8 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Ontario, CA
4-star overall rating with 4-star inspections with 8 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
1950 S Mountain Ave, Ontario, CA
(909) 983-2315
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Beds
59
Certified beds
Average residents
59
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1979-02-16
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.40
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.23
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
2.59
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
4.21
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
1.63
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
0.23
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.40
CMS adjusted RN staffing hours
Adjusted total hours
4.26
CMS adjusted total nurse staffing hours
Case-mix index
1.35
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
48%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Program rank
5,943
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
34.51
Composite VBP score used to determine payment impact.
Payment multiplier
0.9884
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
2.41
Performance 20.32% · Measure score 2.41 · Achievement 2.41 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
1.34
Baseline 7.21% · Performance 7.43% · Measure score 1.34 · Achievement 1.34 · Improvement 0
Total nurse turnover
6.61
Baseline 64.29% · Performance 36.67% · Measure score 6.61 · Achievement 6.61 · Improvement 6.50
Adjusted total nurse staffing
3.45
Baseline 3.76 hours · Performance 4.06 hours · Measure score 3.45 · Achievement 3.45 · Improvement 0.97
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.04% |
10.72%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 67 · Observed rate 11.94% · Lower 95% interval 8.15% |
| Discharge to community | 48.47% |
50.57%
2.1 pts worse
|
No Different than the National Rate · Eligible stays 56 · Observed rate 39.29% · Lower 95% interval 35.63% |
| Medicare spending per beneficiary | 1.4 |
1.02
0.4 pts worse
|
|
| Drug regimen review with follow-up | 97.3% |
95.27%
2 pts better
|
Numerator 36 · Denominator 37 |
| Falls with major injury | 2.7% |
0.77%
1.9 pts worse
|
Numerator 1 · Denominator 37 |
| Discharge self-care score | 44.44% |
53.69%
9.2 pts worse
|
Numerator 12 · Denominator 27 |
| Discharge mobility score | 59.26% |
50.94%
8.3 pts better
|
Numerator 16 · Denominator 27 |
| Pressure ulcers or injuries, new or worsened | 8.11% |
2.29%
5.8 pts worse
|
Numerator 3 · Denominator 37 · Adjusted rate 5.83% |
| Healthcare-associated infections requiring hospitalization | 7.43% |
7.12%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 45 · Observed rate 8.89% · Lower 95% interval 3.9% |
| Staff COVID-19 vaccination coverage | 1.27% |
8.2%
6.9 pts worse
|
Numerator 1 · Denominator 79 |
| Staff flu vaccination coverage | 28.57% |
42%
13.4 pts worse
|
Numerator 26 · Denominator 91 |
| Discharge function score | 44.44% |
56.45%
12 pts worse
|
Numerator 12 · Denominator 27 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 21 · Denominator 21 |
| Resident COVID-19 vaccinations up to date | 38.1% |
25.2%
12.9 pts better
|
Numerator 8 · Denominator 21 |
Quality measures
| 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 2.6 · Expected 2.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.7 |
1.6
0.9 pts better
|
1.8
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.7 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 94.5% |
98.5%
4 pts worse
|
93.4%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 95.7% · Q2 82.1% · Q3 100.0% · Q4 100.0% · 4Q avg 94.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 88.6% |
98.2%
9.6 pts worse
|
95.5%
6.9 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 88.6% |
| 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 | 0.7% |
6.8%
6.1 pts better
|
11.4%
10.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% |
| Percentage of long-stay residents who lose too much weight | 7.1% |
4.1%
3 pts worse
|
5.4%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.5% · Q2 0.0% · Q3 12.1% · Q4 9.1% · 4Q avg 7.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.0% |
13.7%
1.7 pts better
|
19.6%
7.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.2% · Q2 13.9% · Q3 11.1% · Q4 10.8% · 4Q avg 12.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 0.0% |
14.2%
14.2 pts better
|
16.7%
16.7 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 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 | 12.5% |
11.0%
1.5 pts worse
|
16.3%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 12.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 23.4% |
10.7%
12.7 pts worse
|
14.9%
8.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 40.0% · Q2 39.1% · Q3 10.7% · Q4 6.7% · 4Q avg 23.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 4.8% |
1.0%
3.8 pts worse
|
1.0%
3.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 5.4% · Q3 1.8% · Q4 4.4% · 4Q avg 4.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 7.1% |
1.2%
5.9 pts worse
|
1.7%
5.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.6% · Q2 7.9% · Q3 0.0% · Q4 2.9% · 4Q avg 7.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.8% |
10.9%
10.9 pts worse
|
19.8%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.4% · Q2 13.8% · Q3 19.3% · Q4 17.7% · 4Q avg 21.8% |
| Percentage of long-stay residents with pressure ulcers | 3.6% |
4.7%
1.1 pts better
|
5.1%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 6.2% · Q3 1.6% · Q4 1.7% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 94.6% |
94.0%
0.6 pts better
|
81.7%
12.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 89.4% · Q2 90.5% · Q3 95.6% · Q4 100.0% · 4Q avg 94.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.2% |
11.2%
6 pts better
|
12.0%
6.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.2% · Observed 5.0% · Expected 10.7% · 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 | 93.1% |
93.2%
0.1 pts worse
|
79.7%
13.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 93.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 29.6% |
23.2%
6.4 pts worse
|
23.9%
5.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 29.6% · Observed 27.5% · Expected 22.1% · Used in QM five-star |
Survey summary
Top issue: Resident Assessment and Care Planning (3 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Top issue: Environmental (3 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Top issue: Quality of Life and Care (2 deficiencies)
6 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Fire safety
Fire Safety
Use approved construction type or materials.
Corrected 2025-07-01
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-07-10
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-07-09
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-07-10
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-07-10
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-07-01
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-07-10
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-05-22
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-05-22
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-05-22
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-05-22
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-05-22
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-03-29
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2022-03-29
Fire Safety
Provide family notifications of emergency plan.
Corrected 2022-03-29
Fire Safety
Conduct testing and exercise requirements.
Corrected 2022-03-29
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-03-29
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-03-29
Inspection history
Health
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.
Corrected 2025-07-09
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-07-09
Health
Keep all essential equipment working safely.
Corrected 2025-07-09
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2025-07-09
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2025-07-09
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-07-09
Health
Provide and implement an infection prevention and control program.
Corrected 2025-07-09
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-07-09
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-06-10
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-06-10
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2024-06-10
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-06-10
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 2024-06-10
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2024-06-10
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-06-10
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 2024-06-10
Health
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.
Corrected 2024-06-10
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-06-10
Health
Provide and implement an infection prevention and control program.
Corrected 2024-06-10
Health
Keep all essential equipment working safely.
Corrected 2024-06-10
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2024-06-10
Health
Post nurse staffing information every day.
Corrected 2024-06-10
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2024-01-16
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-04-12
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-04-12
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-03-22
Health
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.
Corrected 2022-03-22
Penalties and ownership
Corporate Officer · Individual
Corporate Officer · Individual
Corporate Officer · Individual
Corporate Officer · Individual
Corporate Officer · Individual
Corporate Officer · Individual
Corporate Officer · Individual
Corporate Director · Individual
W-2 Managing Employee · Individual
Corporate Officer · Individual
Corporate Officer · Individual
Corporate Officer · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
W-2 Managing Employee · Individual
Nearby options
Ontario, CA
4-star overall rating with 4-star inspections with 5 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
Chino, CA
5-star overall rating with 5-star inspections with 6 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
Montclair, CA
4-star overall rating with 4-star inspections with $2,098 in total fines with 13 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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