Cycle 1
Health 2025-05-15 · Fire 2025-05-15
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Covina, CA
Emanate Health Inter-Community Hospital- D/P SNF
5-star overall rating with 5-star inspections with 5 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
210 W. San Bernardino Rd., Covina, CA
(626) 915-6215
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
25
Certified beds
Average residents
18
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1994-10-20
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
3.78
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
0.27
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
1.94
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
5.99
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
4.04
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
5.28
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
3.43
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
3.25
CMS adjusted RN staffing hours
Adjusted total hours
5.16
CMS adjusted total nurse staffing hours
Case-mix index
1.59
Higher values indicate more complex resident acuity
RN turnover
25%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
19%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,606
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
55.32
Composite VBP score used to determine payment impact.
Payment multiplier
1.0103
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.57
Baseline 23.56% · Performance 21.55% · Measure score 2.57 · Achievement 0 · Improvement 2.57
Healthcare-associated infections
4.02
Baseline 7.83% · Performance 6.63% · Measure score 4.02 · Achievement 4.02 · Improvement 3.73
Total nurse turnover
10
Baseline 20.83% · Performance 17.86% · Measure score 10 · Achievement 10 · Improvement 9
Adjusted total nurse staffing
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 13.13% |
10.72%
2.4 pts worse
|
No Different than the National Rate · Eligible stays 373 · Observed rate 15.28% · Lower 95% interval 10.7% |
| Discharge to community | 62.04% |
50.57%
11.5 pts better
|
Better than the National Rate · Eligible stays 376 · Observed rate 56.38% · Lower 95% interval 58.25% |
| Medicare spending per beneficiary | 1.06 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 222 · Denominator 222 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 222 |
| Discharge self-care score | 28.39% |
53.69%
25.3 pts worse
|
Numerator 44 · Denominator 155 |
| Discharge mobility score | 14.84% |
50.94%
36.1 pts worse
|
Numerator 23 · Denominator 155 |
| Pressure ulcers or injuries, new or worsened | 1.35% |
2.29%
0.9 pts better
|
Numerator 3 · Denominator 222 · Adjusted rate 1.43% |
| Healthcare-associated infections requiring hospitalization | 6.63% |
7.12%
0.5 pts better
|
No Different than the National Rate · Eligible stays 218 · Observed rate 5.96% · Lower 95% interval 4.43% |
| Staff COVID-19 vaccination coverage | 3.9% |
8.2%
4.3 pts worse
|
Numerator 3 · Denominator 77 |
| Staff flu vaccination coverage | 54.29% |
42%
12.3 pts better
|
Numerator 19 · Denominator 35 |
| Discharge function score | 22.58% |
56.45%
33.9 pts worse
|
Numerator 35 · Denominator 155 |
| Transfer of health information to provider | 88.07% |
95.95%
7.9 pts worse
|
Numerator 155 · Denominator 176 |
| Transfer of health information to patient | 86.67% |
96.28%
9.6 pts worse
|
Numerator 39 · Denominator 45 |
| Resident COVID-19 vaccinations up to date | 15% |
25.2%
10.2 pts worse
|
Numerator 15 · Denominator 100 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.1% |
94.0%
4.1 pts better
|
81.7%
16.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.3% · Q2 98.6% · Q3 97.9% · Q4 96.7% · 4Q avg 98.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 2.9% |
11.2%
8.3 pts better
|
12.0%
9.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 2.9% · Observed 3.4% · Expected 13.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.1% |
1.5%
0.4 pts better
|
1.6%
0.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 0.0% · Q3 0.0% · Q4 2.8% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 93.3% |
93.2%
0.1 pts better
|
79.7%
13.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 93.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.0% |
23.2%
4.2 pts better
|
23.9%
4.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 19.0% · Observed 22.7% · Expected 28.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-15 · Fire 2024-05-15
8 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2023-05-19 · Fire 2023-05-19
6 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-05-15
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-05-21
D · Potential for more than minimal harm
2025-05-15
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-05-19
F · Potential for more than minimal harm
2024-05-15
K342 · Smoke Deficiencies
Fire Safety
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
Corrected 2024-06-05
F · Potential for more than minimal harm
2024-05-15
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-05-17
E · Potential for more than minimal harm
2024-05-15
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-06-05
D · Potential for more than minimal harm
2024-05-15
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.
Corrected 2024-05-17
D · Potential for more than minimal harm
2024-05-15
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-05-16
D · Potential for more than minimal harm
2024-05-15
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-05-16
D · Potential for more than minimal harm
2023-05-19
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2023-06-20
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-05-15
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 2025-06-05
D · Potential for more than minimal harm
2025-05-15
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2025-06-05
D · Potential for more than minimal harm
2025-05-15
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-06-05
D · Potential for more than minimal harm
2025-05-15
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-06-05
D · Potential for more than minimal harm
2025-05-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-05
E · Potential for more than minimal harm
2024-05-15
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.
Corrected 2024-05-22
E · Potential for more than minimal harm
2024-05-15
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-06-03
E · Potential for more than minimal harm
2024-05-15
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-05-21
E · Potential for more than minimal harm
2024-05-15
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-06-05
E · Potential for more than minimal harm
2024-05-15
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2024-06-05
E · Potential for more than minimal harm
2024-05-15
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 2024-05-20
E · Potential for more than minimal harm
2024-05-15
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2024-06-05
E · Potential for more than minimal harm
2024-05-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-05-18
D · Potential for more than minimal harm
2023-09-18
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-10-13
E · Potential for more than minimal harm
2023-05-19
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.
Corrected 2023-06-02
E · Potential for more than minimal harm
2023-05-19
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-06-02
E · Potential for more than minimal harm
2023-05-19
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 2023-06-09
E · Potential for more than minimal harm
2023-05-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-06-20
D · Potential for more than minimal harm
2023-05-19
F578 · Resident Rights Deficiencies
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 2023-06-07
Penalties and ownership
What sits behind the stars
Ownership
Emanate Health
5% Or Greater Direct Ownership Interest · Organization
Bollinger, Bernard
Corporate Director · Individual
Bracy, Jacqueline
Corporate Director · Individual
Bryan, Thomas
Corporate Director · Individual
Casso, James
Corporate Director · Individual
Christ, Clifford
Corporate Director · Individual
Conyers, Lois
Corporate Director · Individual
Conyers, Lois
W-2 Managing Employee · Individual
Curry, Robert
Corporate Director · Individual
Curry, Robert
Corporate Officer · Individual
Curry, Robert
W-2 Managing Employee · Individual
Dimare, John
Corporate Director · Individual
Emanate Health
Operational/Managerial Control · Organization
Gorrell, Patsy
Corporate Director · Individual
Johnson, Richard
Corporate Director · Individual
Kirchen, Mary
Corporate Director · Individual
Ludwick, Arthur
Corporate Director · Individual
Mathewson, Gary
Corporate Director · Individual
Tang, Bill
Corporate Director · Individual
Tye, Kenneth
Corporate Director · Individual
Williams, Carl
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Covina Rehabilitation Center
Covina, CA
2-star overall rating with 2-star inspections with $29,228 in total fines with 18 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Harvard Creek Post Acute
Covina, CA
5-star overall rating with 4-star inspections with 12 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
The Rowland
Covina, CA
3-star overall rating with 2-star inspections with $30,421 in total fines with 16 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
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