Cycle 1
Health 2025-02-06 · Fire 2025-02-06
2 health deficiencies
Top issue: Environmental (1 deficiency)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Redlands, CA
Redlands Healthcare Center
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
1620 West Fern Avenue, Redlands, CA
(909) 793-2609
Overall
5 / 5
CMS overall stars
Health inspections
5 / 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
78
Certified beds
Average residents
74
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Pacs Group
Operator or chain grouping
Approved since
1978-08-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
264 facilities
Chain averages 3 overall / 3 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
0.38
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.23
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
2.60
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
4.21
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
1.61
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
3.80
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.23
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.13
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.29
CMS adjusted RN staffing hours
Adjusted total hours
3.25
CMS adjusted total nurse staffing hours
Case-mix index
1.77
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
46%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,111
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
21.40
Composite VBP score used to determine payment impact.
Payment multiplier
0.9826
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.26
Baseline 21.75% · Performance 19.03% · Measure score 5.26 · Achievement 5.18 · Improvement 5.26
Healthcare-associated infections
0
Baseline 6.83% · Performance 8.52% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
2.51
Baseline 64.05% · Performance 53.41% · Measure score 2.51 · Achievement 2.51 · Improvement 2.21
Adjusted total nurse staffing
0.79
Baseline 3.75 hours · Performance 3.30 hours · Measure score 0.79 · Achievement 0.79 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.13% |
10.72%
0.6 pts better
|
No Different than the National Rate · Eligible stays 166 · Observed rate 9.64% · Lower 95% interval 7.02% |
| Discharge to community | 53.32% |
50.57%
2.8 pts better
|
No Different than the National Rate · Eligible stays 182 · Observed rate 45.05% · Lower 95% interval 46.65% |
| Medicare spending per beneficiary | 1.42 |
1.02
0.4 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 211 · Denominator 211 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 211 |
| Discharge self-care score | 17.78% |
53.69%
35.9 pts worse
|
Numerator 8 · Denominator 45 |
| Discharge mobility score | 22.22% |
50.94%
28.7 pts worse
|
Numerator 10 · Denominator 45 |
| Pressure ulcers or injuries, new or worsened | 0.47% |
2.29%
1.8 pts better
|
Numerator 1 · Denominator 211 · Adjusted rate 0.36% |
| Healthcare-associated infections requiring hospitalization | 8.52% |
7.12%
1.4 pts worse
|
No Different than the National Rate · Eligible stays 131 · Observed rate 10.69% · Lower 95% interval 5.63% |
| Staff COVID-19 vaccination coverage | 5.34% |
8.2%
2.9 pts worse
|
Numerator 7 · Denominator 131 |
| Staff flu vaccination coverage | 41.79% |
42%
0.2 pts worse
|
Numerator 140 · Denominator 335 |
| Discharge function score | 24.44% |
56.45%
32 pts worse
|
Numerator 11 · Denominator 45 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 84 · Denominator 84 |
| Transfer of health information to patient | 98.92% |
96.28%
2.6 pts better
|
Numerator 92 · Denominator 93 |
| Resident COVID-19 vaccinations up to date | 13.79% |
25.2%
11.4 pts worse
|
Numerator 16 · Denominator 116 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.0 |
2.3
0.3 pts better
|
1.9
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 2.3 · Expected 2.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.7 |
1.6
1.1 pts worse
|
1.8
0.9 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.7 · Observed 2.5 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
98.5%
1.5 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
98.2%
1.8 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.2% |
1.6%
0.4 pts better
|
3.3%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 0.0% · Q3 0.0% · Q4 2.4% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 26.3% |
6.8%
19.5 pts worse
|
11.4%
14.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.4% · Q2 25.8% · Q3 30.8% · Q4 18.2% · 4Q avg 26.3% |
| Percentage of long-stay residents who lose too much weight | 1.5% |
4.1%
2.6 pts better
|
5.4%
3.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.3% · Q3 0.0% · Q4 2.9% · 4Q avg 1.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.0% |
13.7%
0.7 pts better
|
19.6%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.7% · Q2 18.2% · Q3 12.5% · Q4 11.8% · 4Q avg 13.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 7.9% |
14.2%
6.3 pts better
|
16.7%
8.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q2 14.3% · Q3 3.7% · Q4 0.0% · 4Q avg 7.9% · 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 | 12.3% |
11.0%
1.3 pts worse
|
16.3%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 12.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.7% |
10.7%
2 pts worse
|
14.9%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.5% · Q2 7.1% · Q3 5.6% · Q4 28.6% · 4Q avg 12.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.7% |
1.0%
0.7 pts worse
|
1.0%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.3% · Q3 4.1% · Q4 0.0% · 4Q avg 1.7% · 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 | 12.9% |
10.9%
2 pts worse
|
19.8%
6.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.7% · Q2 6.9% · Q3 14.7% · Q4 15.4% · 4Q avg 12.9% |
| Percentage of long-stay residents with pressure ulcers | 1.9% |
4.7%
2.8 pts better
|
5.1%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 2.3% · Q3 2.1% · Q4 0.0% · 4Q avg 1.9% · 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 | 16.9% |
11.2%
5.7 pts worse
|
12.0%
4.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 16.9% · Observed 16.3% · Expected 10.8% · 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 | 20.7% |
23.2%
2.5 pts better
|
23.9%
3.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.7% · Observed 22.1% · Expected 25.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-02 · Fire 2024-02-02
6 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
8 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2022-06-10 · Fire 2022-06-10
9 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
7 fire-safety deficiencies
Top issue: Miscellaneous (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-02-06
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-03-03
F · Potential for more than minimal harm
2024-02-02
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-03-12
F · Potential for more than minimal harm
2024-02-02
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-03-12
D · Potential for more than minimal harm
2024-02-02
E32 · Emergency Preparedness Deficiencies
Fire Safety
Provide primary/alternate means for communication.
Corrected 2024-03-12
D · Potential for more than minimal harm
2024-02-02
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-03-12
D · Potential for more than minimal harm
2024-02-02
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-03-12
D · Potential for more than minimal harm
2024-02-02
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2024-03-12
D · Potential for more than minimal harm
2024-02-02
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 2024-03-12
D · Potential for more than minimal harm
2024-02-02
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-03-12
D · Potential for more than minimal harm
2022-06-10
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-07-14
D · Potential for more than minimal harm
2022-06-10
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-07-14
D · Potential for more than minimal harm
2022-06-10
K700 · Miscellaneous Deficiencies
Fire Safety
Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors.
Corrected 2022-07-14
D · Potential for more than minimal harm
2022-06-10
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 2022-07-14
D · Potential for more than minimal harm
2022-06-10
K900 · Miscellaneous Deficiencies
Fire Safety
Meet Health Care Facilities Code mechanical requirements.
Corrected 2022-07-14
D · Potential for more than minimal harm
2022-06-10
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-07-14
C · Minimal harm
2022-06-10
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2022-07-14
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-02-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-01
D · Potential for more than minimal harm
2025-02-06
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2025-03-01
D · Potential for more than minimal harm
2024-04-17
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-04-22
F · Potential for more than minimal harm
2024-02-02
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 2024-02-29
E · Potential for more than minimal harm
2024-02-02
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 2024-02-29
D · Potential for more than minimal harm
2024-02-02
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 2024-02-29
D · Potential for more than minimal harm
2024-02-02
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-02-29
D · Potential for more than minimal harm
2024-02-02
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 2024-02-29
F · Potential for more than minimal harm
2022-06-10
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 2022-07-18
E · Potential for more than minimal harm
2022-06-10
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 2022-07-18
E · Potential for more than minimal harm
2022-06-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-07-18
D · Potential for more than minimal harm
2022-06-10
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 2022-07-18
D · Potential for more than minimal harm
2022-06-10
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 2022-07-18
D · Potential for more than minimal harm
2022-06-10
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 2022-07-18
D · Potential for more than minimal harm
2022-06-10
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 2022-07-18
D · Potential for more than minimal harm
2022-06-10
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 2022-07-18
D · Potential for more than minimal harm
2022-06-10
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 2022-07-18
Penalties and ownership
What sits behind the stars
Ownership
Providence Group Nh, LLC
5% Or Greater Direct Ownership Interest · Organization
Apt, Frederick
Corporate Officer · Individual
Bai, Shuang
Contracted Managing Employee · Individual
Driggs, Daniel
W-2 Managing Employee · Individual
Hancock, Mark
5% Or Greater Indirect Ownership Interest · Individual
Hancock, Mark
Corporate Officer · Individual
Jergensen, Joshua
Corporate Officer · Individual
Mitchell, John
Corporate Officer · Individual
Murray, Jason
5% Or Greater Indirect Ownership Interest · Individual
Murray, Jason
Corporate Officer · Individual
Pacs Group, Inc.
5% Or Greater Indirect Ownership Interest · Organization
Pacs Holdings, LLC
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Other facilities in reach
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Redlands Comm Hosp D/p Snf
Redlands, CA
5-star overall rating with 5-star inspections with 5 recent health deficiencies with 3 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
Brookside Healthcare Center
Redlands, CA
3-star overall rating with 3-star inspections with 12 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
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