Above average — CMS composite of the measures below.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at University Post Acute during CMS and state inspections, most recent first.
Failure to Follow SLP Recommendation for Swallowing Evaluation: A resident with dysphagia, malnutrition, and dementia reported ongoing trouble swallowing, dry mouth, and needing hot drinks to soften food. The SLP documented xerostomia, food sticking, GERD affecting swallowing, and recommended further testing with MBS/FEES and ENT/GI, but the record lacked documentation that the physician was notified or that the MBS was completed.
A resident with dementia, a healing R wrist fracture, and muscle weakness had a physician order and care plan for RNA AAROM to bilateral UE/LE 3 times weekly, but the ADON could not find documentation that the restorative treatment was provided. The resident was observed in a wheelchair and unable to describe whether restorative exercises were being received, and the order was not transcribed on the RNA MAR.
Resident bedrooms in 19 of 21 measured rooms did not meet the required minimum 80 sq ft per resident. During an environmental tour, rooms with two or four beds were found to provide only 69.85 to 77.5 sq ft per resident, and the Administrator and MS confirmed the measurements were accurate. The Administrator also stated the facility had no policy addressing room-size requirements.
A resident with severe cognitive impairment, diagnosed with dementia and Alzheimer's, left the facility unnoticed and traveled 17 miles away. The facility's safety and supervision policy was not followed, as the resident's absence went unnoticed by staff. Interviews with the ADON and DON confirmed the lapse in supervision, which is a core component of the facility's safety policy.
The facility failed to accurately code the MDS assessments for two residents, resulting in deficiencies. One resident receiving hospice care was not coded as such in the MDS, despite an order for hospice services. Another resident taking an antidepressant medication was not reflected in the MDS, even though the medication was administered regularly. The MDS Coordinator, DON, and Administrator acknowledged the errors and emphasized the importance of accurate MDS coding.
A facility failed to complete a PASARR evaluation for a resident who received new mental health diagnoses, including anxiety disorder, depression, and schizoaffective disorder. Despite the resident's severe cognitive impairment and active diagnoses, no PASARR evaluation was documented. The Assistant Director of Nursing was unaware of the need for a new PASARR, and the Director of Nursing acknowledged the oversight.
A resident with serious mental illness and intellectual disabilities was admitted to the facility with a 30-day Exempted Hospital Discharge, but the facility failed to complete a PASARR evaluation after the resident remained beyond the exemption period. The ADON was unfamiliar with the resubmission requirement, leading to non-compliance with federal regulations.
The facility failed to comply with federal regulations regarding resident room size, with 19 out of 21 rooms not meeting the required square footage per resident. Measurements showed that rooms with four beds provided only 73.2 square feet per resident, while two-bed rooms provided between 69.85 and 77.5 square feet per resident. The Director of Maintenance and the Administrator confirmed the accuracy of these measurements and acknowledged the non-compliance.
Failure to Follow SLP Recommendation for Swallowing Evaluation
Penalty
Summary
The facility failed to ensure the Speech Therapist’s recommendation was followed for Resident 22, who was admitted with dysphagia, moderate protein calorie malnutrition, and dementia. During an observation and interview, Resident 22 stated she had difficulty swallowing her food, needed hot drinks to soften foods, had to constantly remind staff to provide hot drinks, and said her mouth felt extremely dry. She also reported telling staff when meal trays were picked up that she could not swallow her food, but said nothing was done about it. Resident 22’s record showed a physician order for an easy-to-chew fortified diet with thin liquids, extra gravy on all meat, and extra fluids on all trays. The SLP evaluation from June 27, 2025 documented that the resident reported xerostomia and food getting stuck, used liquids mixed with textures to soften food before swallowing, and had a history of GERD affecting swallowing efficiency. The evaluation also indicated that further testing with MBS/FEES and ENT/GI was recommended. The ENT consult from the same date documented a very dry mouth, difficulty swallowing and eating, and decreased appetite possibly due to dryness. The Speech Therapist stated she evaluated Resident 22 again on November 18, 2025 because of ongoing swallowing complaints and documented recommendations in the electronic record, but could not recall whether the facility followed up or whether a physician was notified. The DON and ADON stated there was no documentation showing the physician was notified, whether the recommendation was accepted or declined, or why the MBS study was not completed.
Failure to Document Ordered Restorative AAROM
Penalty
Summary
The facility failed to ensure a physician’s order for RNA-provided AAROM was implemented for one resident. The resident was admitted with dementia, a healing fracture of the lower end of the right radius, and muscle weakness. After a witnessed fall in the hallway on June 11, 2025, the resident landed on the right side, including the right wrist, and reported pain rated 7/10 to the right wrist. The resident’s care plan, dated October 16, 2025, identified that she was on a restorative nursing program to maintain current functional status and directed RNA AAROM exercises to bilateral upper and lower extremities daily, three times per week as tolerated. The physician’s order, also dated October 16, 2025, specified RNA AAROM to bilateral upper and lower extremities every Monday, Wednesday, and Friday. During observation, the resident was seated in a wheelchair near the nurse’s station, awake and able to give brief verbal responses, but unable to sustain conversation or describe whether restorative exercises were being received. On review of the EMR with the ADON, no documented evidence could be found that RNA provided the AAROM treatment, and the order had not been transcribed on the RNA MAR. The facility policy stated residents would receive restorative nursing care as needed and that restorative goals would be individualized and outlined in the plan of care, but the ADON could not demonstrate that restorative services were documented as provided in accordance with the care plan or physician orders.
Resident Bedrooms Did Not Meet Minimum Space Requirements
Penalty
Summary
Resident bedrooms did not meet the required minimum 80 square feet per resident in 19 of 21 rooms measured during an environmental tour with the Maintenance Supervisor. Nineteen resident rooms were observed to be below the required space standard, including rooms with four beds in 292.8 square feet of floor area and rooms with two beds in areas ranging from 139.7 to 155 square feet. The measured space per resident ranged from 69.85 square feet to 77.5 square feet in the affected rooms. During interview, the Administrator confirmed that 19 of 21 rooms did not meet the required minimum 80 square feet per resident and stated there had been no resident complaints regarding room size. The Administrator also reported that the facility did not have a policy addressing room-size requirements. The Maintenance Supervisor confirmed that the measurements taken were accurate.
Resident Elopement Due to Lack of Supervision
Penalty
Summary
The facility failed to adhere to its safety and supervision policy when a resident with severe cognitive impairment left the facility without staff knowledge. The resident, who had been diagnosed with unspecified dementia and Alzheimer's disease, was admitted with a Brief Interview for Mental Status (BIMS) score of 4, indicating severe cognitive impairment. The resident left the facility around lunchtime and was found approximately 17 miles away at an acute general hospital later that day. The incident was not noticed by the staff until the resident was reported missing. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) revealed that the resident's absence went unnoticed, and the facility's safety and supervision policy was not followed. The facility's policy emphasized that resident supervision is a core component of safety, with the type and frequency of supervision determined by individual needs and environmental hazards. However, the lack of adherence to this policy resulted in the resident's elopement, posing a potential safety risk.
Inaccurate MDS Assessments for Hospice and Antidepressant Care
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessments for two residents, leading to deficiencies in the documentation of their care. For one resident, who was admitted on December 10, 2021, and had a diagnosis of senile degeneration of the brain, the MDS assessment did not reflect that the resident was receiving hospice care, despite an order for hospice services dated May 23, 2024. The MDS Coordinator acknowledged that hospice care should have been coded in the MDS, but it was not. The Director of Nursing (DON) and the Administrator both stated that the MDS should be coded correctly to accurately reflect the resident's status. For another resident, admitted on November 3, 2022, with a diagnosis of dementia, the MDS assessment failed to indicate that the resident was taking an antidepressant medication, escitalopram, which had been prescribed on April 2, 2024. The Medication Administration Record showed that the medication was administered throughout May 2024. The MDS Coordinator confirmed that the antidepressant should have been coded on the MDS. The DON reiterated the expectation for accurate MDS coding, and the Administrator also expected the MDS to be coded correctly, although he was not directly involved in the MDS process.
Failure to Complete PASARR Evaluation for New Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure a preadmission screening and resident review (PASARR) evaluation was completed for a resident who received new mental health diagnoses. The resident, admitted on March 18, 2022, was diagnosed with anxiety disorder, depression, and schizoaffective disorder on April 6, 2022. A quarterly Minimum Data Set (MDS) assessment on July 2, 2024, indicated the resident had severe cognitive impairment and active diagnoses of anxiety disorder, depression, and schizophrenia. The resident's care plan, updated on February 8, 2024, noted the use of psychotropic medications for schizoaffective disorder and valproic acid for mood disorder. Despite these new diagnoses, the resident's medical record showed no evidence of a completed PASARR evaluation. During interviews, the Assistant Director of Nursing stated that a Level I PASARR was submitted initially, but she was unaware that a new PASARR was required after the resident received new diagnoses. The Director of Nursing confirmed that the PASARR should have been resubmitted to reflect the resident's new serious mental illness diagnoses.
Failure to Complete PASARR Evaluation for Resident with Mental Illness
Penalty
Summary
The facility failed to ensure a preadmission screening and resident review (PASARR) evaluation was completed for a resident with a history of serious mental illness and intellectual disabilities. The resident was admitted with diagnoses including anxiety disorder, schizoaffective disorder, unspecified psychosis, and suicidal ideation. Despite these conditions, the resident's PASARR Level I Screening initially indicated a negative outcome due to a 30-day Exempted Hospital Discharge. However, the facility did not complete a PASARR evaluation after the resident remained in the facility beyond the 30-day exemption period. The Assistant Director of Nursing (ADON) admitted during an interview that the PASARR for the resident was missed because she was not familiar with the 30-day exemption and resubmission requirement. The Director of Nursing confirmed that the PASARR should have been resubmitted after the 30-day period. This oversight resulted in the facility's failure to comply with federal regulations requiring the screening and evaluation of individuals with serious mental illness or intellectual disabilities to determine the appropriate level of care and specialized services needed.
Non-Compliance with Resident Room Size Regulations
Penalty
Summary
The facility failed to ensure that resident rooms met the required minimum square footage per resident, as outlined in federal regulations. Specifically, the facility did not provide at least 80 square feet per resident in multiple occupancy rooms and 100 square feet for single occupancy rooms. The Client Accommodations Analysis, completed by the Administrator, revealed that 19 out of 21 resident rooms did not meet these requirements. Measurements showed that rooms with four beds provided only 73.2 square feet per resident, while rooms with two beds provided between 69.85 and 77.5 square feet per resident. Interviews conducted with the Director of Maintenance and the Administrator confirmed the accuracy of the room measurements and acknowledged that most resident rooms did not comply with federal size regulations. The Administrator also stated that there had been no issues with care related to room size and that the facility did not have a policy regarding room size. This deficiency was identified through document review and interviews, highlighting a significant non-compliance with federal standards for resident accommodations.
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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 Mentone
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Highland Care Center Of Redlands | 3.2 mi | ★★★★★ | 2 | 0 |
| Plymouth Village | 3.7 mi | ★★★★★ | 1 | 0 |
| Cedar Mountain Post Acute | 4 mi | ★★★★★ | 17 | 0 |
| Madison Grove Post Acute | 5.5 mi | ★★★★★ | 17 | 0 |
| Redlands Healthcare Center | 5.5 mi | ★★★★★ | 6 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.