Cycle 1
Health 2025-06-19 · Fire 2025-06-19
6 health deficiencies
Top issue: Infection Control (1 deficiency)
2 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Redlands, CA
Plymouth Village
5-star overall rating with 4-star inspections with 6 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
819 Salem Drive, Redlands, CA
(909) 793-1233
Overall
5 / 5
CMS overall stars
Health inspections
4 / 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
48
Certified beds
Average residents
44
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Humangood
Operator or chain grouping
Approved since
1968-03-29
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
17 facilities
Chain averages 4 overall / 4 health / 5 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
0.31
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.45
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
2.80
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
4.56
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
1.76
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
4.07
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.19
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.32
CMS adjusted RN staffing hours
Adjusted total hours
4.70
CMS adjusted total nurse staffing hours
Case-mix index
1.33
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
43%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,196
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
27.52
Composite VBP score used to determine payment impact.
Payment multiplier
0.9846
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Performance 22.07% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
0.6
Performance 7.66% · Measure score 0.6 · Achievement 0.6 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
4.38
Baseline 60.71% · Performance 45.76% · Measure score 4.38 · Achievement 4.38 · Improvement 3.67
Adjusted total nurse staffing
6.03
Baseline 5.44 hours · Performance 4.79 hours · Measure score 6.03 · Achievement 6.03 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.44% |
10.72%
0.3 pts better
|
No Different than the National Rate · Eligible stays 39 · Observed rate 7.69% · Lower 95% interval 6.13% |
| Discharge to community | 51.43% |
50.57%
0.9 pts better
|
No Different than the National Rate · Eligible stays 32 · Observed rate 46.88% · Lower 95% interval 36.61% |
| Medicare spending per beneficiary | 1.39 |
1.02
0.4 pts worse
|
|
| Drug regimen review with follow-up | 97.14% |
95.27%
1.9 pts better
|
Numerator 34 · Denominator 35 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 35 |
| Discharge self-care score | 76% |
53.69%
22.3 pts better
|
Numerator 19 · Denominator 25 |
| Discharge mobility score | 76% |
50.94%
25.1 pts better
|
Numerator 19 · Denominator 25 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 35 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.65% |
7.12%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 29 · Observed rate 10.34% · Lower 95% interval 3.93% |
| Staff COVID-19 vaccination coverage | 52.27% |
8.2%
44.1 pts better
|
Numerator 46 · Denominator 88 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 84% |
56.45%
27.5 pts better
|
Numerator 21 · Denominator 25 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 25 · Denominator 25 |
| 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 17 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| 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 | 97.5% |
98.2%
0.7 pts worse
|
95.5%
2 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.5% |
| 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 | 0.0% |
6.8%
6.8 pts better
|
11.4%
11.4 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 who lose too much weight | 0.0% |
4.1%
4.1 pts better
|
5.4%
5.4 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 who received an antianxiety or hypnotic medication | 8.2% |
13.7%
5.5 pts better
|
19.6%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.0% · Q2 12.0% · Q3 8.3% · Q4 4.2% · 4Q avg 8.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 2.5% |
14.2%
11.7 pts better
|
16.7%
14.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q4 0.0% · 4Q avg 2.5% · 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 | 14.7% |
11.0%
3.7 pts worse
|
16.3%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 14.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 6.4% |
10.7%
4.3 pts better
|
14.9%
8.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 13.0% · Q3 4.2% · Q4 9.1% · 4Q avg 6.4% · 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 | 4.8% |
1.2%
3.6 pts worse
|
1.7%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 5.3% · Q3 8.8% · Q4 0.0% · 4Q avg 4.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 14.7% |
10.9%
3.8 pts worse
|
19.8%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.4% · Q2 20.4% · Q3 6.0% · Q4 15.3% · 4Q avg 14.7% |
| Percentage of long-stay residents with pressure ulcers | 1.2% |
4.7%
3.5 pts better
|
5.1%
3.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 0.0% · Q3 3.2% · Q4 0.0% · 4Q avg 1.2% · 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 | 13.4% |
11.2%
2.2 pts worse
|
12.0%
1.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.4% · Observed 13.0% · Expected 10.9% · 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 · 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 | 97.4% |
93.2%
4.2 pts better
|
79.7%
17.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 97.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 16.6% |
23.2%
6.6 pts better
|
23.9%
7.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 16.6% · Observed 17.4% · Expected 25.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-04-26 · Fire 2024-04-26
7 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2023-03-10 · Fire 2023-03-10
9 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
15 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-06-19
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-07-16
F · Potential for more than minimal harm
2025-06-19
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 2025-07-16
D · Potential for more than minimal harm
2024-04-26
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-05-24
F · Potential for more than minimal harm
2023-03-10
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-04-20
E · Potential for more than minimal harm
2023-03-10
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-04-20
E · Potential for more than minimal harm
2023-03-10
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2023-04-20
E · Potential for more than minimal harm
2023-03-10
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2023-04-20
D · Potential for more than minimal harm
2023-03-10
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2023-04-20
D · Potential for more than minimal harm
2023-03-10
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2023-04-20
D · Potential for more than minimal harm
2023-03-10
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-04-20
D · Potential for more than minimal harm
2023-03-10
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-04-20
D · Potential for more than minimal harm
2023-03-10
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-04-20
D · Potential for more than minimal harm
2023-03-10
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2023-04-20
D · Potential for more than minimal harm
2023-03-10
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-04-20
D · Potential for more than minimal harm
2023-03-10
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-04-20
D · Potential for more than minimal harm
2023-03-10
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-04-20
D · Potential for more than minimal harm
2023-03-10
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2023-04-20
D · Potential for more than minimal harm
2023-03-10
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-04-20
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-06-19
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 2025-07-10
F · Potential for more than minimal harm
2025-06-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-07-10
D · Potential for more than minimal harm
2025-06-19
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-07-10
D · Potential for more than minimal harm
2025-06-19
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-07-10
D · Potential for more than minimal harm
2025-06-19
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-07-10
D · Potential for more than minimal harm
2025-06-19
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 2025-07-10
F · Potential for more than minimal harm
2024-04-26
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 2024-05-20
F · Potential for more than minimal harm
2024-04-26
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-05-20
F · Potential for more than minimal harm
2024-04-26
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 2024-05-20
D · Potential for more than minimal harm
2024-04-26
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 2024-05-20
D · Potential for more than minimal harm
2024-04-26
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 2024-05-20
D · Potential for more than minimal harm
2024-04-26
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 2024-05-20
D · Potential for more than minimal harm
2024-04-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-05-20
F · Potential for more than minimal harm
2023-03-10
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 2023-04-18
D · Potential for more than minimal harm
2023-03-10
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-04-18
D · Potential for more than minimal harm
2023-03-10
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 2023-04-18
D · Potential for more than minimal harm
2023-03-10
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-04-18
D · Potential for more than minimal harm
2023-03-10
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 2023-04-18
D · Potential for more than minimal harm
2023-03-10
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 2023-04-18
D · Potential for more than minimal harm
2023-03-10
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 2023-04-18
D · Potential for more than minimal harm
2023-03-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-04-18
D · Potential for more than minimal harm
2023-03-10
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 2023-04-18
Penalties and ownership
What sits behind the stars
Ownership
Humangood
5% Or Greater Indirect Ownership Interest · Organization
Humangood Norcal
5% Or Greater Direct Ownership Interest · Organization
Baker, Judith
Corporate Director · Individual
Battison, William
Corporate Director · Individual
Brown, Herman
Corporate Director · Individual
Christopherson, Joanne
Corporate Director · Individual
Cochrane, John
Operational/Managerial Control · Individual
Cochrane, John
Corporate Officer · Individual
Davis, Victoria
Operational/Managerial Control · Individual
Drake, Brett
Operational/Managerial Control · Individual
Feller, Irene
Corporate Director · Individual
Ghassemi, Bethany
Operational/Managerial Control · Individual
Ghassemi, Bethany
Corporate Officer · Individual
Griffith, Alan
Corporate Director · Individual
Harrison, Michael
Operational/Managerial Control · Individual
Holmes, Michelle
Corporate Director · Individual
Humangood Norcal
Operational/Managerial Control · Organization
Humangood Socal
Operational/Managerial Control · Organization
Kelley, Albert
Corporate Director · Individual
Lopez, Jessica
Operational/Managerial Control · Individual
Mcdonald, Andrew
Operational/Managerial Control · Individual
Mcdonald, Andrew
Corporate Officer · Individual
Nassar, Mohamed
Operational/Managerial Control · Individual
Nassar, Mohamed
Contracted Managing Employee · Individual
Ogus, Daniel
Operational/Managerial Control · Individual
Ogus, Daniel
Corporate Officer · Individual
Roth, Sharon
Corporate Director · Individual
Vangelisto, Gwen
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Highland Care Center Of Redlands
Redlands, CA
3-star overall rating with 3-star inspections with $12,931 in total fines with 14 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Madison Grove Post Acute
Redlands, CA
1-star overall rating with 3-star inspections with $9,110 in total fines with 11 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Redlands Healthcare Center
Redlands, CA
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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