Federal inspection record · CMS data as of October 1, 2026

Rio Hondo Subacute & Nursing Center

273 E Beverly Boulevard, Montebello, CA · (323) 724-5100

  • Special Focus Facility

CMS overall rating

Not rated
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Certified beds
200
Residents per day
154
Ownership
For-Profit
Chain
Genesis Healthcare
Medicare / Medicaid
Medicare + Medicaid
Certified since
October 9, 1985

3

What inspectors found

173 health citations on record since 2023. Each one gets a letter: the row says how badly residents were affected, the column how many.

One resident or a fewA patternWidespread

Immediate jeopardyResidents at risk of serious injury or death

J 3 50 pts
K 0 100 pts
L 0 150 pts

Actual harmA resident was hurt

G 9 20 pts
H 0 35 pts
I 0 45 pts

Potential for harmNo one was hurt, but could have been

D 114 4 pts
E 45 8 pts
F 2 16 pts

Minimal harmPaperwork-level problems

A 0 0 pts
B 0 0 pts
C 0 0 pts

Read the rows, not the total. Most citations nationwide are a D: one problem, nobody hurt. Rows G–I mean a resident was harmed; J–L mean inspectors found residents in immediate danger of serious injury or death.

Small numbers in each cell are the inspection points CMS assigns per citation. Those points are what the state curve above ranks.

Harm and immediate-jeopardy citations (12)

  1. G

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

    May 15, 2026 · Complaint inspection · Quality of Life and Care · F689 · Corrected May 18, 2026

  2. G

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

    January 20, 2026 · Complaint inspection · Quality of Life and Care · F686 · Corrected February 8, 2026

  3. G

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

    June 11, 2025 · Complaint inspection · Quality of Life and Care · F689 · Corrected June 15, 2025

  4. G

    Provide safe, appropriate pain management for a resident who requires such services.

    June 11, 2025 · Complaint inspection · Quality of Life and Care · F697 · Corrected June 15, 2025

  5. J

    Provide appropriate treatment and care according to orders, resident’s preferences and goals.

    March 28, 2025 · Complaint inspection · Quality of Life and Care · F684 · Corrected April 24, 2025

  6. G

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

    March 1, 2025 · Complaint inspection · Quality of Life and Care · F686 · Corrected March 24, 2025

  7. G

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

    January 24, 2025 · Complaint inspection · Quality of Life and Care · F686 · Corrected February 10, 2025

  8. G

    Provide appropriate treatment and care according to orders, resident’s preferences and goals.

    January 8, 2025 · Complaint inspection · Quality of Life and Care · F684 · Corrected February 6, 2025

  9. G

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

    October 8, 2024 · Complaint inspection · Freedom from Abuse, Neglect, and Exploitation · F600 · Corrected October 31, 2024

  10. G

    Provide safe, appropriate pain management for a resident who requires such services.

    October 8, 2024 · Complaint inspection · Quality of Life and Care · F697 · Corrected October 31, 2024

  11. J

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

    March 30, 2024 · Complaint inspection · Quality of Life and Care · F689 · Corrected April 26, 2024

  12. J

    Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

    March 30, 2024 · Complaint inspection · Quality of Life and Care · F740 · Corrected April 26, 2024

Everything else, by area of care

Quality of Life and Care41E
  1. E

    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.

    August 6, 2026 · Standard · F688 · Corrected August 25, 2026

  2. E

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

    August 6, 2026 · Standard · F692 · Corrected August 25, 2026

  3. E

    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.

    August 6, 2026 · Standard · F693 · Corrected August 25, 2026

  4. D

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

    August 6, 2026 · Standard · F689 · Corrected August 25, 2026

  5. D

    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

    August 6, 2026 · Standard · F690 · Corrected August 25, 2026

  6. D

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

    June 30, 2026 · Complaint · F689 · Corrected July 1, 2026

  7. D

    Provide safe, appropriate pain management for a resident who requires such services.

    May 15, 2026 · Complaint · F697 · Corrected May 18, 2026

  8. D

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

    April 24, 2026 · Complaint · F689 · Corrected April 25, 2026

  9. D

    Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

    February 10, 2026 · Standard · F676 · Corrected February 16, 2026

  10. D

    Provide appropriate treatment and care according to orders, resident’s preferences and goals.

    February 10, 2026 · Standard · F684 · Corrected February 16, 2026

  11. D

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

    February 10, 2026 · Standard · F686 · Corrected February 16, 2026

  12. D

    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

    February 10, 2026 · Standard · F690 · Corrected February 16, 2026

  13. D

    Provide safe, appropriate dialysis care/services for a resident who requires such services.

    February 10, 2026 · Standard · F698 · Corrected February 16, 2026

  14. D

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

    January 20, 2026 · Complaint · F689 · Corrected February 8, 2026

  15. D

    Provide medically-related social services to help each resident achieve the highest possible quality of life.

    January 20, 2026 · Complaint · F745 · Corrected February 8, 2026

  16. E

    Provide safe, appropriate pain management for a resident who requires such services.

    November 7, 2025 · Complaint · F697 · Corrected November 8, 2025

  17. E

    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

    August 22, 2025 · Standard · F690 · Corrected August 29, 2025

  18. D

    Provide appropriate treatment and care according to orders, resident’s preferences and goals.

    August 22, 2025 · Standard · F684 · Corrected August 29, 2025

  19. D

    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.

    August 22, 2025 · Standard · F688 · Corrected August 29, 2025

  20. D

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

    August 22, 2025 · Standard · F689 · Corrected August 29, 2025

  21. D

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

    August 22, 2025 · Standard · F695 · Corrected August 29, 2025

  22. D

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

    August 9, 2025 · Complaint · F689 · Corrected August 28, 2025

  23. E

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

    April 23, 2025 · Complaint · F686 · Corrected May 6, 2025

  24. D

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

    April 23, 2025 · Complaint · F689 · Corrected May 6, 2025

  25. D

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

    April 23, 2025 · Complaint · F695 · Corrected May 6, 2025

  26. D

    Provide safe, appropriate pain management for a resident who requires such services.

    April 23, 2025 · Complaint · F697 · Corrected May 6, 2025

  27. E

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

    April 3, 2025 · Complaint · F689 · Corrected April 24, 2025

  28. D

    Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

    April 3, 2025 · Complaint · F740 · Corrected April 24, 2025

  29. D

    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.

    March 28, 2025 · Complaint · F693 · Corrected April 24, 2025

  30. D

    Provide safe, appropriate dialysis care/services for a resident who requires such services.

    March 28, 2025 · Complaint · F698 · Corrected April 24, 2025

  31. D

    Provide appropriate treatment and care according to orders, resident’s preferences and goals.

    November 6, 2024 · Complaint · F684 · Corrected November 8, 2024

  32. D

    Provide medically-related social services to help each resident achieve the highest possible quality of life.

    October 8, 2024 · Complaint · F745 · Corrected October 31, 2024

  33. D

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

    September 27, 2024 · Complaint · F689 · Corrected September 27, 2024

  34. D

    Provide care and assistance to perform activities of daily living for any resident who is unable.

    August 2, 2024 · Complaint · F677 · Corrected August 23, 2024

  35. D

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

    June 14, 2024 · Complaint · F689 · Corrected July 3, 2024

  36. D

    Provide medically-related social services to help each resident achieve the highest possible quality of life.

    April 18, 2024 · Complaint · F745 · Corrected April 18, 2024

  37. D

    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.

    February 16, 2024 · Complaint · F700 · Corrected March 5, 2024

  38. D

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

    January 19, 2024 · Complaint · F686 · Corrected February 12, 2024

  39. D

    Provide medically-related social services to help each resident achieve the highest possible quality of life.

    January 19, 2024 · Complaint · F745 · Corrected February 12, 2024

  40. E

    Provide appropriate treatment and care according to orders, resident’s preferences and goals.

    December 22, 2023 · Complaint · F684 · Corrected January 12, 2024

  41. D

    Provide safe, appropriate pain management for a resident who requires such services.

    October 13, 2023 · Complaint · F697 · Corrected November 3, 2023

Resident Rights25E
  1. E

    Reasonably accommodate the needs and preferences of each resident.

    August 6, 2026 · Standard · F558 · Corrected August 25, 2026

  2. D

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

    August 6, 2026 · Standard · F552 · Corrected August 25, 2026

  3. D

    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.

    April 22, 2026 · Complaint · F585 · Corrected April 30, 2026

  4. E

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

    February 10, 2026 · Standard · F552 · Corrected February 17, 2026

  5. E

    Reasonably accommodate the needs and preferences of each resident.

    February 10, 2026 · Standard · F558 · Corrected February 16, 2026

  6. E

    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.

    February 10, 2026 · Standard · F578 · Corrected February 16, 2026

  7. D

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

    February 10, 2026 · Standard · F628 · Corrected February 16, 2026

  8. D

    Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

    January 20, 2026 · Complaint · F561 · Corrected February 8, 2026

  9. D

    Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.

    January 20, 2026 · Complaint · F563 · Corrected February 8, 2026

  10. D

    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.

    January 20, 2026 · Complaint · F585 · Corrected February 8, 2026

  11. D

    Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.

    December 23, 2025 · Complaint · F557 · Corrected December 24, 2025

  12. D

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

    December 8, 2025 · Complaint · F552 · Corrected December 17, 2025

  13. D

    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

    November 13, 2025 · Complaint · F550 · Corrected November 14, 2025

  14. D

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

    August 22, 2025 · Standard · F552 · Corrected August 29, 2025

  15. D

    Reasonably accommodate the needs and preferences of each resident.

    August 22, 2025 · Standard · F558 · Corrected August 29, 2025

  16. D

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

    August 22, 2025 · Standard · F580 · Corrected August 29, 2025

  17. D

    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.

    August 22, 2025 · Standard · F584 · Corrected August 29, 2025

  18. D

    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.

    December 5, 2024 · Complaint · F585 · Corrected December 9, 2024

  19. D

    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.

    October 23, 2024 · Complaint · F585 · Corrected November 6, 2024

  20. D

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

    October 8, 2024 · Complaint · F580 · Corrected October 31, 2024

  21. D

    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.

    October 8, 2024 · Complaint · F584 · Corrected October 31, 2024

  22. D

    Reasonably accommodate the needs and preferences of each resident.

    August 2, 2024 · Complaint · F558 · Corrected August 23, 2024

  23. D

    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.

    June 14, 2024 · Complaint · F585 · Corrected July 3, 2024

  24. D

    Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.

    March 30, 2024 · Complaint · F563 · Corrected April 26, 2024

  25. D

    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

    October 11, 2023 · Complaint · F550 · Corrected November 3, 2023

Pharmacy Service25E
  1. E

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

    August 6, 2026 · Standard · F755 · Corrected August 25, 2026

  2. E

    Ensure medication error rates are not 5 percent or greater.

    August 6, 2026 · Standard · F759 · Corrected August 25, 2026

  3. D

    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

    August 6, 2026 · Standard · F756 · Corrected August 25, 2026

  4. E

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

    June 30, 2026 · Complaint · F755 · Corrected July 1, 2026

  5. D

    Ensure that residents are free from significant medication errors.

    May 15, 2026 · Complaint · F760 · Corrected May 18, 2026

  6. E

    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.

    February 10, 2026 · Standard · F761 · Corrected February 16, 2026

  7. D

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

    February 10, 2026 · Standard · F755 · Corrected February 16, 2026

  8. D

    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

    February 10, 2026 · Standard · F756 · Corrected February 16, 2026

  9. D

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

    December 8, 2025 · Complaint · F755 · Corrected December 17, 2025

  10. E

    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

    August 22, 2025 · Standard · F756 · Corrected August 29, 2025

  11. D

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

    August 22, 2025 · Standard · F755 · Corrected August 29, 2025

  12. D

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

    June 30, 2025 · Complaint · F755 · Corrected July 1, 2025

  13. D

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

    June 11, 2025 · Complaint · F755 · Corrected June 15, 2025

  14. D

    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.

    June 11, 2025 · Complaint · F761 · Corrected June 15, 2025

  15. E

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

    October 29, 2024 · Complaint · F755 · Corrected November 13, 2024

  16. D

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

    October 29, 2024 · Complaint · F757 · Corrected November 13, 2024

  17. E

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

    October 8, 2024 · Complaint · F755 · Corrected October 31, 2024

  18. E

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

    August 2, 2024 · Complaint · F755 · Corrected August 23, 2024

  19. D

    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

    August 2, 2024 · Complaint · F756 · Corrected August 23, 2024

  20. D

    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.

    July 26, 2024 · Complaint · F758 · Corrected August 21, 2024

  21. E

    Ensure that residents are free from significant medication errors.

    January 19, 2024 · Complaint · F760 · Corrected February 12, 2024

  22. E

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

    December 22, 2023 · Complaint · F755 · Corrected January 12, 2024

  23. D

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

    November 22, 2023 · Complaint · F755 · Corrected December 22, 2023

  24. E

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

    October 2, 2023 · Complaint · F755 · Corrected October 27, 2023

  25. E

    Ensure that residents are free from significant medication errors.

    October 2, 2023 · Complaint · F760 · Corrected October 27, 2023

Resident Assessment and Care Planning25E
  1. D

    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

    August 6, 2026 · Standard · F656 · Corrected August 25, 2026

  2. D

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

    June 30, 2026 · Complaint · F842 · Corrected July 1, 2026

  3. D

    Provide doctor's orders for the resident's immediate care at the time the resident was admitted.

    May 15, 2026 · Complaint · F635 · Corrected May 18, 2026

  4. E

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

    February 10, 2026 · Standard · F842 · Corrected February 16, 2026

  5. D

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

    February 10, 2026 · Standard · F655 · Corrected February 16, 2026

  6. D

    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

    February 10, 2026 · Standard · F656 · Corrected February 16, 2026

  7. D

    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

    December 11, 2025 · Complaint · F656 · Corrected December 17, 2025

  8. D

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

    December 8, 2025 · Complaint · F842 · Corrected December 17, 2025

  9. D

    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

    November 13, 2025 · Complaint · F656 · Corrected November 14, 2025

  10. D

    PASARR screening for Mental disorders or Intellectual Disabilities

    August 22, 2025 · Standard · F645 · Corrected August 29, 2025

  11. D

    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

    August 22, 2025 · Standard · F656 · Corrected August 29, 2025

  12. D

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

    August 22, 2025 · Standard · F658 · Corrected August 29, 2025

  13. D

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

    August 22, 2025 · Standard · F842 · Corrected August 29, 2025

  14. D

    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

    June 11, 2025 · Complaint · F656 · Corrected June 15, 2025

  15. D

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

    May 15, 2025 · Complaint · F842 · Corrected May 18, 2025

  16. E

    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

    April 23, 2025 · Complaint · F657 · Corrected May 6, 2025

  17. D

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

    March 28, 2025 · Complaint · F842 · Corrected April 24, 2025

  18. E

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

    January 24, 2025 · Complaint · F842 · Corrected February 10, 2025

  19. E

    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

    October 29, 2024 · Complaint · F656 · Corrected November 13, 2024

  20. D

    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

    July 26, 2024 · Complaint · F656 · Corrected August 21, 2024

  21. D

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

    July 2, 2024 · Complaint · F842 · Corrected July 26, 2024

  22. D

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

    June 14, 2024 · Complaint · F658 · Corrected July 3, 2024

  23. D

    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

    December 22, 2023 · Complaint · F656 · Corrected January 12, 2024

  24. D

    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

    December 22, 2023 · Complaint · F657 · Corrected January 12, 2024

  25. D

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

    October 25, 2023 · Complaint · F658 · Corrected November 8, 2023

Freedom from Abuse, Neglect, and Exploitation15E
  1. D

    Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

    August 6, 2026 · Standard · F605 · Corrected August 25, 2026

  2. D

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

    January 20, 2026 · Complaint · F607 · Corrected February 8, 2026

  3. D

    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

    January 20, 2026 · Complaint · F609 · Corrected February 8, 2026

  4. D

    Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

    August 22, 2025 · Standard · F605 · Corrected August 29, 2025

  5. D

    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

    April 23, 2025 · Complaint · F609 · Corrected May 6, 2025

  6. D

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

    March 28, 2025 · Complaint · F600 · Corrected April 24, 2025

  7. D

    Respond appropriately to all alleged violations.

    March 28, 2025 · Complaint · F610 · Corrected April 24, 2025

  8. E

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

    October 23, 2024 · Complaint · F607 · Corrected November 6, 2024

  9. D

    Not hire anyone with a finding of abuse, neglect, exploitation, or theft.

    October 23, 2024 · Complaint · F606 · Corrected November 6, 2024

  10. D

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

    July 26, 2024 · Complaint · F607 · Corrected August 21, 2024

  11. E

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

    June 14, 2024 · Complaint · F600 · Corrected July 3, 2024

  12. D

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

    March 14, 2024 · Complaint · F600 · Corrected March 30, 2024

  13. D

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

    March 14, 2024 · Complaint · F607 · Corrected March 30, 2024

  14. D

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

    February 16, 2024 · Complaint · F600 · Corrected March 5, 2024

  15. D

    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

    February 16, 2024 · Complaint · F609 · Corrected March 5, 2024

Infection Control11F
  1. E

    Provide and implement an infection prevention and control program.

    July 8, 2026 · Complaint · F880 · Corrected July 14, 2026

  2. E

    Provide and implement an infection prevention and control program.

    February 10, 2026 · Standard · F880 · Corrected February 16, 2026

  3. F

    Provide and implement an infection prevention and control program.

    August 9, 2025 · Complaint · F880 · Corrected August 28, 2025

  4. E

    Provide and implement an infection prevention and control program.

    April 23, 2025 · Complaint · F880 · Corrected May 6, 2025

  5. E

    Provide and implement an infection prevention and control program.

    March 18, 2025 · Complaint · F880 · Corrected March 24, 2025

  6. E

    Provide and implement an infection prevention and control program.

    January 24, 2025 · Complaint · F880 · Corrected February 10, 2025

  7. E

    Provide and implement an infection prevention and control program.

    December 25, 2024 · Complaint · F880 · Corrected January 8, 2025

  8. D

    Provide and implement an infection prevention and control program.

    July 26, 2024 · Complaint · F880 · Corrected August 21, 2024

  9. D

    Provide and implement an infection prevention and control program.

    June 25, 2024 · Complaint · F880 · Corrected June 25, 2024

  10. E

    Provide and implement an infection prevention and control program.

    March 7, 2024 · Complaint · F880 · Corrected March 30, 2024

  11. D

    Provide and implement an infection prevention and control program.

    December 22, 2023 · Complaint · F880 · Corrected January 12, 2024

Nursing and Physician Services7E
  1. D

    Ensure that the resident and his/her doctor meet face-to-face at all required visits.

    February 10, 2026 · Standard · F712 · Corrected February 16, 2026

  2. E

    Post nurse staffing information every day.

    November 13, 2025 · Complaint · F732 · Corrected November 14, 2025

  3. E

    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.

    June 11, 2025 · Complaint · F726 · Corrected June 15, 2025

  4. E

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

    October 23, 2024 · Complaint · F725 · Corrected November 6, 2024

  5. E

    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.

    August 2, 2024 · Complaint · F726 · Corrected August 23, 2024

  6. E

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

    July 10, 2024 · Complaint · F725 · Corrected July 12, 2024

  7. D

    Post nurse staffing information every day.

    April 18, 2024 · Complaint · F732 · Corrected April 18, 2024

Nutrition and Dietary6F
  1. E

    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

    August 6, 2026 · Standard · F812 · Corrected August 25, 2026

  2. E

    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

    February 10, 2026 · Standard · F812 · Corrected February 16, 2026

  3. F

    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.

    August 22, 2025 · Standard · F803 · Corrected August 29, 2025

  4. E

    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

    August 22, 2025 · Standard · F812 · Corrected August 29, 2025

  5. D

    Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

    August 20, 2024 · Complaint · F806 · Corrected August 20, 2024

  6. D

    Have a policy regarding use and storage of foods brought to residents by family and other visitors.

    May 3, 2024 · Complaint · F813 · Corrected May 3, 2024

Environmental4D
  1. D

    Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

    December 1, 2025 · Complaint · F925 · Corrected January 2, 2026

  2. D

    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

    June 30, 2025 · Complaint · F921 · Corrected July 1, 2025

  3. D

    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

    May 15, 2025 · Complaint · F921 · Corrected May 18, 2025

  4. D

    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

    August 2, 2024 · Complaint · F921 · Corrected August 23, 2024

Administration2D
  1. D

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

    July 8, 2026 · Complaint · F770 · Corrected July 14, 2026

  2. D

    Have an agreement with an approved laboratory to obtain services, if on-site laboratory services aren't provided.

    January 19, 2024 · Complaint · F772 · Corrected February 12, 2024

Inspection history

  1. 2026-08-06

    42 health deficiencies · 4 fire-safety deficiencies

    Top issue: Quality of Life and Care (13 deficiencies)

  2. 2026-02-10

    67 health deficiencies · 7 fire-safety deficiencies

    Top issue: Quality of Life and Care (23 deficiencies)

  3. 2025-08-22

    64 health deficiencies · 2 fire-safety deficiencies

    Top issue: Quality of Life and Care (16 deficiencies)

4

Nursing time per resident, per day

Each resident here gets about 4 h 35 min of nursing staff time a day, 33 min of it from a registered nurse.

This home

4 h 35 min

California average

4 h 33 min

U.S. average

3 h 54 min

  • Registered nurse
  • Licensed practical nurse
  • Nurse aide

Turnover: 62% of nursing staff and 75% of registered nurses left in the past year, along with 2 administrators.

Reported hours from payroll data the home submits to CMS, divided by its daily resident count. Not adjusted for how sick residents are.

5

Fines and payment denials

$368,943 in federal fines on record over the past three years.

DatePenaltyAmount
2026-04-22Fine$14,882
2026-01-20Fine$82,250
2025-06-11Fine$9,698
2025-03-01Fine$129,784
2025-03-01Payment Denial · 38 day denial$0
2025-01-08Fine$47,405
2025-01-08Payment Denial · 3 day denial$0
2024-09-27Fine$45,625
2024-09-27Payment Denial · 6 day denial$0
2024-03-07Fine$39,299
2024-03-07Payment Denial · 6 day denial$0

6

Resident outcomes

Quality measures compared with state and national averages. Most come from assessments the home itself reports.

MeasureThis homeStateU.S.
Number of hospitalizations per 1000 long-stay resident days1.8 pts worse4.02.21.8
Number of outpatient emergency department visits per 1000 long-stay resident days2.2 pts worse3.71.51.7
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine4 pts worse94.7%98.7%93.7%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine0.7 pts worse97.2%97.9%95.3%
Percentage of long-stay residents experiencing one or more falls with major injury0.1 pts worse1.7%1.6%3.2%
Percentage of long-stay residents who have depressive symptoms6.7 pts better0.9%7.6%13.5%
Percentage of long-stay residents who lose too much weight4.6 pts worse8.7%4.1%5.1%
Percentage of long-stay residents who received an antianxiety or hypnotic medication3.3 pts better10.4%13.7%19.5%
Percentage of long-stay residents who received an antipsychotic medication4.4 pts better7.9%12.3%15.4%
Percentage of long-stay residents who were physically restrained0.3 pts better0.0%0.3%0.1%
Percentage of long-stay residents whose ability to walk independently worsened1 pts worse9.9%8.9%12.7%
Percentage of long-stay residents whose need for help with daily activities has increased5.5 pts better4.7%10.2%13.5%
Percentage of long-stay residents with a catheter inserted and left in their bladder0.4 pts better0.3%0.7%0.7%
Percentage of long-stay residents with a urinary tract infection1.2 pts better0.0%1.2%1.5%
Percentage of long-stay residents with new or worsened bowel or bladder incontinence3 pts worse12.8%9.8%18.3%
Percentage of long-stay residents with pressure ulcers2.5 pts worse6.8%4.3%4.5%
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine8.8 pts worse85.8%94.6%82.3%
Percentage of short-stay residents who had an outpatient emergency department visit6.7 pts worse17.8%11.1%11.8%
Percentage of short-stay residents who newly received an antipsychotic medication0.2 pts worse1.5%1.3%1.5%
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine6.9 pts worse86.2%93.1%80.1%
Percentage of short-stay residents who were rehospitalized after a nursing home admission16.1 pts worse38.7%22.6%23.4%

·

Who owns and runs it

19 owners and managers reported to CMS. The last column counts how many nursing homes each one is tied to.

Show ownership list
NameRoleShareHomes
Ghc Holdings LLC5% Or Greater Indirect Ownership Interest · Organization50%118 facilities
Dhawan, RahulOperational/Managerial Control · Individual0%1 facilities
Dhawan, RahulAdp Of The SNF · Individual0%1 facilities
Dor-Oscar, MarieOperational/Managerial Control · Individual0%1 facilities
Dor-Oscar, MarieAdp Of The SNF · Individual0%1 facilities
Fishman, StevenIndirect Ownership Interest · Individual0%15 facilities
Fung, JessicaOperational/Managerial Control · Individual0%1 facilities
Fung, JessicaAdp Of The SNF · Individual0%1 facilities
Newgen Administrative Services, LLCOperational/Managerial Control · Organization0%30 facilities
Newgen Administrative Services, LLCAdp Of The SNF · Organization0%30 facilities
Powerback Rehabilitation LLCAdp Of The SNF · Organization0%23 facilities
Robin, AaronManaging Control - Governing Body · Individual0%29 facilities
Shaw, PamelaOperational/Managerial Control · Individual0%39 facilities
Shaw, PamelaAdp Of The SNF · Individual0%39 facilities
Sundance Rehabilitation Holdco IncIndirect Ownership Interest · Organization0%9 facilities
Tress, AvrohomOperational/Managerial Control · Individual0%30 facilities
Tress, AvrohomAdp Of The SNF · Individual0%30 facilities
Welltower Op LLCIndirect Ownership Interest · Organization0%158 facilities
Zac Properties Xi LLCIndirect Ownership Interest · Organization0%8 facilities

·

Fire safety

13 life-safety citations (sprinklers, exits, alarms). These don't count toward the star rating.

Smoke6E
  1. E

    Inspect, test, and maintain automatic sprinkler systems.

    February 10, 2026 · K353 · Corrected February 16, 2026

  2. D

    Install an approved automatic sprinkler system.

    February 10, 2026 · K351 · Corrected February 16, 2026

  3. D

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

    August 22, 2025 · K342 · Corrected August 29, 2025

  4. D

    Inspect, test, and maintain automatic sprinkler systems.

    August 22, 2025 · K353 · Corrected August 29, 2025

  5. D

    Properly select, install, inspect, or maintain portable fire extinguishes.

    August 22, 2025 · K355 · Corrected August 29, 2025

  6. E

    Install an approved automatic sprinkler system.

    March 1, 2025 · K351 · Corrected March 17, 2025

Gas, Vacuum, and Electrical Systems2E
  1. E

    Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

    February 10, 2026 · K914 · Corrected February 16, 2026

  2. D

    Ensure proper usage of power strips and extension cords.

    August 22, 2025 · K920 · Corrected August 29, 2025

Emergency Preparedness2C
  1. C

    Provide primary/alternate means for communication.

    February 10, 2026 · E32 · Corrected February 16, 2026

  2. C

    Conduct testing and exercise requirements.

    February 10, 2026 · E39 · Corrected February 16, 2026

Egress2E
  1. E

    Have corridors or aisles that are unobstructed and are at least 8 feet in width.

    August 22, 2025 · K232 · Corrected August 29, 2025

  2. D

    Keep aisles, corridors, and exits free of obstruction in case of emergency.

    March 1, 2025 · K211 · Corrected March 17, 2025

Miscellaneous1D
  1. D

    To conduct inspection, testing and maintenance of fire doors by qualified individuals.

    February 10, 2026 · K761 · Corrected February 16, 2026

·

Other homes nearby

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