Cycle 1
Health 2025-06-05 · Fire 2025-06-05
7 health deficiencies
Top issue: Environmental (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Ontario, CA
Ontario Grove Healthcare & Wellness Centre, LP
4-star overall rating with 4-star inspections with 7 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
933 East Deodar Street, Ontario, CA
(909) 985-2731
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
59
Certified beds
Average residents
56
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Country Villa Health Services
Operator or chain grouping
Approved since
1971-09-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
6 facilities
Chain averages 3 overall / 2 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
0.44
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.18
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
2.45
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
4.07
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
1.62
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
3.73
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.29
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.20
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.37
CMS adjusted RN staffing hours
Adjusted total hours
3.41
CMS adjusted total nurse staffing hours
Case-mix index
1.63
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
22%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,168
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
37.16
Composite VBP score used to determine payment impact.
Payment multiplier
0.9904
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
6.26
Baseline 45.00% · Performance 38.09% · Measure score 6.26 · Achievement 6.26 · Improvement 2.93
Adjusted total nurse staffing
1.17
Baseline 3.74 hours · Performance 3.41 hours · Measure score 1.17 · Achievement 1.17 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.26% |
10.72%
1.5 pts worse
|
No Different than the National Rate · Eligible stays 33 · Observed rate 24.24% · Lower 95% interval 7.9% |
| Discharge to community | 44.14% |
50.57%
6.4 pts worse
|
No Different than the National Rate · Eligible stays 28 · Observed rate 32.14% · Lower 95% interval 27.43% |
| Medicare spending per beneficiary | 1.27 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 87 · Denominator 87 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 87 |
| Discharge self-care score | 35.85% |
53.69%
17.8 pts worse
|
Numerator 19 · Denominator 53 |
| Discharge mobility score | 43.4% |
50.94%
7.5 pts worse
|
Numerator 23 · Denominator 53 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 87 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 24 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 18.8% |
8.2%
10.6 pts better
|
Numerator 22 · Denominator 117 |
| Staff flu vaccination coverage | 41.86% |
42%
0.1 pts worse
|
Numerator 54 · Denominator 129 |
| Discharge function score | 43.4% |
56.45%
13.1 pts worse
|
Numerator 23 · Denominator 53 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 37 · Denominator 37 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 27.08% |
25.2%
1.9 pts better
|
Numerator 13 · Denominator 48 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.3 |
2.3
1 pts worse
|
1.9
1.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.3 · Observed 4.1 · Expected 2.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.0 |
1.6
0.4 pts worse
|
1.8
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 2.1 · Expected 1.7 · 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 | 0.5% |
1.6%
1.1 pts better
|
3.3%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 6.0% |
6.8%
0.8 pts better
|
11.4%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 6.4% · Q3 7.0% · Q4 4.9% · 4Q avg 6.0% |
| Percentage of long-stay residents who lose too much weight | 5.8% |
4.1%
1.7 pts worse
|
5.4%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 8.5% · Q3 2.4% · Q4 9.8% · 4Q avg 5.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 5.5% |
13.7%
8.2 pts better
|
19.6%
14.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 8.0% · Q3 4.3% · Q4 4.7% · 4Q avg 5.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 9.0% |
14.2%
5.2 pts better
|
16.7%
7.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.9% · Q2 8.8% · Q3 8.6% · Q4 5.9% · 4Q avg 9.0% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.4%
0.4 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 7.9% |
11.0%
3.1 pts better
|
16.3%
8.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 8.4% · 4Q avg 7.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.4% |
10.7%
2.3 pts better
|
14.9%
6.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 6.8% · Q3 10.5% · Q4 8.3% · 4Q avg 8.4% · 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 | 1.2% |
1.2%
About the same
|
1.7%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 2.1% · Q3 0.0% · Q4 0.0% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 3.6% |
10.9%
7.3 pts better
|
19.8%
16.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 0.0% · Q3 2.4% · Q4 8.0% · 4Q avg 3.6% |
| Percentage of long-stay residents with pressure ulcers | 2.7% |
4.7%
2 pts better
|
5.1%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 2.9% · Q3 2.7% · Q4 2.4% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
94.0%
6 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.1% |
11.2%
1.9 pts worse
|
12.0%
1.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.1% · Observed 13.2% · Expected 11.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 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 | 20.2% |
23.2%
3 pts better
|
23.9%
3.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.2% · Observed 25.0% · Expected 29.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-12-02 · Fire 2022-12-02
10 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
3 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Cycle 3
Health 2019-05-31 · Fire 2019-05-31
13 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
6 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-06-05
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-06-20
F · Potential for more than minimal harm
2025-06-05
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-06-23
D · Potential for more than minimal harm
2025-06-05
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-06-17
D · Potential for more than minimal harm
2022-12-02
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2023-01-03
D · Potential for more than minimal harm
2022-12-02
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 2023-01-03
D · Potential for more than minimal harm
2022-12-02
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-01-03
D · Potential for more than minimal harm
2019-05-31
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2019-07-03
D · Potential for more than minimal harm
2019-05-31
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2019-07-03
D · Potential for more than minimal harm
2019-05-31
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2019-07-03
D · Potential for more than minimal harm
2019-05-31
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2019-07-03
D · Potential for more than minimal harm
2019-05-31
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-07-03
D · Potential for more than minimal harm
2019-05-31
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2019-07-03
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-23
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2026-01-09
F · Potential for more than minimal harm
2025-06-05
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 2025-06-26
D · Potential for more than minimal harm
2025-06-05
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 2025-06-26
D · Potential for more than minimal harm
2025-06-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-26
D · Potential for more than minimal harm
2025-06-05
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2025-06-26
B · Minimal harm
2025-06-05
F912 · Environmental Deficiencies
Health
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Corrected 2025-06-26
D · Potential for more than minimal harm
2025-03-03
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-03-24
D · Potential for more than minimal harm
2024-09-18
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-10-14
E · Potential for more than minimal harm
2023-03-30
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2023-04-14
F · Potential for more than minimal harm
2022-12-02
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 2022-12-30
D · Potential for more than minimal harm
2022-12-02
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 2022-12-30
D · Potential for more than minimal harm
2022-12-02
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2022-12-30
D · Potential for more than minimal harm
2022-12-02
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 2022-12-30
D · Potential for more than minimal harm
2022-12-02
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 2022-12-30
D · Potential for more than minimal harm
2022-12-02
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 2022-12-30
D · Potential for more than minimal harm
2022-12-02
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 2022-12-30
D · Potential for more than minimal harm
2022-12-02
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-12-30
B · Minimal harm
2022-12-02
F912 · Environmental Deficiencies
Health
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Corrected 2022-12-30
D · Potential for more than minimal harm
2019-05-31
F557 · Resident Rights Deficiencies
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2019-06-21
D · Potential for more than minimal harm
2019-05-31
F635 · Resident Assessment and Care Planning Deficiencies
Health
Provide doctor's orders for the resident's immediate care at the time the resident was admitted.
Corrected 2019-06-21
D · Potential for more than minimal harm
2019-05-31
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2019-06-21
D · Potential for more than minimal harm
2019-05-31
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 2019-06-21
D · Potential for more than minimal harm
2019-05-31
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2019-06-21
D · Potential for more than minimal harm
2019-05-31
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2019-06-21
D · Potential for more than minimal harm
2019-05-31
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 2019-06-21
D · Potential for more than minimal harm
2019-05-31
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 2019-06-21
D · Potential for more than minimal harm
2019-05-31
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 2019-06-21
D · Potential for more than minimal harm
2019-05-31
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-06-21
D · Potential for more than minimal harm
2019-05-31
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2019-06-21
B · Minimal harm
2019-05-31
F912 · Environmental Deficiencies
Health
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Corrected 2019-06-21
Penalties and ownership
What sits behind the stars
Ownership
Bartolome, Nenita
Operational/Managerial Control · Individual
Corporate Interface Services LLC
Operational/Managerial Control · Organization
Ontario Grove Wellness Gp, LLC
General Partnership Interest · Organization
Rechnitz, Shlomo
Limited Partnership Interest · Individual
Rockport Administrative Services, LLC
Operational/Managerial Control · Organization
Thiagarajan, Deepak
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
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Ontario, CA
2-star overall rating with 2-star inspections with $70,925 in total fines with 18 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Upland Rehabilitation and Care Center
Upland, CA
5-star overall rating with 4-star inspections with 16 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Heritage Park Nursing Center
Upland, CA
5-star overall rating with 4-star inspections with 5 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
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