Cycle 1
Health 2025-07-03 · Fire 2025-07-03
10 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Loma Linda, CA
Loma Linda Post Acute
4-star overall rating with 4-star inspections with 10 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
25383 Cole Street, Loma Linda, CA
(909) 796-0235
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
83
Certified beds
Average residents
80
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Pacs Group
Operator or chain grouping
Approved since
1967-01-01
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
0.39
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.13
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
4.11
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
1.52
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
3.72
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.30
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.37
CMS adjusted RN staffing hours
Adjusted total hours
3.88
CMS adjusted total nurse staffing hours
Case-mix index
1.45
Higher values indicate more complex resident acuity
RN turnover
67%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
38%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,634
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
19.68
Composite VBP score used to determine payment impact.
Payment multiplier
0.9822
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 18.16% · Performance 22.97% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 6.05% · Performance 8.59% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
5.16
Baseline 35.53% · Performance 42.57% · Measure score 5.16 · Achievement 5.16 · Improvement 0
Adjusted total nurse staffing
2.71
Baseline 4.18 hours · Performance 3.85 hours · Measure score 2.71 · Achievement 2.71 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.11% |
10.72%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 134 · Observed rate 11.94% · Lower 95% interval 8.56% |
| Discharge to community | 45.92% |
50.57%
4.6 pts worse
|
No Different than the National Rate · Eligible stays 118 · Observed rate 38.98% · Lower 95% interval 34.61% |
| Medicare spending per beneficiary | 1.44 |
1.02
0.4 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 202 · Denominator 202 |
| Falls with major injury | 0.5% |
0.77%
0.3 pts better
|
Numerator 1 · Denominator 202 |
| Discharge self-care score | 41.3% |
53.69%
12.4 pts worse
|
Numerator 38 · Denominator 92 |
| Discharge mobility score | 29.35% |
50.94%
21.6 pts worse
|
Numerator 27 · Denominator 92 |
| Pressure ulcers or injuries, new or worsened | 0.5% |
2.29%
1.8 pts better
|
Numerator 1 · Denominator 202 · Adjusted rate 0.34% |
| Healthcare-associated infections requiring hospitalization | 8.59% |
7.12%
1.5 pts worse
|
No Different than the National Rate · Eligible stays 118 · Observed rate 10.17% · Lower 95% interval 5.53% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 125 |
| Staff flu vaccination coverage | 47.06% |
42%
5.1 pts better
|
Numerator 112 · Denominator 238 |
| Discharge function score | 39.13% |
56.45%
17.3 pts worse
|
Numerator 36 · Denominator 92 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 81 · Denominator 81 |
| Transfer of health information to patient | 93.85% |
96.28%
2.4 pts worse
|
Numerator 61 · Denominator 65 |
| Resident COVID-19 vaccinations up to date | 10.09% |
25.2%
15.1 pts worse
|
Numerator 11 · Denominator 109 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.0 |
2.3
0.7 pts worse
|
1.9
1.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.0 · Observed 4.8 · Expected 3.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.0 |
1.6
0.6 pts better
|
1.8
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 1.3 · Expected 2.1 · 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 | 9.0% |
6.8%
2.2 pts worse
|
11.4%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 11.8% · Q3 5.9% · Q4 7.4% · 4Q avg 9.0% |
| Percentage of long-stay residents who lose too much weight | 6.2% |
4.1%
2.1 pts worse
|
5.4%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 2.0% · Q3 10.4% · Q4 7.8% · 4Q avg 6.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 10.2% |
13.7%
3.5 pts better
|
19.6%
9.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.5% · Q2 5.5% · Q3 13.5% · Q4 14.5% · 4Q avg 10.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 7.1% |
14.2%
7.1 pts better
|
16.7%
9.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 3.3% · Q3 7.9% · Q4 10.5% · 4Q avg 7.1% · 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 | 13.0% |
11.0%
2 pts worse
|
16.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 13.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.9% |
10.7%
3.2 pts worse
|
14.9%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 21.6% · Q2 18.0% · Q3 4.2% · Q4 11.5% · 4Q avg 13.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.0% |
1.0%
About the same
|
1.0%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.2% · Q3 3.0% · Q4 0.0% · 4Q avg 1.0% · 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 | 12.1% |
10.9%
1.2 pts worse
|
19.8%
7.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 21.1% · Q2 16.9% · Q3 8.3% · Q4 2.0% · 4Q avg 12.1% |
| Percentage of long-stay residents with pressure ulcers | 6.6% |
4.7%
1.9 pts worse
|
5.1%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 5.7% · Q3 6.6% · Q4 10.7% · 4Q avg 6.6% · 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 99.3% · 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 | 12.9% |
11.2%
1.7 pts worse
|
12.0%
0.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.9% · Observed 14.3% · Expected 12.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.1% |
1.5%
0.6 pts worse
|
1.6%
0.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 1.2% · Q3 2.3% · Q4 1.3% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 99.3% |
93.2%
6.1 pts better
|
79.7%
19.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 99.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.6% |
23.2%
2.4 pts worse
|
23.9%
1.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.6% · Observed 29.8% · Expected 27.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-06-20 · Fire 2024-06-20
2 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
9 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Cycle 3
Health 2023-01-10 · Fire 2023-01-10
17 health deficiencies
Top issue: Quality of Life and Care (8 deficiencies)
3 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
2025-07-03
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-07-25
F · Potential for more than minimal harm
2025-07-03
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-07-25
F · Potential for more than minimal harm
2025-07-03
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-07-25
D · Potential for more than minimal harm
2025-07-03
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-07-25
D · Potential for more than minimal harm
2025-07-03
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-07-25
D · Potential for more than minimal harm
2025-07-03
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-07-25
E · Potential for more than minimal harm
2024-06-20
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-07-16
D · Potential for more than minimal harm
2024-06-20
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2024-07-16
D · Potential for more than minimal harm
2024-06-20
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-07-16
D · Potential for more than minimal harm
2024-06-20
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-07-16
D · Potential for more than minimal harm
2024-06-20
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-07-16
D · Potential for more than minimal harm
2024-06-20
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-07-16
D · Potential for more than minimal harm
2024-06-20
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-07-16
D · Potential for more than minimal harm
2024-06-20
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-07-16
D · Potential for more than minimal harm
2024-06-20
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-07-16
D · Potential for more than minimal harm
2023-01-10
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-02-07
D · Potential for more than minimal harm
2023-01-10
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-02-07
D · Potential for more than minimal harm
2023-01-10
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-02-07
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-07-03
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 2025-07-25
D · Potential for more than minimal harm
2025-07-03
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2025-07-25
D · Potential for more than minimal harm
2025-07-03
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 2025-07-25
D · Potential for more than minimal harm
2025-07-03
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 2025-07-25
D · Potential for more than minimal harm
2025-07-03
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-07-25
D · Potential for more than minimal harm
2025-07-03
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-07-25
D · Potential for more than minimal harm
2025-07-03
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-07-25
D · Potential for more than minimal harm
2025-07-03
F761 · Pharmacy Service Deficiencies
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 2025-07-25
B · Minimal harm
2025-07-03
F577 · Resident Rights Deficiencies
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2025-07-25
D · Potential for more than minimal harm
2025-05-29
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 2025-06-03
D · Potential for more than minimal harm
2024-06-20
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2024-07-20
D · Potential for more than minimal harm
2024-06-04
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-06-14
D · Potential for more than minimal harm
2023-12-12
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-01-03
D · Potential for more than minimal harm
2023-12-07
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 2023-12-26
D · Potential for more than minimal harm
2023-08-03
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 2023-08-18
D · Potential for more than minimal harm
2023-04-13
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-04-28
F · Potential for more than minimal harm
2023-01-10
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 2023-02-03
F · Potential for more than minimal harm
2023-01-10
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 2023-02-03
E · Potential for more than minimal harm
2023-01-10
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-02-03
E · Potential for more than minimal harm
2023-01-10
F761 · Pharmacy Service Deficiencies
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 2023-02-03
D · Potential for more than minimal harm
2023-01-10
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 2023-02-03
D · Potential for more than minimal harm
2023-01-10
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2023-02-03
D · Potential for more than minimal harm
2023-01-10
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2023-02-03
D · Potential for more than minimal harm
2023-01-10
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 2023-02-03
D · Potential for more than minimal harm
2023-01-10
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 2023-02-03
D · Potential for more than minimal harm
2023-01-10
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-02-03
D · Potential for more than minimal harm
2023-01-10
F688 · Quality of Life and Care Deficiencies
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 2023-02-03
D · Potential for more than minimal harm
2023-01-10
F693 · Quality of Life and Care Deficiencies
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 2023-02-03
D · Potential for more than minimal harm
2023-01-10
F885 · Infection Control Deficiencies
Health
Report COVID19 data to residents and families.
Corrected 2023-02-03
Penalties and ownership
What sits behind the stars
Ownership
Loma Linda Master Tenant LLC
5% Or Greater Direct Ownership Interest · Organization
Apt, Frederick
Operational/Managerial Control · Individual
Dimaunahan, Joel
Operational/Managerial Control · Individual
Hancock, Mark
5% Or Greater Indirect Ownership Interest · Individual
Jardine, Kenneth
Operational/Managerial Control · Individual
Jergensen, Joshua
Operational/Managerial Control · Individual
Lords, Trevor
Operational/Managerial Control · Individual
Mitchell, John
Operational/Managerial Control · 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
Pai, Shantharam
Operational/Managerial Control · Individual
Providence Group Nh, LLC
5% Or Greater Indirect Ownership Interest · Organization
Truist Bank
5% Or Greater Security Interest · Organization
Nearby options
Other facilities in reach
#1
Heritage Gardens Health Care Center
Loma Linda, CA
3-star overall rating with 3-star inspections with 9 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Asistencia Villa Healthcare Center
Redlands, CA
2-star overall rating with 3-star inspections with $10,206 in total fines with 13 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#3
Totally Kids Rehabilitation Hospital - D/P SNF
Loma Linda, CA
5-star overall rating with 4-star inspections with 9 recent health deficiencies
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