Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Heritage Gardens Health Care Center during CMS and state inspections, most recent first.
A CNA engaged in a verbal altercation with a resident who has hemiplegia and hemiparesis, after the CNA forcefully pulled the resident's pillow, prompting the resident to use profanity. The CNA responded with repeated expletives, escalating the situation and violating facility policy requiring staff to treat residents with respect and dignity. The incident was witnessed by another staff member and confirmed by facility leadership.
The facility failed to store the ice scoop for the kitchen's ice machine in a clean and sanitary manner, as required by policy. The ice scoop was found in an uncovered container, posing a risk of contamination. Staff acknowledged the oversight, which could impact the health and safety of all residents receiving food and beverages from the kitchen.
The facility failed to follow infection control policies, including not changing or labeling medical equipment for residents and neglecting hand hygiene practices. A resident's CVC dressing was overdue for a change, and another's oxygen tubing was not changed for 17 days. Staff did not perform hand hygiene during medication administration and meal assistance, increasing infection risks.
A facility failed to complete a Significant Change of Status Assessment (SCSA) within 14 days for a resident admitted to hospice care, delaying the update of the resident's care plan. The resident, with cerebrovascular and atherosclerosis heart disease, was enrolled in hospice, but the SCSA was not conducted, resulting in a delay of over six months. This oversight was acknowledged by the MDS Nurse, indicating non-compliance with facility policy and OBRA regulations.
Two residents in the facility had inaccuracies in their MDS assessments. One resident with Type 2 diabetes mellitus did not have their insulin injections coded, despite receiving them on six days within the look-back period. Another resident on a prescribed antibiotic regimen for osteomyelitis had their antibiotic use omitted from the MDS assessment, despite daily administration. The errors were acknowledged by the MDS nurses, and the facility's policy for certifying assessment accuracy was not followed.
A facility failed to ensure a physician's order for a Speech Therapy evaluation was communicated to the hospice provider for a resident with severe cognitive impairment and difficulty chewing. The order, made on November 23, 2024, was not documented as completed, and the facility's policy requiring coordination with hospice was not followed, potentially risking the resident's health.
The facility failed to implement RNP recommendations for two residents, leading to a deficiency in care. A resident with muscle weakness did not receive recommended ambulation with a walker, and another with muscle contracture did not receive ROM exercises. The DON and DOR were unaware of these recommendations due to poor communication between departments, resulting in a lack of documented evidence and non-compliance with the facility's policy on Restorative Nursing Services.
A resident was administered oxygen therapy without a physician's order, contrary to the facility's policy. The resident, who had dementia and other medical conditions, was observed using a nasal cannula with an oxygen concentrator. The DON confirmed the absence of a physician's order and acknowledged the policy was not followed.
A facility failed to ensure a Licensed Vocational Nurse (LVN) maintained an active license, allowing the LVN to work with an expired license. The Director of Nursing (DON) admitted responsibility for checking licenses but did not verify expiration dates, leading to the LVN working without a valid license. The job description required current licensure, which was not followed.
A facility failed to adhere to its policy for blood glucose monitoring for a resident with type 2 diabetes, leading to a delayed blood sugar check. The resident, who had moderate cognitive impairment, was supposed to have blood sugar checks before meals and at bedtime, but the check was conducted later than scheduled. This failure potentially led to a change in the resident's condition and transfer to a hospital for evaluation.
A facility failed to follow its ADL policy, resulting in a resident with dementia having long and unclean fingernails. The resident required assistance with personal hygiene, and both the Administrator and Resident Assessment Coordinator acknowledged the issue, stating it was the CNAs' responsibility. The facility's policy required providing necessary services for grooming and hygiene.
A CNA wrapped a resident's waist and legs in linen sheets, failing to follow the facility's restraint policy. The resident, with severe cognitive impairment and other medical conditions, was found in this state by another CNA, who reported it to an LVN. The facility's policy states that restraints should only be used for safety and well-being after other alternatives have been tried, and never for staff convenience. The DON confirmed the policy was not followed.
CNA Engages in Verbal Altercation with Resident, Violating Dignity and Respect
Penalty
Summary
A Certified Nursing Assistant (CNA) engaged in a verbal altercation with a resident who had hemiplegia and hemiparesis. The incident began when the CNA pulled the resident's pillow forcefully, which upset the resident and led him to use profanity toward the CNA. In response, the CNA used expletives multiple times in return, escalating the exchange of offensive language. This interaction was witnessed by another staff member and was later validated by the CNA involved. The facility's policy requires all employees to treat residents with kindness, respect, and dignity, and prohibits the use of expletives in interactions with residents. The Director of Nursing and Administrator confirmed that the CNA's actions were in violation of this policy. The resident involved was alert and oriented at the time of the incident and expressed that such behavior should not occur in the facility.
Improper Storage of Ice Scoop in Kitchen
Penalty
Summary
The facility failed to ensure the ice scoop used for the kitchen's ice machine was stored in a clean and sanitary manner, as required by the facility's policy. During an observation and interview with the Dietary Services Supervisor (DSS), the ice scoop was found resting inside an uncovered blue container near the ice machine. The DSS confirmed that the ice scoop should always be stored in a clean, covered container to prevent contamination. This oversight posed a potential risk for contamination of ice, which could lead to foodborne illness and negatively impact the health and safety of all 96 residents who received food and beverages from the kitchen. Further interviews and record reviews revealed that the facility's policy, titled 'Ice Machines and Ice Storage Chest' dated January 2012, was not followed. The Maintenance Director (MD-1) acknowledged that the ice scoop should have been stored in a covered container, as per the policy. The Infection Control Prevention Nurse (ICP Nurse) also confirmed that the ice scoop placement did not follow protocol, emphasizing that ice is considered a food item and must be protected with a lid to prevent contamination. The failure to adhere to these protocols was acknowledged by the staff involved.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to its infection control policies for several residents, leading to potential cross-contamination and infection risks. Resident 44's Central Venous Catheter (CVC) dressing was not changed according to the facility's policy, which requires a change every seven days or when soiled. The dressing was last changed on January 1, 2025, but should have been changed by January 8, 2025. Additionally, Resident 44's intravenous (IV) tubing was not dated as required by the facility's policy, which mandates labeling with the date, time, and initials upon assembly. Resident 33's oxygen tubing was not changed for 17 days, contrary to the facility's policy of changing it every seven days. Similarly, Resident 65's oxygen tubing was not labeled with the date, violating the same policy. These oversights in labeling and changing medical equipment increase the risk of infection among residents. Furthermore, staff members failed to perform proper hand hygiene during care activities. LVN 1 did not wash hands after touching Resident 5 and before administering medication, while CNA 1 did not change gloves or perform hand hygiene between assisting two residents with breakfast. These actions contravene the facility's hand hygiene policy, which requires handwashing before and after resident contact and before handling medications.
Failure to Complete Timely SCSA for Hospice Resident
Penalty
Summary
The facility failed to complete a Significant Change of Status Assessment (SCSA) for a resident within the required 14-day period after the resident was admitted to hospice care. This oversight was identified during a review of the resident's clinical records and interviews with the Minimum Data Set (MDS) Nurse. The resident, who was admitted with diagnoses including cerebrovascular disease and atherosclerosis heart disease, was enrolled in hospice care on May 24, 2024. However, the SCSA, which should have been completed by June 6, 2024, was not conducted, resulting in a delay of over six months. The failure to complete the SCSA meant that the resident's care plan was not updated to reflect her current status, potentially delaying the identification and implementation of necessary care and support. The facility's policy, which aligns with the OBRA regulations and the CMS RAI manual, mandates a comprehensive assessment when a significant change in a resident's condition occurs, such as enrollment in hospice care. The MDS Nurse acknowledged that the facility did not adhere to this policy, which is crucial for ensuring a coordinated plan of care between the hospice and the nursing home.
Inaccurate MDS Assessments for Insulin and Antibiotic Use
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessments for two residents, leading to potential inaccuracies in identifying their care and support needs. Resident 9, who was admitted with Type 2 diabetes mellitus and required long-term insulin use, had insulin injections that were not coded on the MDS assessment. Despite receiving insulin injections on six days within the seven-day look-back period, the MDS assessment inaccurately indicated that no insulin was administered. This discrepancy was acknowledged by the MDS Nurse 2 during a review of the Medication Administration Record (MAR) and the MDS Section N - Medications. Similarly, Resident 19, who was admitted with complications related to an orthopedic implant and osteomyelitis, was on a prescribed antibiotic regimen. The MDS assessment for Resident 19 failed to reflect the administration of antibiotics, despite the MAR indicating daily antibiotic administration throughout December. The MDS Nurse 1 acknowledged the error during a review of the MAR and MDS Section N, admitting it was a mistake. The Director of Nursing (DON) confirmed that the facility's policy and procedure for certifying the accuracy of resident assessments were not followed in both cases. The CMS RAI manual guidelines, which require accurate recording of medication administration during the look-back period, were also not adhered to. These failures in accurately coding the MDS assessments for both residents were identified through interviews and record reviews with the MDS nurses and the DON.
Failure to Communicate Speech Therapy Order for Hospice Resident
Penalty
Summary
The facility failed to ensure a physician's order for a Speech Therapy (ST) evaluation was carried out timely for a resident receiving hospice care. The resident, who was admitted with diagnoses including cerebral atherosclerosis, unspecified dementia, and was receiving palliative care, had a severe cognitive impairment as indicated by a BIMS score of 6. A Nutrition/Dietary Note dated November 22, 2024, recommended an ST evaluation due to the resident's difficulty chewing, which was subsequently ordered by the physician on November 23, 2024. However, the order was not communicated to the hospice provider, and there was no documentation of the ST evaluation being conducted. During interviews and record reviews, the Director of Nursing (DON) confirmed the lack of documentation for the ST evaluation and identified that a Registered Nurse from the registry failed to communicate the order with the facility or the hospice provider. The facility's policy and procedure for hospice care, which requires coordination with the hospice provider and documentation of communication, was not followed. This oversight had the potential to place the resident at risk for aspiration, weight loss, and further nutritional decline.
Failure to Implement Restorative Nursing Program Recommendations
Penalty
Summary
The facility failed to implement the Restorative Nursing Program (RNP) recommendations for two residents, leading to a deficiency in providing necessary care and services for maintaining or improving their activities of daily living. Resident 44, who was admitted with muscle weakness and difficulty walking, did not receive the recommended ambulation with a front wheel walker as suggested by the Physical Therapist (PT). The Director of Nursing (DON) and the Director of Rehabilitation (DOR) were unaware of the PT's recommendation, indicating a lack of communication between the nursing and rehabilitation departments. Similarly, Resident 54, who was admitted with muscle contracture and weakness, did not receive the recommended Range of Motion (ROM) exercises as advised by both the PT and Occupational Therapist (OT). The DON and DOR confirmed the absence of documented evidence showing the implementation of these recommendations. The lack of communication between the nursing and rehabilitation departments was again highlighted as the reason for this oversight. The facility's policy on Restorative Nursing Services, which emphasizes the need for individualized and resident-centered care, was not followed. The policy outlines that residents should receive restorative nursing care to promote optimal safety and independence, and that such care should be documented in the resident's plan of care. The failure to adhere to this policy resulted in a delay in the continuity of care for the residents involved.
Failure to Obtain Physician's Order for Oxygen Therapy
Penalty
Summary
The facility failed to obtain a physician's order for oxygen therapy for a resident, identified as Resident 33, who was admitted with diagnoses including dementia, retropharyngeal and parapharyngeal abscess, and shortness of breath. During an observation, Resident 33 was found using a nasal cannula attached to an oxygen concentrator set at 2 liters per minute, without a corresponding physician's order documented in their clinical record. This oversight was confirmed during an interview and record review with the Director of Nursing (DON), who acknowledged the absence of the necessary order. The facility's policy and procedure for oxygen administration, which requires verification of a physician's order before administering oxygen, was not adhered to in this instance. The DON reviewed the policy, which was last revised in October 2010, and confirmed that it was not followed. This failure to comply with the established protocol had the potential to expose Resident 33 to risks associated with unmonitored oxygen therapy, such as oxygen toxicity.
Expired Nursing License Overlooked
Penalty
Summary
The facility failed to ensure that their professional staff maintained an active and current nursing license, as evidenced by a Licensed Vocational Nurse (LVN) working with an expired license. The LVN worked from a specified date through another specified date with a delinquent license, which was not renewed within the required timeframe. During an interview and record review, the Director of Nursing (DON) acknowledged that it was her responsibility to verify the nurses' licenses. Although the DON checked the LVN's license the previous month and found it active, she did not verify the expiration date. The facility's job description for the LVN position required current nursing licensure in the state of California, which was not adhered to, resulting in the LVN working without a valid license during the specified period.
Failure to Adhere to Blood Glucose Monitoring Schedule
Penalty
Summary
The facility failed to implement its policy for blood glucose monitoring for a resident with type 2 diabetes mellitus, which potentially led to a change in the resident's condition and subsequent transfer to a general acute hospital for evaluation and treatment. The resident, who was admitted with a diagnosis of type 2 diabetes and had moderate cognitive impairment, was supposed to have blood sugar checks conducted before meals and at bedtime as per physician's orders. However, a review of the resident's Blood Sugar Summary indicated that the blood sugar check was conducted later than the scheduled time, specifically at 1:38 p.m., instead of before meals around 11:30 a.m. During an interview, the Maternal Data Set Assistant Coordinator confirmed the delay in conducting the blood sugar check and acknowledged that the facility did not adhere to the physician's orders. The facility's policy and procedure for glucose monitoring, dated December 2015, stated that the management of individuals with diabetes mellitus should follow relevant protocols and guidelines, and the physician would order the frequency of glucose monitoring. This failure to adhere to the scheduled blood glucose monitoring had the potential to jeopardize the health and well-being of the medically compromised resident.
Failure to Maintain Resident's Personal Hygiene
Penalty
Summary
The facility failed to adhere to its policy and procedure for activities of daily living (ADL) by not ensuring proper grooming and personal hygiene for a resident. The deficiency was identified during an observation of a resident who had notably long and unclean fingernails. This resident, who was admitted with a diagnosis of unspecified dementia and had a Brief Interview for Mental Status (BIMS) score indicating moderate cognitive impairment, required partial/moderate assistance with personal hygiene according to their MDS Section G assessment. During an observation and interview, both the Administrator and the Resident Assessment Coordinator acknowledged the resident's unclean and untrimmed fingernails. The Administrator stated that it was the responsibility of the CNAs to clean or trim the resident's fingernails. The facility's policy, dated March 2018, indicated that residents unable to perform ADLs independently should receive necessary services to maintain grooming and personal hygiene. The failure to maintain the resident's fingernails put the resident at risk for infection.
Failure to Follow Restraint Policy
Penalty
Summary
The facility failed to follow its policy and procedure for restraints when a Certified Nursing Assistant (CNA) wrapped a resident's waist and legs in linen sheets. This incident involved a resident with severe cognitive impairment, dementia, an unspecified fracture of the right lower leg, and schizoaffective disorder. The resident was admitted to the facility with a care plan that required all care to be delivered by licensed nursing staff and adjunct professional medical personnel. The resident's care plan also indicated a risk for decline in psychosocial well-being due to involuntary seclusion and required staff education on the use of restraints and types of restraints. On the day of the incident, the resident was observed sitting in a Geri-chair in the activities room, smiling and grabbing at the upper part of her pants. The resident was unable to recall the incident. During a telephone interview, the CNA admitted to placing the sheet around the resident to prevent her from digging into her pants and smearing feces, based on information told to her by someone else. The CNA acknowledged that this was not the right measure. Another CNA reported the incident to an LVN, who conducted a body assessment and found no markings on the resident's skin. The LVN then informed the Director of Nursing (DON). The facility's policy and procedure on the use of restraints, revised in April 2017, stated that restraints should only be used for the safety and well-being of the resident and only after other alternatives have been tried unsuccessfully. Restraints should never be used for discipline or staff convenience. The policy defined physical restraints and specified that practices preventing resident mobility, such as tucking sheets tightly, are considered restraints and are not permitted. The DON confirmed that the policy and procedure were not followed in this case.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Loma Linda
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Loma Linda Post Acute | 0.3 mi | — | 0 | 0 |
| Asistencia Villa Healthcare Center | 1.1 mi | — | 18 | 0 |
| Totally Kids Rehabilitation Hospital - D/p Snf | 1.7 mi | — | 10 | 0 |
| The Canyons Post-acute | 2.3 mi | — | 7 | 0 |
| Brookside Healthcare Center | 2.3 mi | — | 0 | 0 |
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