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
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
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
Chain footprint
32 facilities
Chain averages 3 overall / 2 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
RN hours / resident day
0.33
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.32
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
2.41
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
4.06
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
1.65
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
3.59
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.18
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.32
CMS adjusted RN staffing hours
Adjusted total hours
3.86
CMS adjusted total nurse staffing hours
Case-mix index
1.44
Higher values indicate more complex resident acuity
RN turnover
56%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
43%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Program rank
11,119
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
17.96
Composite VBP score used to determine payment impact.
Payment multiplier
0.9819
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
0
Baseline 18.76% · Performance 21.51% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 7.75% · Performance 9.98% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
5.14
Baseline 33.33% · Performance 42.67% · Measure score 5.14 · Achievement 5.14 · Improvement 0
Adjusted total nurse staffing
2.04
Baseline 3.28 hours · Performance 3.66 hours · Measure score 2.04 · Achievement 2.04 · Improvement 1.02
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.77% |
10.72%
1 pts better
|
No Different than the National Rate · Eligible stays 67 · Observed rate 7.46% · Lower 95% interval 6.19% |
| Discharge to community | 41.25% |
50.57%
9.3 pts worse
|
No Different than the National Rate · Eligible stays 59 · Observed rate 32.2% · Lower 95% interval 30.4% |
| Medicare spending per beneficiary | 1.62 |
1.02
0.6 pts worse
|
|
| Drug regimen review with follow-up | 98.36% |
95.27%
3.1 pts better
|
Numerator 60 · Denominator 61 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 61 |
| Discharge self-care score | 51.72% |
53.69%
2 pts worse
|
Numerator 15 · Denominator 29 |
| Discharge mobility score | 51.72% |
50.94%
0.8 pts better
|
Numerator 15 · Denominator 29 |
| Pressure ulcers or injuries, new or worsened | 3.28% |
2.29%
1 pts worse
|
Numerator 2 · Denominator 61 · Adjusted rate 2.1% |
| Healthcare-associated infections requiring hospitalization | 9.98% |
7.12%
2.9 pts worse
|
No Different than the National Rate · Eligible stays 50 · Observed rate 18% · Lower 95% interval 6.03% |
| Staff COVID-19 vaccination coverage | 8.24% |
8.2%
About the same
|
Numerator 7 · Denominator 85 |
| Staff flu vaccination coverage | 78.7% |
42%
36.7 pts better
|
Numerator 85 · Denominator 108 |
| Discharge function score | 37.93% |
56.45%
18.5 pts worse
|
Numerator 11 · Denominator 29 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 23 · Denominator 23 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 16.67% |
25.2%
8.5 pts worse
|
Numerator 5 · Denominator 30 |
Quality measures
| 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 · Adjusted 3.8 · Observed 3.6 · Expected 1.8 · Used in QM five-star |
| 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 · Adjusted 3.6 · Observed 3.3 · Expected 1.5 · 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 | 1.5% |
1.6%
0.1 pts better
|
3.3%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.9% · Q4 2.0% · 4Q avg 1.5% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 2.2% · Q4 2.4% · 4Q avg 1.1% |
| 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 · Q1 8.7% · Q2 7.3% · Q3 4.4% · Q4 15.6% · 4Q avg 9.0% |
| 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 · Q1 5.9% · Q2 4.5% · Q3 10.9% · Q4 13.3% · 4Q avg 8.6% |
| 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 · Q1 7.3% · Q2 8.3% · Q3 5.6% · Q4 0.0% · 4Q avg 5.3% · 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 | 9.4% |
11.0%
1.6 pts better
|
16.3%
6.9 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 9.4% · Used in QM five-star |
| 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 · Q1 4.5% · Q2 17.9% · Q3 4.9% · Q4 4.8% · 4Q avg 7.8% · Used in QM five-star |
| 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 · Q1 1.4% · Q2 1.6% · Q3 0.0% · Q4 1.4% · 4Q avg 1.1% · 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 | 9.9% |
10.9%
1 pts better
|
19.8%
9.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 12.6% · Q3 16.2% · Q4 4.4% · 4Q avg 9.9% |
| 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 · Q1 8.4% · Q2 9.6% · Q3 4.1% · Q4 4.1% · 4Q avg 6.5% · Used in QM five-star |
| 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 · Q1 97.6% · Q2 98.1% · Q3 100.0% · Q4 100.0% · 4Q avg 99.1% |
| 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 · Adjusted 20.7% · Observed 20.4% · Expected 11.0% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 3.1% · Q3 2.5% · Q4 2.6% · 4Q avg 2.2% · Used in QM five-star |
| 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 · 4Q avg 100.0% |
| 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 · Adjusted 25.9% · Observed 25.9% · Expected 23.8% · Used in QM five-star |
Survey summary
Top issue: Quality of Life and Care (7 deficiencies)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Top issue: Quality of Life and Care (2 deficiencies)
6 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Top issue: Infection Control (2 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-03-21
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-03-21
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-03-21
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-03-21
Fire Safety
Establish staff and initial training requirements.
Corrected 2024-03-07
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-03-07
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
Fire Safety
Have exits that are accessible at all times.
Corrected 2024-03-07
Fire Safety
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
Corrected 2024-03-07
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-03-07
Fire Safety
Conduct testing and exercise requirements.
Corrected 2022-01-01
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-01-01
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2022-01-01
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
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Not marked corrected
Health
Respond appropriately to all alleged violations.
Not marked corrected
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Not marked corrected
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
Health
Dispose of garbage and refuse properly.
Corrected 2025-08-15
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
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-03-17
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-03-17
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-03-17
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-03-17
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
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
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
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-17
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
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-03-17
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-03-17
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
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-03-17
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
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
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-03-17
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2025-03-17
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2025-03-17
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
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-03-07
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2024-03-07
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-03-07
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-03-07
Health
Post nurse staffing information every day.
Corrected 2024-03-07
Health
Provide and implement an infection prevention and control program.
Corrected 2024-03-07
Health
Provide and implement an infection prevention and control program.
Corrected 2023-06-23
Health
Provide and implement an infection prevention and control program.
Corrected 2022-02-07
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
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
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
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2022-01-11
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
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2022-01-11
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2022-01-11
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
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
Health
Post nurse staffing information every day.
Corrected 2022-01-11
Penalties and ownership
Fine · fine $2,797
Fine
Fine · fine $2,447
Fine
Fine · fine $5,244
Fine
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Direct Ownership Interest · Organization
Operational/Managerial Control · Individual
Operational/Managerial Control · Organization
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
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