Baldwin Park, CA

Garden View Post Acute Rehabilitation

4-star overall rating with 3-star inspections with 12 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle

14475 Garden View Lane, Baldwin Park, CA

(626) 962-7095

Compare this facility

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

Facility snapshot

Beds

97

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

1972-06-01

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

Hours and turnover

RN hours / resident day

0.44

Registered nurse staffing · state 0.65 · national 0.68

LPN hours / resident day

1.15

Licensed practical nurse staffing · state 1.22 · national 0.87

Aide hours / resident day

2.56

Nurse aide staffing · state 2.64 · national 2.35

Total nurse hours

4.14

All reported nurse hours · state 4.51 · national 3.89

Licensed hours

1.58

RN + LPN hours · state 1.87 · national 1.54

Weekend hours

3.73

Weekend nurse staffing · state 4.08 · national 3.43

Weekend RN hours

0.39

Weekend registered nurse coverage · state 0.50 · national 0.47

Physical therapist

0.17

Reported PT staffing · state 0.10 · national 0.07

Adjusted RN hours

0.39

CMS adjusted RN staffing hours

Adjusted total hours

3.65

CMS adjusted total nurse staffing hours

Case-mix index

1.55

Higher values indicate more complex resident acuity

RN turnover

14%

Annual RN turnover · state 42% · national 45%

Total nurse turnover

39%

Annual nurse turnover · state 38% · national 46%

SNF VBP

Value-based purchasing

Program rank

9,697

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

22.81

Composite VBP score used to determine payment impact.

Payment multiplier

0.9830

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

0

Baseline 21.88% · Performance 22.19% · Measure score 0 · Achievement 0 · Improvement 0

Healthcare-associated infections

0.18

Baseline 10.98% · Performance 10.58% · Measure score 0.18 · Achievement 0 · Improvement 0.18

Total nurse turnover

6.23

Baseline 27.54% · Performance 38.20% · Measure score 6.23 · Achievement 6.23 · Improvement 0

Adjusted total nurse staffing

2.72

Baseline 3.48 hours · Performance 3.85 hours · Measure score 2.72 · Achievement 2.72 · Improvement 1.12

SNF QRP

Medicare quality reporting measures

Measure Facility National Note
Potentially preventable 30-day readmission 11.12%
10.72%
0.4 pts worse
No Different than the National Rate · Eligible stays 237 · Observed rate 11.39% · Lower 95% interval 7.97%
Discharge to community 56.93%
50.57%
6.4 pts better
No Different than the National Rate · Eligible stays 261 · Observed rate 47.89% · Lower 95% interval 49.87%
Medicare spending per beneficiary 1.45
1.02
0.4 pts worse
Drug regimen review with follow-up 100%
95.27%
4.7 pts better
Numerator 197 · Denominator 197
Falls with major injury 0%
0.77%
0.8 pts better
Numerator 0 · Denominator 197
Discharge self-care score 64.86%
53.69%
11.2 pts better
Numerator 48 · Denominator 74
Discharge mobility score 58.11%
50.94%
7.2 pts better
Numerator 43 · Denominator 74
Pressure ulcers or injuries, new or worsened 3.05%
2.29%
0.8 pts worse
Numerator 6 · Denominator 197 · Adjusted rate 1.91%
Healthcare-associated infections requiring hospitalization 10.58%
7.12%
3.5 pts worse
Worse than the National Rate · Eligible stays 210 · Observed rate 14.29% · Lower 95% interval 7.37%
Staff COVID-19 vaccination coverage 0%
8.2%
8.2 pts worse
Numerator 0 · Denominator 148
Staff flu vaccination coverage 41.62%
42%
0.4 pts worse
Numerator 72 · Denominator 173
Discharge function score 68.92%
56.45%
12.5 pts better
Numerator 51 · Denominator 74
Transfer of health information to provider 98.92%
95.95%
3 pts better
Numerator 92 · Denominator 93
Transfer of health information to patient 98.33%
96.28%
2 pts better
Numerator 59 · Denominator 60
Resident COVID-19 vaccinations up to date 23.86%
25.2%
1.3 pts worse
Numerator 21 · Denominator 88

Quality measures

Resident outcomes and process scores

Measure Facility State National Note
Number of hospitalizations per 1000 long-stay resident days 2.8
2.3
0.5 pts worse
1.9
0.9 pts worse
Long Stay · 20240701-20250630 · Adjusted 2.8 · Observed 3.8 · Expected 2.6 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days 1.2
1.6
0.4 pts better
1.8
0.6 pts better
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.2 · Expected 1.8 · 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 3.5%
6.8%
3.3 pts better
11.4%
7.9 pts better
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 3.8% · Q3 5.1% · Q4 1.6% · 4Q avg 3.5%
Percentage of long-stay residents who lose too much weight 6.6%
4.1%
2.5 pts worse
5.4%
1.2 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 7.0% · Q3 4.8% · Q4 9.5% · 4Q avg 6.6%
Percentage of long-stay residents who received an antianxiety or hypnotic medication 13.2%
13.7%
0.5 pts better
19.6%
6.4 pts better
Long Stay · 2024Q4-2025Q3 · Q1 14.5% · Q2 11.3% · Q3 13.6% · Q4 13.2% · 4Q avg 13.2%
Percentage of long-stay residents who received an antipsychotic medication 4.8%
14.2%
9.4 pts better
16.7%
11.9 pts better
Long Stay · 2024Q4-2025Q3 · Q1 7.3% · Q2 5.6% · Q3 2.3% · Q4 4.4% · 4Q avg 4.8% · 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 7.7%
11.0%
3.3 pts better
16.3%
8.6 pts better
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · 4Q avg 7.7% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased 12.3%
10.7%
1.6 pts worse
14.9%
2.6 pts better
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 14.9% · Q3 15.1% · Q4 15.8% · 4Q avg 12.3% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder 3.4%
1.0%
2.4 pts worse
1.0%
2.4 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 2.6% · Q3 5.1% · Q4 4.9% · 4Q avg 3.4% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection 0.8%
1.2%
0.4 pts better
1.7%
0.9 pts better
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.5% · Q3 0.0% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence 18.2%
10.9%
7.3 pts worse
19.8%
1.6 pts better
Long Stay · 2024Q4-2025Q3 · Q1 17.3% · Q2 27.2% · Q3 15.4% · Q4 14.1% · 4Q avg 18.2%
Percentage of long-stay residents with pressure ulcers 4.9%
4.7%
0.2 pts worse
5.1%
0.2 pts better
Long Stay · 2024Q4-2025Q3 · Q1 6.6% · Q2 6.0% · Q3 3.8% · Q4 3.3% · 4Q avg 4.9% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine 99.8%
94.0%
5.8 pts better
81.7%
18.1 pts better
Short Stay · 2024Q4-2025Q3 · Q1 99.1% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.8%
Percentage of short-stay residents who had an outpatient emergency department visit 4.2%
11.2%
7 pts better
12.0%
7.8 pts better
Short Stay · 20240701-20250630 · Adjusted 4.2% · Observed 4.5% · Expected 12.0% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication 2.5%
1.5%
1 pts worse
1.6%
0.9 pts worse
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 5.1% · Q4 5.4% · 4Q avg 2.5% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 79.7%
93.2%
13.5 pts worse
79.7%
About the same
Short Stay · 2024Q3-2025Q2 · 4Q avg 79.7%
Percentage of short-stay residents who were rehospitalized after a nursing home admission 20.2%
23.2%
3 pts better
23.9%
3.7 pts better
Short Stay · 20240701-20250630 · Adjusted 20.2% · Observed 23.4% · Expected 27.7% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-01-10 · Fire 2025-01-10

12 health deficiencies

Top issue: Quality of Life and Care (5 deficiencies)

5 fire-safety deficiencies

Top issue: Smoke (4 deficiencies)

Cycle 2 Health 2024-01-05 · Fire 2024-01-05

13 health deficiencies

Top issue: Quality of Life and Care (7 deficiencies)

2 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Cycle 3 Health 2021-06-18 · Fire 2021-06-18

12 health deficiencies

Top issue: Quality of Life and Care (3 deficiencies)

7 fire-safety deficiencies

Top issue: Smoke (4 deficiencies)

Fire safety

Fire-safety citations

D · Potential for more than minimal harm 2025-01-10

K321 · Smoke Deficiencies

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 2025-01-14

D · Potential for more than minimal harm 2025-01-10

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2025-01-08

D · Potential for more than minimal harm 2025-01-10

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2025-01-08

C · Minimal harm 2025-01-10

K346 · Smoke Deficiencies

Fire Safety

Follow proper procedures when the fire alarm was out of service for more than 4 hours.

Corrected 2025-01-14

C · Minimal harm 2025-01-10

K354 · Smoke Deficiencies

Fire Safety

Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.

Corrected 2025-01-14

E · Potential for more than minimal harm 2024-01-05

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2024-01-15

E · Potential for more than minimal harm 2024-01-05

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-01-15

F · Potential for more than minimal harm 2021-06-18

K291 · Egress Deficiencies

Fire Safety

Install emergency lighting that can last at least 1 1/2 hours.

Corrected 2021-08-18

F · Potential for more than minimal harm 2021-06-18

K346 · Smoke Deficiencies

Fire Safety

Follow proper procedures when the fire alarm was out of service for more than 4 hours.

Corrected 2021-08-18

F · Potential for more than minimal harm 2021-06-18

K354 · Smoke Deficiencies

Fire Safety

Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.

Corrected 2021-08-18

E · Potential for more than minimal harm 2021-06-18

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 2021-08-18

D · Potential for more than minimal harm 2021-06-18

K321 · Smoke Deficiencies

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 2021-08-18

D · Potential for more than minimal harm 2021-06-18

K331 · Smoke Deficiencies

Fire Safety

Construct fire resistant interior walls.

Corrected 2021-08-18

D · Potential for more than minimal harm 2021-06-18

K925 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure that sources of ignition are removed from patients receiving respiratory therapy.

Corrected 2021-08-18

Inspection history

Recent health citations

E · Potential for more than minimal harm 2025-01-10

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 2025-02-15

E · Potential for more than minimal harm 2025-01-10

F558 · Resident Rights Deficiencies

Health

Reasonably accommodate the needs and preferences of each resident.

Corrected 2025-02-15

E · Potential for more than minimal harm 2025-01-10

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 2025-02-15

E · Potential for more than minimal harm 2025-01-10

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 2025-02-15

E · Potential for more than minimal harm 2025-01-10

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-02-15

D · Potential for more than minimal harm 2025-01-10

F676 · Quality of Life and Care Deficiencies

Health

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Corrected 2025-02-15

D · Potential for more than minimal harm 2025-01-10

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 2025-02-15

D · Potential for more than minimal harm 2025-01-10

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2025-02-15

D · Potential for more than minimal harm 2025-01-10

F756 · Pharmacy Service Deficiencies

Health

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Corrected 2025-02-15

D · Potential for more than minimal harm 2025-01-10

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 2025-02-15

D · Potential for more than minimal harm 2025-01-10

F921 · Environmental Deficiencies

Health

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Corrected 2025-02-15

B · Minimal harm 2025-01-10

F732 · Nursing and Physician Services Deficiencies

Health

Post nurse staffing information every day.

Corrected 2025-02-15

D · Potential for more than minimal harm 2024-11-25

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 2024-12-20

D · Potential for more than minimal harm 2024-11-25

F687 · Quality of Life and Care Deficiencies

Health

Provide appropriate foot care.

Corrected 2024-12-20

E · Potential for more than minimal harm 2024-01-05

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 2024-01-30

E · Potential for more than minimal harm 2024-01-05

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2024-01-30

E · Potential for more than minimal harm 2024-01-05

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 2024-01-30

E · Potential for more than minimal harm 2024-01-05

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 2024-01-30

E · Potential for more than minimal harm 2024-01-05

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-01-30

D · Potential for more than minimal harm 2024-01-05

F558 · Resident Rights Deficiencies

Health

Reasonably accommodate the needs and preferences of each resident.

Corrected 2024-01-30

D · Potential for more than minimal harm 2024-01-05

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2024-01-30

D · Potential for more than minimal harm 2024-01-05

F676 · Quality of Life and Care Deficiencies

Health

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Corrected 2024-01-30

D · Potential for more than minimal harm 2024-01-05

F685 · Quality of Life and Care Deficiencies

Health

Assist a resident in gaining access to vision and hearing services.

Corrected 2024-01-30

D · Potential for more than minimal harm 2024-01-05

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 2024-01-30

D · Potential for more than minimal harm 2024-01-05

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2024-01-30

E · Potential for more than minimal harm 2023-12-19

F710 · Nursing and Physician Services Deficiencies

Health

Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.

Corrected 2024-01-11

D · Potential for more than minimal harm 2023-05-11

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2023-06-15

E · Potential for more than minimal harm 2021-06-18

F726 · Nursing and Physician Services Deficiencies

Health

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Corrected 2021-07-21

E · Potential for more than minimal harm 2021-06-18

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2021-07-21

D · Potential for more than minimal harm 2021-06-18

F558 · Resident Rights Deficiencies

Health

Reasonably accommodate the needs and preferences of each resident.

Corrected 2021-07-21

D · Potential for more than minimal harm 2021-06-18

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2021-07-21

D · Potential for more than minimal harm 2021-06-18

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 2021-07-21

D · Potential for more than minimal harm 2021-06-18

F657 · Resident Assessment and Care Planning Deficiencies

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 2021-07-21

D · Potential for more than minimal harm 2021-06-18

F694 · Quality of Life and Care Deficiencies

Health

Provide for the safe, appropriate administration of IV fluids for a resident when needed.

Corrected 2021-07-21

D · Potential for more than minimal harm 2021-06-18

F698 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Corrected 2021-07-21

D · Potential for more than minimal harm 2021-06-18

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 2021-07-21

D · Potential for more than minimal harm 2021-06-18

F825 · Quality of Life and Care Deficiencies

Health

Provide or get specialized rehabilitative services as required for a resident.

Corrected 2021-07-21

Penalties and ownership

What sits behind the stars

Ownership

Flagstone Healthcare South LLC

5% Or Greater Direct Ownership Interest · Organization

100% 41 facilities 2022-11-08
The Ensign Group Inc

5% Or Greater Indirect Ownership Interest · Organization

100% 209 facilities 2023-02-01
Burnam, Soon

Corporate Officer · Individual

0% 323 facilities 2022-11-08
Gamero, Alicia

Corporate Officer · Individual

0% 7 facilities 2023-02-01
Keetch, Chad

Corporate Officer · Individual

0% 176 facilities 2011-03-01
Leet, Ryan

Operational/Managerial Control · Individual

0% 3 facilities 2023-02-01
Sato, Ami

Corporate Officer · Individual

0% 101 facilities 2024-09-09
Singh, Jhujhar

Operational/Managerial Control · Individual

0% 2 facilities 2025-02-01
Willits, Adam

Corporate Director · Individual

0% 69 facilities 2023-02-01

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3-star overall rating with 3-star inspections with $86,320 in total fines with 13 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle

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Staffing
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Fines
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#2

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5-star overall rating with 4-star inspections with 9 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle

Overall
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#3

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5-star overall rating with 5-star inspections with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle

Overall
5 / 5
Health
5 / 5
Staffing
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Fines
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