Cycle 1
Health 2024-10-24 · Fire 2024-10-24
5 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
4 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Ontario, CA
Ontario Healthcare Center
4-star overall rating with 4-star inspections with 5 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
1661 South Euclid Avenue, Ontario, CA
(909) 984-6713
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
57
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Cambridge Healthcare Services
Operator or chain grouping
Approved since
1969-05-01
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
0.32
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.11
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
2.29
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
3.73
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
1.44
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
3.50
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.31
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
0.33
CMS adjusted RN staffing hours
Adjusted total hours
3.80
CMS adjusted total nurse staffing hours
Case-mix index
1.34
Higher values indicate more complex resident acuity
RN turnover
57%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
45%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,373
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
20.61
Composite VBP score used to determine payment impact.
Payment multiplier
0.9824
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
1.82
Baseline 41.07% · Performance 56.25% · Measure score 1.82 · Achievement 1.82 · Improvement 0
Adjusted total nurse staffing
2.30
Baseline 3.93 hours · Performance 3.73 hours · Measure score 2.30 · Achievement 2.30 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.63% |
10.72%
1.1 pts better
|
No Different than the National Rate · Eligible stays 32 · Observed rate 3.13% · Lower 95% interval 6.37% |
| Discharge to community | 45.35% |
50.57%
5.2 pts worse
|
No Different than the National Rate · Eligible stays 26 · Observed rate 34.62% · Lower 95% interval 29.31% |
| Medicare spending per beneficiary | 1.29 |
1.02
0.3 pts worse
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 13 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 13 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 14.46% |
8.2%
6.3 pts better
|
Numerator 12 · Denominator 83 |
| Staff flu vaccination coverage | 24.78% |
42%
17.2 pts worse
|
Numerator 28 · Denominator 113 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 4.0 |
2.3
1.7 pts worse
|
1.9
2.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 4.0 · Observed 3.6 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.6 |
1.6
1 pts worse
|
1.8
0.8 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.6 · Observed 2.3 · 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 | 97.9% |
98.2%
0.3 pts worse
|
95.5%
2.4 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.9% |
| 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 | 2.6% |
6.8%
4.2 pts better
|
11.4%
8.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 0.0% · Q3 2.3% · Q4 5.3% · 4Q avg 2.6% |
| Percentage of long-stay residents who lose too much weight | 4.1% |
4.1%
About the same
|
5.4%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 5.6% · Q3 2.6% · Q4 5.4% · 4Q avg 4.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.7% |
13.7%
5 pts worse
|
19.6%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q2 18.9% · Q3 22.5% · Q4 18.4% · 4Q avg 18.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 23.9% |
14.2%
9.7 pts worse
|
16.7%
7.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.2% · Q3 27.6% · Q4 22.7% · 4Q avg 23.9% · 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 | 4.8% |
11.0%
6.2 pts better
|
16.3%
11.5 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 4.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.6% |
10.7%
1.9 pts worse
|
14.9%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.6% · Q2 11.8% · Q3 11.1% · Q4 12.1% · 4Q avg 12.6% · 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 2.6% · Q2 2.3% · 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 | 14.2% |
10.9%
3.3 pts worse
|
19.8%
5.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 35.3% · Q2 15.6% · Q3 6.7% · Q4 2.3% · 4Q avg 14.2% |
| Percentage of long-stay residents with pressure ulcers | 3.4% |
4.7%
1.3 pts better
|
5.1%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.3% · Q3 6.7% · Q4 2.0% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 83.3% |
94.0%
10.7 pts worse
|
81.7%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 82.4% · Q2 78.2% · Q3 85.1% · Q4 86.8% · 4Q avg 83.3% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.4% |
1.5%
1.1 pts better
|
1.6%
1.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.4% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 80.0% |
93.2%
13.2 pts worse
|
79.7%
0.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 80.0% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-02-14 · Fire 2022-02-14
12 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
18 fire-safety deficiencies
Top issue: Emergency Preparedness (8 deficiencies)
Cycle 3
Health 2019-03-29 · Fire 2019-03-29
6 health deficiencies
Top issue: Administration (1 deficiency)
8 fire-safety deficiencies
Top issue: Egress (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-10-24
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2024-11-14
F · Potential for more than minimal harm
2024-10-24
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-11-14
F · Potential for more than minimal harm
2024-10-24
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2024-11-14
F · Potential for more than minimal harm
2024-10-24
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-11-14
F · Potential for more than minimal harm
2022-02-14
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2022-03-28
E · Potential for more than minimal harm
2022-02-14
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2022-03-28
D · Potential for more than minimal harm
2022-02-14
E20 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures including evacuation.
Corrected 2022-03-28
D · Potential for more than minimal harm
2022-02-14
E24 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2022-03-28
D · Potential for more than minimal harm
2022-02-14
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2022-03-28
D · Potential for more than minimal harm
2022-02-14
E34 · Emergency Preparedness Deficiencies
Fire Safety
Provide a means of sharing information on occupancy/needs.
Corrected 2022-03-28
D · Potential for more than minimal harm
2022-02-14
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2022-03-28
D · Potential for more than minimal harm
2022-02-14
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2022-03-28
D · Potential for more than minimal harm
2022-02-14
E9 · Emergency Preparedness Deficiencies
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2022-03-28
D · Potential for more than minimal harm
2022-02-14
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2022-03-28
D · Potential for more than minimal harm
2022-02-14
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2022-03-28
D · Potential for more than minimal harm
2022-02-14
K361 · Smoke Deficiencies
Fire Safety
Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.
Corrected 2022-03-28
D · Potential for more than minimal harm
2022-02-14
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-03-28
D · Potential for more than minimal harm
2022-02-14
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-03-28
D · Potential for more than minimal harm
2022-02-14
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-03-28
D · Potential for more than minimal harm
2022-02-14
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-03-28
D · Potential for more than minimal harm
2022-02-14
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-03-28
D · Potential for more than minimal harm
2022-02-14
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-03-28
D · Potential for more than minimal harm
2019-03-29
E23 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for medical documentation.
Corrected 2019-06-20
D · Potential for more than minimal harm
2019-03-29
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2019-06-20
D · Potential for more than minimal harm
2019-03-29
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2019-06-20
D · Potential for more than minimal harm
2019-03-29
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 2019-06-20
D · Potential for more than minimal harm
2019-03-29
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2019-06-20
D · Potential for more than minimal harm
2019-03-29
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2019-06-20
D · Potential for more than minimal harm
2019-03-29
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2019-06-20
D · Potential for more than minimal harm
2019-03-29
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2019-06-20
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-10-24
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 2024-11-13
D · Potential for more than minimal harm
2024-10-24
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2024-11-13
D · Potential for more than minimal harm
2024-10-24
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-11-13
D · Potential for more than minimal harm
2024-10-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-13
B · Minimal harm
2024-10-24
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 2024-11-13
F · Potential for more than minimal harm
2022-02-14
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 2022-03-14
F · Potential for more than minimal harm
2022-02-14
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2022-03-14
E · Potential for more than minimal harm
2022-02-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-03-14
D · Potential for more than minimal harm
2022-02-14
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 2022-03-14
D · Potential for more than minimal harm
2022-02-14
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2022-03-14
D · Potential for more than minimal harm
2022-02-14
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-03-14
D · Potential for more than minimal harm
2022-02-14
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 2022-03-14
D · Potential for more than minimal harm
2022-02-14
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-03-14
D · Potential for more than minimal harm
2022-02-14
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-03-14
D · Potential for more than minimal harm
2022-02-14
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 2022-03-14
D · Potential for more than minimal harm
2022-02-14
F886 · Infection Control Deficiencies
Health
Perform COVID19 testing on residents and staff.
Corrected 2022-03-14
B · Minimal harm
2022-02-14
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 2022-03-14
K · Immediate jeopardy
2019-03-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-06-17
E · Potential for more than minimal harm
2019-03-29
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2019-05-15
E · Potential for more than minimal harm
2019-03-29
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 2019-05-15
D · Potential for more than minimal harm
2019-03-29
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 2019-05-15
D · Potential for more than minimal harm
2019-03-29
F836 · Administration Deficiencies
Health
Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.
Corrected 2019-05-15
B · Minimal harm
2019-03-29
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 2019-05-15
Penalties and ownership
What sits behind the stars
Ownership
Ksnf Ii LLC
5% Or Greater Indirect Ownership Interest · Organization
Butenko, Julie
Operational/Managerial Control · Individual
Cambridge Healthcare Services LLC
Operational/Managerial Control · Organization
Capela, Heidi
Operational/Managerial Control · Individual
Cardenas, Sonia
Operational/Managerial Control · Individual
Hassell, Lance
Operational/Managerial Control · Individual
Kirkside Facilities Operations LLC
5% Or Greater Direct Ownership Interest · Organization
Ksnf LLC
5% Or Greater Direct Ownership Interest · Organization
Lutz, Linda
Operational/Managerial Control · Individual
Quadros, Sylvi
Operational/Managerial Control · Individual
Salazar, Paulina
Operational/Managerial Control · Individual
Smedra, Ira
Operational/Managerial Control · Individual
Vidales, Miguel
Operational/Managerial Control · Individual
Wertz, Brittany
Operational/Managerial Control · Individual
Wintner, Jacob
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Inland Christian Home
Ontario, CA
4-star overall rating with 4-star inspections with 8 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#2
Trellis Chino
Chino, CA
5-star overall rating with 5-star inspections with 6 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
#3
Las Colinas Post Acute
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
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