harm
2023-12-13
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-02-05
D · Potential for more than minimal harm
2023-12-13
K352 · Smoke Deficiencies
Fire Safety
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Corrected 2024-02-05
D · Potential for more than minimal harm
2023-12-13
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-02-05
D · Potential for more than minimal harm
2023-12-13
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2024-02-05
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-02-12
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Not marked corrected
D · Potential for more than minimal harm
2026-02-12
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Not marked corrected
D · Potential for more than minimal harm
2026-02-12
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Not marked corrected
D · Potential for more than minimal harm
2026-02-12
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Not marked corrected
D · Potential for more than minimal harm
2026-02-12
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Not marked corrected
D · Potential for more than minimal harm
2026-02-12
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Not marked corrected
D · Potential for more than minimal harm
2026-02-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Not marked corrected
D · Potential for more than minimal harm
2026-02-12
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Not marked corrected
D · Potential for more than minimal harm
2025-09-10
F627 · Resident Rights Deficiencies
Health
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
Corrected 2025-09-22
D · Potential for more than minimal harm
2025-08-13
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-08-27
D · Potential for more than minimal harm
2025-03-20
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-03-27
D · Potential for more than minimal harm
2025-02-27
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-03-20
E · Potential for more than minimal harm
2025-01-24
F803 · Nutrition and Dietary Deficiencies
Health
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.
Corrected 2025-02-14
D · Potential for more than minimal harm
2025-01-24
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2025-02-13
D · Potential for more than minimal harm
2025-01-24
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-02-12
D · Potential for more than minimal harm
2025-01-24
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-02-14
D · Potential for more than minimal harm
2025-01-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-12
J · Immediate jeopardy
2024-11-13
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-11-29
D · Potential for more than minimal harm
2024-09-26
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-10-21
D · Potential for more than minimal harm
2024-09-17
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-09-30
E · Potential for more than minimal harm
2023-12-13
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-01-08
D · Potential for more than minimal harm
2023-12-13
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2024-01-08
D · Potential for more than minimal harm
2023-12-13
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-01-08
D · Potential for more than minimal harm
2023-12-13
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-01-08
D · Potential for more than minimal harm
2023-12-13
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-01-08
D · Potential for more than minimal harm
2023-12-13
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2024-01-08
D · Potential for more than minimal harm
2023-12-13
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2024-01-08
D · Potential for more than minimal harm
2023-12-13
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-01-08
D · Potential for more than minimal harm
2023-12-13
F646 · Resident Assessment and Care Planning Deficiencies
Health
Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.
Corrected 2024-01-08
D · Potential for more than minimal harm
2023-12-13
F700 · Quality of Life and Care Deficiencies
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 2024-01-08
D · Potential for more than minimal harm
2023-12-13
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-01-08
D · Potential for more than minimal harm
2023-12-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-01-08
D · Potential for more than minimal harm
2023-12-13
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-01-08
E · Potential for more than minimal harm
2023-06-20
F622 · Resident Rights Deficiencies
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2023-07-03
Penalties and ownership
What sits behind the stars
$43,930
2024-11-13
Fine
Fine · fine $43,930
Fine
Ownership
Providence Group Of Southern California LLC
5% Or Greater Direct Ownership Interest · Organization
Apt, Frederick
Corporate Officer · Individual
Eskander, Ashraf
Contracted Managing Employee · Individual
Hancock, Mark
5% Or Greater Indirect Ownership Interest · Individual
Hancock, Mark
Corporate Officer · Individual
Jenkins, Nicoletta
Operational/Managerial Control · Individual
Jenkins, Nicoletta
W-2 Managing Employee · Individual
Jergensen, Joshua
Corporate Officer · Individual
Mitchell, John
Corporate Officer · Individual
Murray, Jason
5% Or Greater Indirect Ownership Interest · Individual
Pacs Group, Inc.
5% Or Greater Indirect Ownership Interest · Organization
Pacs Holdings, LLC
5% Or Greater Indirect Ownership Interest · Organization
Providence Group Inc
5% Or Greater Indirect Ownership Interest · Organization
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#3
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