Heritage Gardens Health Care Center

Name: Heritage Gardens Health Care Center
Address: 25271 Barton Rd, Loma Linda, CA, 92354, US
Telephone: 9097960216

25271 Barton Rd, Loma Linda, CA 92354 · San Bernardino County · 110 certified beds · avg 102 residents/day · certified since Jan 1, 1967

Part of chain: PROGRESSIVE HEALTH CARE CENTERS (5 facilities, chain avg rating 3.8★)

3/5

Health inspection rating (on-site)

Serious findings on record

Fines, last 3 years

3.91

Nurse hours/resident/day (adjusted)

What health inspectors found (on-site government inspections — the most independent evidence available)

Health inspection rating: ★★★☆☆3/5 · CMS overall rating: 4/5

The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.

All citations in the current public record (46)

CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.

Date	Severity	What the facility was cited for
Jul 2, 2026	D · Potential for harm, one-off	The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint
May 7, 2026	F · Potential for harm, facility-wide	The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
May 7, 2026	F · Potential for harm, facility-wide	The facility did not maintain an effective pest control program to prevent or deal with mice, insects, or other pests.
May 7, 2026	E · Potential for harm, repeated	The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care.
May 7, 2026	D · Potential for harm, one-off	The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights.
May 7, 2026	D · Potential for harm, one-off	The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
May 7, 2026	D · Potential for harm, one-off	The facility did not reassess a resident after a significant change in their condition, such as a sudden decline in health. A full new assessment is required when a resident's condition changes in a major way.
May 7, 2026	D · Potential for harm, one-off	The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives.
May 7, 2026	D · Potential for harm, one-off	The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist.
May 7, 2026	D · Potential for harm, one-off	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
May 7, 2026	D · Potential for harm, one-off	The facility did not have a working call system — the button or cord residents use to summon help — in each resident's bathroom and bathing area.
May 7, 2026	C · Minimal risk, facility-wide	The facility did not make its inspection results easy for residents to see, or made it hard for residents to contact advocacy agencies like the ombudsman.
May 6, 2025	D · Potential for harm, one-off	The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint
Jan 16, 2025	F · Potential for harm, facility-wide	The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Jan 16, 2025	F · Potential for harm, facility-wide	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Jan 16, 2025	D · Potential for harm, one-off	The facility did not reassess a resident after a significant change in their condition, such as a sudden decline in health. A full new assessment is required when a resident's condition changes in a major way.
Jan 16, 2025	D · Potential for harm, one-off	The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives.
Jan 16, 2025	D · Potential for harm, one-off	The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Jan 16, 2025	D · Potential for harm, one-off	The facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline.
Jan 16, 2025	D · Potential for harm, one-off	The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it.
Jan 16, 2025	D · Potential for harm, one-off	The facility employed staff who were not licensed, certified, or registered as required by state law. · from a complaint
Dec 12, 2024	D · Potential for harm, one-off	The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint
Sep 5, 2024	D · Potential for harm, one-off	The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint
May 3, 2024	D · Potential for harm, one-off	The facility used physical restraints — devices that limit a resident's movement — when they weren't needed for medical treatment. · from a complaint
Dec 19, 2023	D · Potential for harm, one-off	The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint
Nov 4, 2023	D · Potential for harm, one-off	The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint
Sep 29, 2023	D · Potential for harm, one-off	The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. · from a complaint
Sep 24, 2023	D · Potential for harm, one-off	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint
Sep 10, 2023	D · Potential for harm, one-off	The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. · from a complaint
Jul 15, 2022	F · Potential for harm, facility-wide	The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Jul 15, 2022	E · Potential for harm, repeated	The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist.
Jul 15, 2022	E · Potential for harm, repeated	The facility did not prepare and serve food in a form that meets each resident's individual needs — for example, chopped, pureed, or softened food for residents with chewing or swallowing problems.
Jul 15, 2022	D · Potential for harm, one-off	The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups.
Jul 15, 2022	D · Potential for harm, one-off	The facility did not keep residents' personal and medical information private and confidential.
Jul 15, 2022	D · Potential for harm, one-off	The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives.
Jul 15, 2022	D · Potential for harm, one-off	The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Jul 15, 2022	D · Potential for harm, one-off	The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration.
Jul 15, 2022	D · Potential for harm, one-off	The facility used feeding tubes without a valid medical reason or the resident's agreement, or did not provide proper care to residents who have feeding tubes.
Jul 15, 2022	D · Potential for harm, one-off	The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it.
Jul 15, 2022	D · Potential for harm, one-off	The facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail.
Jul 15, 2022	D · Potential for harm, one-off	The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time.
Jul 15, 2022	D · Potential for harm, one-off	The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock.
Jul 15, 2022	D · Potential for harm, one-off	The facility did not have enough support staff to safely and effectively run its food and nutrition service.
Jul 15, 2022	D · Potential for harm, one-off	The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards.
Jul 15, 2022	D · Potential for harm, one-off	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Jul 15, 2022	D · Potential for harm, one-off	The facility did not keep all essential equipment working safely — things like heating and cooling systems, kitchen equipment, and medical devices.

Inspection trend by year

Citations from standard inspections increased between the last two inspection cycles (8 → 11).

Year	Citations	Worst severity that year
2022	17	F
2023	5	D
2024	3	D
2025	9	F
2026	12	F

Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.

Fines and enforcement (last 3 years)

No fines or payment denials in the published 3-year window.

Nurse staffing (from payroll records, adjusted for how much care residents need)

Measure	This facility	California avg	U.S. avg	Where it stands
Total nurse staffing (hours per resident per day)	3.91	4.31	3.95	bottom 34% in California; top 43% in the U.S.
Registered Nurse hours	0.32	0.61	0.69	bottom 15% in California; bottom 12% in the U.S.
Weekend total nurse staffing	3.57	3.90	3.50	bottom 36% in California; top 39% in the U.S.
Weekend RN hours (not acuity-adjusted)	0.25	0.51	0.48	bottom 22% in California; bottom 23% in the U.S.
Total nursing staff turnover (%)	100.0	36.7	45.8	bottom 1% in California; bottom 1% in the U.S.
RN turnover (%)	100.0	38.1	42.9	bottom 1% in California; bottom 1% in the U.S.

Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.81, RN 0.31, weekend 3.48. Staffing rating: 2/5.

Self-reported quality measures

Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.

Quality measures rating: 5/5 · long-stay residents: 5/5 · short-stay residents: —/5

Who owns this facility

For profit - Corporation

Owner / manager	Type	Role	Stake	Since
Armstrong, John	Individual	5% or Greater Direct Ownership Interest	11%	03/13/1992
Armstrong, Laura	Individual	5% or Greater Direct Ownership Interest	11%	03/13/1992
Cotton Family Revocable Trust	Organization	5% or Greater Direct Ownership Interest	13%	05/20/2016
Goings, Gregory	Individual	5% or Greater Direct Ownership Interest	16%	03/13/1992
Goings, Patricia	Individual	5% or Greater Direct Ownership Interest	16%	03/13/1992
Goings, Verna	Individual	5% or Greater Direct Ownership Interest	16%	03/13/1992
Helen Louise Larson Revocable Trust	Organization	5% or Greater Direct Ownership Interest	6%	10/23/2019
The Larson Family Trust of 2010	Organization	5% or Greater Direct Ownership Interest	6%	11/19/2013
Goings, Gregory	Individual	Corporate Officer	NOT APPLICABLE	01/01/2002
Goings, Samuel	Individual	W-2 Managing Employee	NOT APPLICABLE	02/06/2018
Kilian, James	Individual	Corporate Officer	NOT APPLICABLE	01/08/1998

Questions to ask on your visit

Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.

"What systems do you use to prevent medication errors, and what happens when one occurs?"
"What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
"How is pest control handled here, and when was the last treatment or inspection?"
"How do you record and honor each resident's treatment wishes and advance directives, and how do staff know about them?"
"Can you give me examples of how your staff protect residents' dignity in everyday care, like bathing and dressing?"
"Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
"If my family member's health suddenly changes, how quickly do you reassess them and update their care?"
"Who completes resident assessments here, and how do you check them for accuracy?"
"What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
"Can I see the results and plan of correction from your most recent state inspection?"

Nearby facilities (within 20 miles)

Facility	Distance	City	Overall	Inspection
Loma Linda Post Acute	0.3 mi	Loma Linda, CA	★★★★☆	4/5
Asistencia Villa Healthcare Center	1.1 mi	Redlands, CA	★★☆☆☆	3/5
Totally Kids Rehabilitation Hospital - D/P SNF	1.7 mi	Loma Linda, CA	★★★★★	4/5
The Canyons Post-Acute	2.3 mi	Colton, CA	★★☆☆☆	2/5
Brookside Healthcare Center	2.3 mi	Redlands, CA	★★★☆☆	3/5
Meadows Ridge Care Center	2.9 mi	Colton, CA	★★★★☆	4/5
Madison Grove Post Acute	2.9 mi	Redlands, CA	★★★☆☆	3/5
Redlands Healthcare Center	3.0 mi	Redlands, CA	★★★★☆	4/5
Redlands Comm Hosp D/P SNF	3.0 mi	Redlands, CA	★★★★☆	5/5
Grand Terrace Health Care Center	3.5 mi	Grand Terrace, CA	★★★★★	5/5

Compare this facility with the 3 closest →

All facilities in Loma Linda →

Facility data as of CMS processing date 2026-08-01. CCN 055183.

The Care File

Visit checklist — Heritage Gardens Health Care Center

25271 Barton Rd, Loma Linda, CA 92354 · 9097960216

Health inspection rating 3/5 · CMS overall 4/5· Fines (3y): $0

Questions for the administrator:

☐ "What systems do you use to prevent medication errors, and what happens when one occurs?"
☐ "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
☐ "How is pest control handled here, and when was the last treatment or inspection?"
☐ "How do you record and honor each resident's treatment wishes and advance directives, and how do staff know about them?"
☐ "Can you give me examples of how your staff protect residents' dignity in everyday care, like bathing and dressing?"
☐ "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
☐ "If my family member's health suddenly changes, how quickly do you reassess them and update their care?"
☐ "Who completes resident assessments here, and how do you check them for accuracy?"
☐ "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
☐ "Can I see the results and plan of correction from your most recent state inspection?"

While you're there, notice:

☐ Smell and cleanliness in hallways, not just the lobby
☐ How staff speak to residents; call lights answered promptly
☐ Residents up, dressed, and engaged (visit mealtimes and a weekend if you can)

Data: CMS Provider Data Catalog, version 2026-08-01 · CCN 055183 · Verify at medicare.gov/care-compare · Printed from The Care File (thecarefile.com)