Sylmar, CA

Mountain View Conv Hosp

2-star overall rating with 1-star inspections with 36 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle

13333 Fenton Avenue, Sylmar, CA

(818) 367-1033

Compare this facility

Overall

2 / 5

CMS overall stars

Health inspections

1 / 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

114

Certified beds

Average residents

103

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Cambridge Healthcare Services

Operator or chain grouping

Approved since

1977-04-01

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

Hours and turnover

RN hours / resident day

0.59

Registered nurse staffing · state 0.65 · national 0.68

LPN hours / resident day

1.51

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

4.50

All reported nurse hours · state 4.51 · national 3.89

Licensed hours

2.10

RN + LPN hours · state 1.87 · national 1.54

Weekend hours

4.13

Weekend nurse staffing · state 4.08 · national 3.43

Weekend RN hours

0.49

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

0.46

CMS adjusted RN staffing hours

Adjusted total hours

3.51

CMS adjusted total nurse staffing hours

Case-mix index

1.75

Higher values indicate more complex resident acuity

RN turnover

20%

Annual RN turnover · state 42% · national 45%

Total nurse turnover

28%

Annual nurse turnover · state 38% · national 46%

SNF VBP

Value-based purchasing

Program rank

4,506

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

Performance score

39.67

Composite VBP score used to determine payment impact.

Payment multiplier

0.9926

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

5.08

Performance 19.08% · Measure score 5.08 · Achievement 5.08 · This facility did not have sufficient data to calculate a baseline period measure result.

Healthcare-associated infections

0.61

Performance 7.65% · Measure score 0.61 · Achievement 0.61 · This facility did not have sufficient data to calculate a baseline period measure result.

Total nurse turnover

8.62

Baseline 61.48% · Performance 28.44% · Measure score 8.62 · Achievement 8.62 · Improvement 8.52

Adjusted total nurse staffing

1.56

Baseline 3.41 hours · Performance 3.52 hours · Measure score 1.56 · Achievement 1.56 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure Facility National Note
Potentially preventable 30-day readmission 11.15%
10.72%
0.4 pts worse
No Different than the National Rate · Eligible stays 56 · Observed rate 14.29% · Lower 95% interval 7.33%
Discharge to community 39.41%
50.57%
11.2 pts worse
No Different than the National Rate · Eligible stays 62 · Observed rate 25.81% · Lower 95% interval 27.92%
Medicare spending per beneficiary 1.32
1.02
0.3 pts worse
Drug regimen review with follow-up 95.12%
95.27%
0.1 pts worse
Numerator 39 · Denominator 41
Falls with major injury 0%
0.77%
0.8 pts better
Numerator 0 · Denominator 41
Discharge self-care score 60.87%
53.69%
7.2 pts better
Numerator 14 · Denominator 23
Discharge mobility score 43.48%
50.94%
7.5 pts worse
Numerator 10 · Denominator 23
Pressure ulcers or injuries, new or worsened 0%
2.29%
2.3 pts better
Numerator 0 · Denominator 41 · Adjusted rate 0%
Healthcare-associated infections requiring hospitalization 7.65%
7.12%
0.5 pts worse
No Different than the National Rate · Eligible stays 46 · Observed rate 10.87% · Lower 95% interval 4.36%
Staff COVID-19 vaccination coverage 9.32%
8.2%
1.1 pts better
Numerator 15 · Denominator 161
Staff flu vaccination coverage 50%
42%
8 pts better
Numerator 84 · Denominator 168
Discharge function score 47.83%
56.45%
8.6 pts worse
Numerator 11 · Denominator 23
Transfer of health information to provider Not Available
95.95%
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly.
Transfer of health information to patient Not Available
96.28%
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date 30.77%
25.2%
5.6 pts better
Numerator 8 · Denominator 26

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 4.6 · Expected 3.1 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days 0.2
1.6
1.4 pts better
1.8
1.6 pts better
Long Stay · 20240701-20250630 · Adjusted 0.2 · Observed 0.3 · Expected 2.0 · 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 9.1%
6.8%
2.3 pts worse
11.4%
2.3 pts better
Long Stay · 2024Q4-2025Q3 · Q1 10.1% · Q2 16.7% · Q3 7.4% · Q4 1.5% · 4Q avg 9.1%
Percentage of long-stay residents who lose too much weight 4.4%
4.1%
0.3 pts worse
5.4%
1 pts better
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 5.3% · Q3 2.8% · Q4 6.7% · 4Q avg 4.4%
Percentage of long-stay residents who received an antianxiety or hypnotic medication 8.3%
13.7%
5.4 pts better
19.6%
11.3 pts better
Long Stay · 2024Q4-2025Q3 · Q1 6.3% · Q2 5.2% · Q3 9.2% · Q4 12.5% · 4Q avg 8.3%
Percentage of long-stay residents who received an antipsychotic medication 9.6%
14.2%
4.6 pts better
16.7%
7.1 pts better
Long Stay · 2024Q4-2025Q3 · Q1 8.9% · Q2 2.8% · Q3 12.2% · Q4 13.3% · 4Q avg 9.6% · 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 4.6%
11.0%
6.4 pts better
16.3%
11.7 pts better
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 4.9% · Q4 8.0% · 4Q avg 4.6% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased 6.1%
10.7%
4.6 pts better
14.9%
8.8 pts better
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 5.8% · Q3 10.0% · Q4 7.1% · 4Q avg 6.1% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder 0.0%
1.0%
1 pts better
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% · 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 3.9%
10.9%
7 pts better
19.8%
15.9 pts better
Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 3.1% · Q3 4.9% · Q4 1.4% · 4Q avg 3.9%
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 3.9% · Q2 4.5% · Q3 7.6% · Q4 3.8% · 4Q avg 4.9% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine 99.9%
94.0%
5.9 pts better
81.7%
18.2 pts better
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 99.5% · 4Q avg 99.9%
Percentage of short-stay residents who had an outpatient emergency department visit 10.7%
11.2%
0.5 pts better
12.0%
1.3 pts better
Short Stay · 20240701-20250630 · Adjusted 10.7% · Observed 11.6% · Expected 12.1% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication 1.1%
1.5%
0.4 pts better
1.6%
0.5 pts better
Short Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 2.3% · Q3 0.0% · Q4 0.0% · 4Q avg 1.1% · 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 14.7%
23.2%
8.5 pts better
23.9%
9.2 pts better
Short Stay · 20240701-20250630 · Adjusted 14.7% · Observed 20.9% · Expected 34.0% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-12-06 · Fire 2024-12-06

36 health deficiencies

Top issue: Resident Assessment and Care Planning (9 deficiencies)

4 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Cycle 2 Health 2023-11-30 · Fire 2023-11-30

30 health deficiencies

Top issue: Quality of Life and Care (9 deficiencies)

4 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)

Cycle 3 Health 2022-11-23 · Fire 2022-11-23

41 health deficiencies

Top issue: Quality of Life and Care (10 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Fire safety

Fire-safety citations

D · Potential for more than minimal harm 2024-12-06

K342 · Smoke Deficiencies

Fire Safety

Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.

Corrected 2024-12-24

D · Potential for more than minimal harm 2024-12-06

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2024-12-24

D · Potential for more than minimal harm 2024-12-06

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-12-24

D · Potential for more than minimal harm 2024-12-06

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2024-12-24

E · Potential for more than minimal harm 2023-11-30

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2023-12-18

E · Potential for more than minimal harm 2023-11-30

K912 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have power receptacles that are properly grounded.

Corrected 2023-12-18

D · Potential for more than minimal harm 2023-11-30

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2023-12-18

C · Minimal harm 2023-11-30

E41 · Emergency Preparedness Deficiencies

Fire Safety

Implement emergency and standby power systems.

Corrected 2023-12-18

Inspection history

Recent health citations

E · Potential for more than minimal harm 2026-01-06

F755 · Pharmacy Service Deficiencies

Health

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected 2026-01-22

D · Potential for more than minimal harm 2026-01-06

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 2026-01-22

D · Potential for more than minimal harm 2026-01-06

F686 · Quality of Life and Care Deficiencies

Health

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

Corrected 2026-01-22

D · Potential for more than minimal harm 2026-01-06

F881 · Infection Control Deficiencies

Health

Implement a program that monitors antibiotic use.

Corrected 2026-01-22

D · Potential for more than minimal harm 2025-10-14

F583 · Resident Rights Deficiencies

Health

Keep residents' personal and medical records private and confidential.

Corrected 2025-11-26

D · Potential for more than minimal harm 2025-10-14

F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Corrected 2025-11-26

D · Potential for more than minimal harm 2025-10-14

F842 · Resident Assessment and Care Planning Deficiencies

Health

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected 2025-11-26

D · Potential for more than minimal harm 2025-08-12

F628 · Resident Rights Deficiencies

Health

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

Corrected 2025-08-21

D · Potential for more than minimal harm 2025-08-05

F842 · Resident Assessment and Care Planning Deficiencies

Health

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected 2025-08-20

D · Potential for more than minimal harm 2025-06-09

F585 · Resident Rights Deficiencies

Health

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Corrected 2025-06-24

E · Potential for more than minimal harm 2025-06-02

F573 · Resident Rights Deficiencies

Health

Let each resident or the resident's legal representative access or purchase copies of all the resident's records.

Corrected 2025-06-13

D · Potential for more than minimal harm 2025-06-02

F842 · Resident Assessment and Care Planning Deficiencies

Health

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected 2025-06-13

D · Potential for more than minimal harm 2025-05-12

F580 · Resident Rights Deficiencies

Health

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Corrected 2025-05-30

D · Potential for more than minimal harm 2025-05-12

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 2025-05-30

D · Potential for more than minimal harm 2025-03-11

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.

Corrected 2025-04-03

D · Potential for more than minimal harm 2025-01-24

F655 · Resident Assessment and Care Planning Deficiencies

Health

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Corrected 2025-02-13

E · Potential for more than minimal harm 2024-12-06

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 2024-12-30

E · Potential for more than minimal harm 2024-12-06

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 2024-12-30

E · Potential for more than minimal harm 2024-12-06

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 2024-12-30

E · Potential for more than minimal harm 2024-12-06

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 2024-12-30

E · Potential for more than minimal harm 2024-12-06

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 2024-12-30

E · Potential for more than minimal harm 2024-12-06

F755 · Pharmacy Service Deficiencies

Health

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected 2024-12-30

E · Potential for more than minimal harm 2024-12-06

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 2024-12-30

E · Potential for more than minimal harm 2024-12-06

F759 · Pharmacy Service Deficiencies

Health

Ensure medication error rates are not 5 percent or greater.

Corrected 2024-12-30

E · Potential for more than minimal harm 2024-12-06

F805 · Nutrition and Dietary Deficiencies

Health

Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

Corrected 2024-12-30

E · Potential for more than minimal harm 2024-12-06

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 2024-12-30

D · Potential for more than minimal harm 2024-12-06

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 2024-12-30

D · Potential for more than minimal harm 2024-12-06

F580 · Resident Rights Deficiencies

Health

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Corrected 2024-12-30

D · Potential for more than minimal harm 2024-12-06

F655 · Resident Assessment and Care Planning Deficiencies

Health

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Corrected 2024-12-30

D · Potential for more than minimal harm 2024-12-06

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 2024-12-30

D · Potential for more than minimal harm 2024-12-06

F695 · Quality of Life and Care Deficiencies

Health

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

Corrected 2024-12-30

D · Potential for more than minimal harm 2024-12-06

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 2024-12-30

D · Potential for more than minimal harm 2024-12-06

F804 · Nutrition and Dietary Deficiencies

Health

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Corrected 2024-12-30

D · Potential for more than minimal harm 2024-12-06

F842 · Resident Assessment and Care Planning Deficiencies

Health

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected 2024-12-30

D · Potential for more than minimal harm 2024-12-06

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-12-30

D · Potential for more than minimal harm 2024-12-06

F881 · Infection Control Deficiencies

Health

Implement a program that monitors antibiotic use.

Corrected 2024-12-30

B · Minimal harm 2024-12-06

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2024-12-30

D · Potential for more than minimal harm 2024-11-27

F686 · Quality of Life and Care Deficiencies

Health

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

Corrected 2024-12-18

D · Potential for more than minimal harm 2024-11-27

F757 · Pharmacy Service Deficiencies

Health

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Corrected 2024-12-18

D · Potential for more than minimal harm 2024-11-27

F842 · Resident Assessment and Care Planning Deficiencies

Health

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected 2024-12-18

D · Potential for more than minimal harm 2024-10-29

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2024-11-19

D · Potential for more than minimal harm 2024-10-29

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.

Corrected 2024-11-19

D · Potential for more than minimal harm 2024-10-29

F842 · Resident Assessment and Care Planning Deficiencies

Health

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected 2024-11-19

D · Potential for more than minimal harm 2024-08-19

F686 · Quality of Life and Care Deficiencies

Health

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

Corrected 2024-08-29

D · Potential for more than minimal harm 2024-08-15

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-09-04

D · Potential for more than minimal harm 2024-05-21

F686 · Quality of Life and Care Deficiencies

Health

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

Corrected 2024-06-11

D · Potential for more than minimal harm 2024-03-14

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 2024-03-22

D · Potential for more than minimal harm 2024-03-14

F694 · Quality of Life and Care Deficiencies

Health

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

Corrected 2024-03-22

D · Potential for more than minimal harm 2024-02-02

F692 · Quality of Life and Care Deficiencies

Health

Provide enough food/fluids to maintain a resident's health.

Corrected 2024-02-15

D · Potential for more than minimal harm 2023-12-08

F573 · Resident Rights Deficiencies

Health

Let each resident or the resident's legal representative access or purchase copies of all the resident's records.

Corrected 2023-12-27

E · Potential for more than minimal harm 2023-11-30

F558 · Resident Rights Deficiencies

Health

Reasonably accommodate the needs and preferences of each resident.

Corrected 2023-12-22

E · Potential for more than minimal harm 2023-11-30

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 2023-12-22

E · Potential for more than minimal harm 2023-11-30

F658 · Resident Assessment and Care Planning Deficiencies

Health

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected 2023-12-22

E · Potential for more than minimal harm 2023-11-30

F694 · Quality of Life and Care Deficiencies

Health

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

Corrected 2023-12-22

E · Potential for more than minimal harm 2023-11-30

F755 · Pharmacy Service Deficiencies

Health

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected 2023-12-22

E · Potential for more than minimal harm 2023-11-30

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 2023-12-22

D · Potential for more than minimal harm 2023-11-30

F554 · Resident Rights Deficiencies

Health

Allow residents to self-administer drugs if determined clinically appropriate.

Corrected 2023-12-22

D · Potential for more than minimal harm 2023-11-30

F625 · Resident Rights Deficiencies

Health

Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

Corrected 2023-12-22

D · Potential for more than minimal harm 2023-11-30

F655 · Resident Assessment and Care Planning Deficiencies

Health

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Corrected 2023-12-22

D · Potential for more than minimal harm 2023-11-30

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 2023-12-22

D · Potential for more than minimal harm 2023-11-30

F686 · Quality of Life and Care Deficiencies

Health

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

Corrected 2023-12-22

D · Potential for more than minimal harm 2023-11-30

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 2023-12-22

D · Potential for more than minimal harm 2023-11-30

F725 · Nursing and Physician Services Deficiencies

Health

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Corrected 2023-12-22

D · Potential for more than minimal harm 2023-11-30

F744 · Quality of Life and Care Deficiencies

Health

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Corrected 2023-12-22

D · Potential for more than minimal harm 2023-11-30

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 2023-12-22

D · Potential for more than minimal harm 2023-11-30

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2023-12-22

D · Potential for more than minimal harm 2023-11-30

F919 · Environmental Deficiencies

Health

Make sure that a working call system is available in each resident's bathroom and bathing area.

Corrected 2023-12-22

B · Minimal harm 2023-11-30

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2023-12-22

F · Potential for more than minimal harm 2023-10-20

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 2023-10-27

D · Potential for more than minimal harm 2023-09-29

F582 · Resident Rights Deficiencies

Health

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Corrected 2023-10-13

D · Potential for more than minimal harm 2023-09-27

F694 · Quality of Life and Care Deficiencies

Health

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

Corrected 2023-10-13

J · Immediate jeopardy 2023-09-14

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2023-10-16

E · Potential for more than minimal harm 2023-09-14

F695 · Quality of Life and Care Deficiencies

Health

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

Corrected 2023-10-16

D · Potential for more than minimal harm 2023-09-14

F552 · Resident Rights Deficiencies

Health

Ensure that residents are fully informed and understand their health status, care and treatments.

Corrected 2023-10-16

D · Potential for more than minimal harm 2023-09-14

F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Corrected 2023-10-16

D · Potential for more than minimal harm 2023-09-14

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 2023-10-16

D · Potential for more than minimal harm 2023-09-14

F842 · Resident Assessment and Care Planning Deficiencies

Health

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected 2023-10-16

D · Potential for more than minimal harm 2023-09-14

F849 · Administration Deficiencies

Health

Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

Corrected 2023-10-16

D · Potential for more than minimal harm 2023-09-14

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2023-10-16

D · Potential for more than minimal harm 2023-07-05

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 2023-07-20

D · Potential for more than minimal harm 2023-07-05

F695 · Quality of Life and Care Deficiencies

Health

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

Corrected 2023-07-20

D · Potential for more than minimal harm 2023-07-05

F755 · Pharmacy Service Deficiencies

Health

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected 2023-07-20

D · Potential for more than minimal harm 2023-07-05

F770 · Administration Deficiencies

Health

Provide timely, quality laboratory services/tests to meet the needs of residents.

Corrected 2023-07-20

E · Potential for more than minimal harm 2023-05-24

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2023-06-12

D · Potential for more than minimal harm 2023-05-24

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 2023-06-12

D · Potential for more than minimal harm 2023-05-24

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 2023-06-12

D · Potential for more than minimal harm 2023-05-24

F842 · Resident Assessment and Care Planning Deficiencies

Health

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected 2023-06-12

E · Potential for more than minimal harm 2022-11-23

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 2022-12-16

E · Potential for more than minimal harm 2022-11-23

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 2022-12-16

E · Potential for more than minimal harm 2022-11-23

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 2022-12-16

E · Potential for more than minimal harm 2022-11-23

F730 · Nursing and Physician Services Deficiencies

Health

Observe each nurse aide's job performance and give regular training.

Corrected 2022-12-16

E · Potential for more than minimal harm 2022-11-23

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 2022-12-16

E · Potential for more than minimal harm 2022-11-23

F825 · Quality of Life and Care Deficiencies

Health

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

Corrected 2022-12-16

E · Potential for more than minimal harm 2022-11-23

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2022-12-16

D · Potential for more than minimal harm 2022-11-23

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 2022-12-16

D · Potential for more than minimal harm 2022-11-23

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 2022-12-16

D · Potential for more than minimal harm 2022-11-23

F583 · Resident Rights Deficiencies

Health

Keep residents' personal and medical records private and confidential.

Corrected 2022-12-16

D · Potential for more than minimal harm 2022-11-23

F585 · Resident Rights Deficiencies

Health

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Corrected 2022-12-16

D · Potential for more than minimal harm 2022-11-23

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2022-12-16

D · Potential for more than minimal harm 2022-11-23

F645 · Resident Assessment and Care Planning Deficiencies

Health

PASARR screening for Mental disorders or Intellectual Disabilities

Corrected 2022-12-16

D · Potential for more than minimal harm 2022-11-23

F658 · Resident Assessment and Care Planning Deficiencies

Health

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected 2022-12-16

D · Potential for more than minimal harm 2022-11-23

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 2022-12-16

D · Potential for more than minimal harm 2022-11-23

F686 · Quality of Life and Care Deficiencies

Health

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

Corrected 2022-12-16

D · Potential for more than minimal harm 2022-11-23

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 2022-12-16

D · Potential for more than minimal harm 2022-11-23

F755 · Pharmacy Service Deficiencies

Health

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected 2022-12-16

D · Potential for more than minimal harm 2022-11-23

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 2022-12-16

D · Potential for more than minimal harm 2022-11-23

F886 · Infection Control Deficiencies

Health

Perform COVID19 testing on residents and staff.

Corrected 2022-12-16

Penalties and ownership

What sits behind the stars

Ownership

Win Win Enterprises, LLC

5% Or Greater Direct Ownership Interest · Organization

49% 28 facilities 1977-04-01
Jennifer Nurit Smedra Trust 1997 Trust

5% Or Greater Direct Ownership Interest · Organization

19% 5 facilities 1998-05-27
Shersher LP

5% Or Greater Direct Ownership Interest · Organization

11% 6 facilities 1998-05-27
Jenmax Enterprises LLC

5% Or Greater Direct Ownership Interest · Organization

8% 9 facilities 1998-05-27
Latt, Maureen

5% Or Greater Direct Ownership Interest · Individual

7% 3 facilities 1998-05-27
Smedra, Ira

5% Or Greater Indirect Ownership Interest · Individual

6% 98 facilities 1998-05-27
Bhardwaj, Ashwani

Operational/Managerial Control · Individual

0% 3 facilities 2023-06-24
Butenko, Julie

Operational/Managerial Control · Individual

0% 20 facilities 2023-07-24
Cambridge Healthcare Services LLC

Operational/Managerial Control · Organization

0% 20 facilities 2014-04-01
Capela, Heidi

Operational/Managerial Control · Individual

0% 20 facilities 2023-04-03
Gervacio, Josefina

Operational/Managerial Control · Individual

0% 2 facilities 2023-11-20
Hassell, Lance

Operational/Managerial Control · Individual

0% 37 facilities 2022-04-25
Lutz, Linda

Operational/Managerial Control · Individual

0% 20 facilities 2012-02-01
Moore, Amanda

Operational/Managerial Control · Individual

0% 7 facilities 2023-05-08
Morales, Marieta

Operational/Managerial Control · Individual

0% 1 facilities 2023-03-01
Preferred Bank

Operational/Managerial Control · Organization

0% 2 facilities 2024-09-06
Salazar, Paulina

Operational/Managerial Control · Individual

0% 25 facilities 2020-12-14
Smedra, Ira

Operational/Managerial Control · Individual

0% 98 facilities 1998-05-27
Wintner, Jacob

Operational/Managerial Control · Individual

0% 35 facilities 1998-05-27

Nearby options

Other facilities in reach

#1

Astoria Healthcare Center

Sylmar, CA

1-star overall rating with 1-star inspections with Special Focus status with $16,820 in total fines with 51 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle

Overall
1 / 5
Health
1 / 5
Staffing
3 / 5
Fines
$16,820
#2

Maclay Healthcare Center

Sylmar, CA

2-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $297,315 in total fines with 46 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle

Overall
2 / 5
Health
1 / 5
Staffing
3 / 5
Fines
$297,315
#3

The Grove Post-Acute Care Center

Sylmar, CA

2-star overall rating with 1-star inspections with $17,345 in total fines with 33 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle

Overall
2 / 5
Health
1 / 5
Staffing
3 / 5
Fines
$17,345

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