Cycle 1
Health 2025-02-21 · Fire 2025-02-21
24 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Duarte, CA
Monte Vista Healthcare Center
2-star overall rating with 2-star inspections with $10,488 in total fines with 24 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
802 Buena Vista Street, Duarte, CA
(626) 359-8141
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
69
Certified beds
Average residents
61
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Cambridge Healthcare Services
Operator or chain grouping
Approved since
1967-09-05
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.33
Registered nurse staffing
LPN hours / resident day
1.32
Licensed practical nurse staffing
Aide hours / resident day
2.41
Nurse aide staffing
Weekend hours
3.59
Weekend nurse staffing
RN turnover
56%
Annual RN turnover
Total nurse turnover
43%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.8 |
2.3
1.5 pts worse
|
1.9
1.9 pts worse
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.6 |
1.6
2 pts worse
|
1.8
1.8 pts worse
|
Long Stay · 20240701-20250630 |
| 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 |
| 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 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.5% |
1.6%
0.1 pts better
|
3.3%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 1.1% |
6.8%
5.7 pts better
|
11.4%
10.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 9.0% |
4.1%
4.9 pts worse
|
5.4%
3.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 8.6% |
13.7%
5.1 pts better
|
19.6%
11 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 5.3% |
14.2%
8.9 pts better
|
16.7%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents whose ability to walk independently worsened | 9.4% |
11.0%
1.6 pts better
|
16.3%
6.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 7.8% |
10.7%
2.9 pts better
|
14.9%
7.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.1% |
1.0%
0.1 pts worse
|
1.0%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 9.9% |
10.9%
1 pts better
|
19.8%
9.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 6.5% |
4.7%
1.8 pts worse
|
5.1%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.1% |
94.0%
5.1 pts better
|
81.7%
17.4 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 20.7% |
11.2%
9.5 pts worse
|
12.0%
8.7 pts worse
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.2% |
1.5%
0.7 pts worse
|
1.6%
0.6 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
93.2%
6.8 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.9% |
23.2%
2.7 pts worse
|
23.9%
2 pts worse
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-11 · Fire 2024-02-11
7 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
6 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Cycle 3
Health 2021-11-12 · Fire 2021-11-12
12 health deficiencies
Top issue: Infection Control (2 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-02-21
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-03-21
E · Potential for more than minimal harm
2025-02-21
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-03-21
E · Potential for more than minimal harm
2025-02-21
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-03-21
D · Potential for more than minimal harm
2025-02-21
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-03-21
F · Potential for more than minimal harm
2024-02-11
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2024-03-07
F · Potential for more than minimal harm
2024-02-11
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-03-07
E · Potential for more than minimal harm
2024-02-11
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 2024-03-07
E · Potential for more than minimal harm
2024-02-11
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2024-03-07
D · Potential for more than minimal harm
2024-02-11
K342 · Smoke Deficiencies
Fire Safety
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
Corrected 2024-03-07
D · Potential for more than minimal harm
2024-02-11
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-03-07
F · Potential for more than minimal harm
2021-11-12
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2022-01-01
F · Potential for more than minimal harm
2021-11-12
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-01-01
E · Potential for more than minimal harm
2021-11-12
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2022-01-01
D · Potential for more than minimal harm
2021-11-12
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 2022-01-01
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-09
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.
Not marked corrected
D · Potential for more than minimal harm
2026-01-09
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Not marked corrected
D · Potential for more than minimal harm
2026-01-09
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Not marked corrected
D · Potential for more than minimal harm
2025-07-23
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 2025-08-15
D · Potential for more than minimal harm
2025-07-23
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2025-08-15
E · Potential for more than minimal harm
2025-02-21
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2025-03-17
E · Potential for more than minimal harm
2025-02-21
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-03-17
E · Potential for more than minimal harm
2025-02-21
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-03-17
E · Potential for more than minimal harm
2025-02-21
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-03-17
E · Potential for more than minimal harm
2025-02-21
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-03-17
E · Potential for more than minimal harm
2025-02-21
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 2025-03-17
E · Potential for more than minimal harm
2025-02-21
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 2025-03-17
E · Potential for more than minimal harm
2025-02-21
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 2025-03-17
E · Potential for more than minimal harm
2025-02-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-17
E · Potential for more than minimal harm
2025-02-21
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 2025-03-17
D · Potential for more than minimal harm
2025-02-21
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 2025-03-17
D · Potential for more than minimal harm
2025-02-21
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-03-17
D · Potential for more than minimal harm
2025-02-21
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 2025-03-17
D · Potential for more than minimal harm
2025-02-21
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 2025-03-17
D · Potential for more than minimal harm
2025-02-21
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 2025-03-17
D · Potential for more than minimal harm
2025-02-21
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 2025-03-17
D · Potential for more than minimal harm
2025-02-21
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-03-17
D · Potential for more than minimal harm
2025-02-21
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2025-03-17
D · Potential for more than minimal harm
2025-02-21
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2025-03-17
E · Potential for more than minimal harm
2024-02-11
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 2024-03-07
E · Potential for more than minimal harm
2024-02-11
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-03-07
E · Potential for more than minimal harm
2024-02-11
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2024-03-07
E · Potential for more than minimal harm
2024-02-11
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-03-07
D · Potential for more than minimal harm
2024-02-11
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-03-07
D · Potential for more than minimal harm
2024-02-11
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-03-07
D · Potential for more than minimal harm
2024-02-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-03-07
D · Potential for more than minimal harm
2023-05-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-06-23
K · Immediate jeopardy
2021-11-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-02-07
E · Potential for more than minimal harm
2021-11-12
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 2022-02-07
E · Potential for more than minimal harm
2021-11-12
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 2022-01-11
E · Potential for more than minimal harm
2021-11-12
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 2022-01-11
E · Potential for more than minimal harm
2021-11-12
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2022-01-11
E · Potential for more than minimal harm
2021-11-12
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 2022-01-11
D · Potential for more than minimal harm
2021-11-12
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2022-01-11
D · Potential for more than minimal harm
2021-11-12
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2022-01-11
D · Potential for more than minimal harm
2021-11-12
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 2022-01-11
D · Potential for more than minimal harm
2021-11-12
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 2022-01-11
B · Minimal harm
2021-11-12
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2022-01-11
Penalties and ownership
What sits behind the stars
$2,797
2023-06-26
Fine
Fine · fine $2,797
Fine
$2,447
2023-06-20
Fine
Fine · fine $2,447
Fine
$5,244
2023-05-30
Fine
Fine · fine $5,244
Fine
Ownership
Ira E Smedra Living Trust
5% Or Greater Direct Ownership Interest · Organization
Smedra, Ira
5% Or Greater Indirect Ownership Interest · Individual
Win Win Enterprises, LLC
5% Or Greater Direct Ownership Interest · Organization
Bh Alliance
5% Or Greater Direct Ownership Interest · Organization
Butenko, Julie
Operational/Managerial Control · Individual
Cambridge Healthcare Services LLC
Operational/Managerial Control · Organization
Capela, Heidi
Operational/Managerial Control · Individual
Gazarian, Levon
Operational/Managerial Control · Individual
Hassell, Lance
Operational/Managerial Control · Individual
Lawler, Emelyn
Operational/Managerial Control · Individual
Lutz, Linda
Operational/Managerial Control · Individual
Salazar, Paulina
Operational/Managerial Control · Individual
Smedra, Ira
Operational/Managerial Control · Individual
Ventanilla, Dianne
Operational/Managerial Control · Individual
Vidales, Miguel
Operational/Managerial Control · Individual
Wintner, Jacob
Operational/Managerial Control · Individual
Wintner, Jacob
Corporate Officer · Individual
Nearby options
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3-star overall rating with 2-star inspections with 28 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#2
Royal Oaks Manor-Bradbury Oaks
Duarte, CA
3-star overall rating with 3-star inspections with 10 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Royal Terrace Healthcare
Duarte, CA
4-star overall rating with 3-star inspections with 16 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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