Cycle 1
Health 2025-01-09 · Fire 2025-01-09
9 health deficiencies
Top issue: Pharmacy Service (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Loma Linda, CA
Totally Kids Rehabilitation Hospital - D/P SNF
5-star overall rating with 4-star inspections with 9 recent health deficiencies
1720 Mountain View, Loma Linda, CA
(909) 796-6915
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
56
Certified beds
Average residents
56
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1994-02-04
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Hospital-based
Yes
CMS reports the provider resides in a hospital
Staffing
Hours and turnover
RN hours / resident day
1.47
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
4.23
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
4.39
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
10.10
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
5.70
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
9.37
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
1.11
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.56
CMS adjusted RN staffing hours
Adjusted total hours
3.86
CMS adjusted total nurse staffing hours
Case-mix index
3.58
Higher values indicate more complex resident acuity
RN turnover
31%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
35%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,149
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
59.44
Composite VBP score used to determine payment impact.
Payment multiplier
1.0146
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
7.84
Performance 31.65% · Measure score 7.84 · Achievement 7.84 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
4.05
Baseline 4.28 hours · Performance 4.23 hours · Measure score 4.05 · Achievement 4.05 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · No data were submitted for this measure. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · No data were submitted for this measure. |
| Medicare spending per beneficiary | Not Available |
1.02
|
No data were submitted for this measure. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator Not Available · Adjusted rate Not Available · No data were submitted for this measure. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · No data were submitted for this measure. |
| Staff COVID-19 vaccination coverage | 1.1% |
8.2%
7.1 pts worse
|
Numerator 4 · Denominator 365 |
| Staff flu vaccination coverage | 73.87% |
42%
31.9 pts better
|
Numerator 424 · Denominator 574 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 50.5% |
98.5%
48 pts worse
|
93.4%
42.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 58.3% · Q2 54.9% · Q3 50.0% · Q4 39.2% · 4Q avg 50.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 92.3% |
98.2%
5.9 pts worse
|
95.5%
3.2 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 92.3% |
| 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% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 1.0% |
4.1%
3.1 pts better
|
5.4%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 0.0% · Q3 0.0% · Q4 2.0% · 4Q avg 1.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 66.5% |
13.7%
52.8 pts worse
|
19.6%
46.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 58.3% · Q2 64.7% · Q3 68.0% · Q4 74.5% · 4Q avg 66.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 3.6% |
14.2%
10.6 pts better
|
16.7%
13.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q3 0.0% · Q4 2.9% · 4Q avg 3.6% · 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 need for help with daily activities has increased | 14.8% |
10.7%
4.1 pts worse
|
14.9%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 14.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.2% |
1.0%
0.2 pts worse
|
1.0%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 1.6% · Q3 1.5% · Q4 0.0% · 4Q avg 1.2% · 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 | 0.0% |
10.9%
10.9 pts better
|
19.8%
19.8 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 with pressure ulcers | 1.6% |
4.7%
3.1 pts better
|
5.1%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 1.6% · Q3 1.6% · Q4 1.4% · 4Q avg 1.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-12 · Fire 2024-01-12
7 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2023-01-12 · Fire 2023-01-12
3 health deficiencies
Top issue: Infection Control (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2023-01-12
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-01-30
D · Potential for more than minimal harm
2023-01-12
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-01-30
D · Potential for more than minimal harm
2023-01-12
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-01-30
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-07-18
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-08-25
E · Potential for more than minimal harm
2025-01-09
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2025-02-07
E · Potential for more than minimal harm
2025-01-09
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2025-02-07
E · Potential for more than minimal harm
2025-01-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-07
D · Potential for more than minimal harm
2025-01-09
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 2025-02-07
D · Potential for more than minimal harm
2025-01-09
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 2025-02-07
D · Potential for more than minimal harm
2025-01-09
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2025-02-07
D · Potential for more than minimal harm
2025-01-09
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 2025-02-07
D · Potential for more than minimal harm
2025-01-09
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 2025-01-22
E · Potential for more than minimal harm
2024-01-12
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2024-02-12
E · Potential for more than minimal harm
2024-01-12
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2024-02-12
D · Potential for more than minimal harm
2024-01-12
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 2024-02-12
D · Potential for more than minimal harm
2024-01-12
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 2024-02-12
D · Potential for more than minimal harm
2024-01-12
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 2024-02-12
D · Potential for more than minimal harm
2024-01-12
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 2024-02-12
D · Potential for more than minimal harm
2024-01-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-02-12
D · Potential for more than minimal harm
2023-01-12
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 2023-02-10
D · Potential for more than minimal harm
2023-01-12
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 2023-02-10
D · Potential for more than minimal harm
2023-01-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-02-10
Penalties and ownership
What sits behind the stars
Ownership
Lambooy, Sallie
5% Or Greater Indirect Ownership Interest · Individual
Nydam, Jack
5% Or Greater Indirect Ownership Interest · Individual
Nydam, James
5% Or Greater Indirect Ownership Interest · Individual
Nydam, Linda
5% Or Greater Indirect Ownership Interest · Individual
Nydam, Robert
5% Or Greater Indirect Ownership Interest · Individual
Arden, Racquel
Operational/Managerial Control · Individual
Bilicke, Robert
Operational/Managerial Control · Individual
Callicott, Cecelia
Operational/Managerial Control · Individual
Callicott, Cecelia
Corporate Director · Individual
Capetillo, Cynthia
Operational/Managerial Control · Individual
Capetillo, Cynthia
Corporate Officer · Individual
Ecapital Healthcare Corp
5% Or Greater Security Interest · Organization
Faculty Physicians And Surgeons Of Llusm
Operational/Managerial Control · Organization
Gil, Margarita
Operational/Managerial Control · Individual
Halliday & Company, Certified Public Accountants
Operational/Managerial Control · Organization
Hansen, Irwin
Operational/Managerial Control · Individual
Hansen, Irwin
Corporate Officer · Individual
Hennessey, Pauline
Operational/Managerial Control · Individual
Lambooy, Sallie
Limited Partnership Interest · Individual
Mountain View Child Care, Inc.
5% Or Greater Direct Ownership Interest · Organization
Mountain View Child Care, Inc.
Operational/Managerial Control · Organization
Nydam Limited Partnership
Limited Partnership Interest · Organization
Nydam Limited Partnership
Operational/Managerial Control · Organization
Nydam, Jack
Limited Partnership Interest · Individual
Nydam, James
Limited Partnership Interest · Individual
Nydam, Linda
Limited Partnership Interest · Individual
Nydam, Linda
Operational/Managerial Control · Individual
Nydam, Linda
Corporate Director · Individual
Nydam, Robert
Limited Partnership Interest · Individual
Padgett, Cynthia
5% Or Greater Direct Ownership Interest · Individual
Padgett, Cynthia
Operational/Managerial Control · Individual
Padgett, Cynthia
Corporate Director · Individual
Padgett, Douglas
5% Or Greater Direct Ownership Interest · Individual
Padgett, Douglas
Operational/Managerial Control · Individual
Padgett, Douglas
Corporate Director · Individual
Padgett, Douglas
Corporate Officer · Individual
Rao, Ravindra
Operational/Managerial Control · Individual
Rao, Ravindra
Corporate Director · Individual
Rochette, Blake
Operational/Managerial Control · Individual
Rochette, Blake
Corporate Officer · Individual
South Pacific Rehabilitation Services, Inc
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Loma Linda Post Acute
Loma Linda, CA
4-star overall rating with 4-star inspections with 10 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#2
Asistencia Villa Healthcare Center
Redlands, CA
2-star overall rating with 3-star inspections with $10,206 in total fines with 13 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#3
Heritage Gardens Health Care Center
Loma Linda, CA
3-star overall rating with 3-star inspections with 9 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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