Cycle 1
Health 2026-01-15 · Fire 2026-01-15
3 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
West Covina, CA
Beacon Healthcare Center
5-star overall rating with 5-star inspections with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
919 N Sunset Ave, West Covina, CA
(626) 962-4489
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
54
Certified beds
Average residents
38
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Nahs
Operator or chain grouping
Approved since
1976-06-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
12 facilities
Chain averages 4 overall / 3 health / 3 staffing / 5 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.36
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.67
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
2.70
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
4.72
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
2.02
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
4.08
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.30
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.31
CMS adjusted RN staffing hours
Adjusted total hours
4.12
CMS adjusted total nurse staffing hours
Case-mix index
1.57
Higher values indicate more complex resident acuity
RN turnover
20%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
32%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,542
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
29.48
Composite VBP score used to determine payment impact.
Payment multiplier
0.9855
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.82
Baseline 23.00% · Performance 21.61% · Measure score 1.82 · Achievement 0 · Improvement 1.82
Healthcare-associated infections
1.20
Baseline 11.76% · Performance 10.61% · Measure score 1.20 · Achievement 0 · Improvement 1.20
Total nurse turnover
5.70
Baseline 56.36% · Performance 40.38% · Measure score 5.70 · Achievement 5.70 · Improvement 4.57
Adjusted total nurse staffing
3.07
Baseline 3.87 hours · Performance 3.95 hours · Measure score 3.07 · Achievement 3.07 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.24% |
10.72%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 181 · Observed rate 11.6% · Lower 95% interval 8.45% |
| Discharge to community | 52.23% |
50.57%
1.7 pts better
|
No Different than the National Rate · Eligible stays 216 · Observed rate 45.37% · Lower 95% interval 44.26% |
| Medicare spending per beneficiary | 1.47 |
1.02
0.4 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 170 · Denominator 170 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 170 |
| Discharge self-care score | 69.66% |
53.69%
16 pts better
|
Numerator 62 · Denominator 89 |
| Discharge mobility score | 65.17% |
50.94%
14.2 pts better
|
Numerator 58 · Denominator 89 |
| Pressure ulcers or injuries, new or worsened | 1.18% |
2.29%
1.1 pts better
|
Numerator 2 · Denominator 170 · Adjusted rate 0.79% |
| Healthcare-associated infections requiring hospitalization | 10.61% |
7.12%
3.5 pts worse
|
Worse than the National Rate · Eligible stays 148 · Observed rate 14.19% · Lower 95% interval 7.56% |
| Staff COVID-19 vaccination coverage | 69.41% |
8.2%
61.2 pts better
|
Numerator 59 · Denominator 85 |
| Staff flu vaccination coverage | 100% |
42%
58 pts better
|
Numerator 100 · Denominator 100 |
| Discharge function score | 64.04% |
56.45%
7.6 pts better
|
Numerator 57 · Denominator 89 |
| Transfer of health information to provider | 92.77% |
95.95%
3.2 pts worse
|
Numerator 77 · Denominator 83 |
| Transfer of health information to patient | 95.31% |
96.28%
1 pts worse
|
Numerator 61 · Denominator 64 |
| Resident COVID-19 vaccinations up to date | 5.75% |
25.2%
19.4 pts worse
|
Numerator 5 · Denominator 87 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.3 |
2.3
1 pts worse
|
1.9
1.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.3 · Observed 5.7 · Expected 3.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.0 |
1.6
0.6 pts better
|
1.8
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 1.3 · Expected 2.0 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
98.5%
1.5 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 100.0% · Q3 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.7% |
98.2%
2.5 pts worse
|
95.5%
0.2 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.3% |
1.6%
0.3 pts better
|
3.3%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 0.0% · Q3 0.0% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 6.0% |
6.8%
0.8 pts better
|
11.4%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 6.0% |
| Percentage of long-stay residents who lose too much weight | 8.2% |
4.1%
4.1 pts worse
|
5.4%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 14.3% · 4Q avg 8.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 6.5% |
13.7%
7.2 pts better
|
19.6%
13.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 4.5% · Q3 5.0% · 4Q avg 6.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 0.0% |
14.2%
14.2 pts better
|
16.7%
16.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · 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 · Q2 0.0% · Q3 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 0.0% |
11.0%
11 pts better
|
16.3%
16.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 1.6% |
10.7%
9.1 pts better
|
14.9%
13.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.0%
1 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · 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 · Q2 0.0% · Q3 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 · 4Q avg 0.0% |
| Percentage of long-stay residents with pressure ulcers | 3.1% |
4.7%
1.6 pts better
|
5.1%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 3.1% · Q3 0.0% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
94.0%
6 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.7% |
11.2%
3.5 pts better
|
12.0%
4.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.7% · Observed 7.9% · Expected 11.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.8% |
1.5%
0.7 pts better
|
1.6%
0.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.6% · Q4 1.3% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.9% |
93.2%
2.7 pts better
|
79.7%
16.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.9% |
23.2%
2.7 pts worse
|
23.9%
2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.9% · Observed 27.9% · Expected 25.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-11-17 · Fire 2024-11-17
12 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2023-11-19 · Fire 2023-11-19
13 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2026-01-15
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2026-02-09
F · Potential for more than minimal harm
2026-01-15
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2026-02-06
D · Potential for more than minimal harm
2026-01-15
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2026-02-06
F · Potential for more than minimal harm
2024-11-17
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-12-10
F · Potential for more than minimal harm
2024-11-17
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-12-11
D · Potential for more than minimal harm
2024-11-17
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-12-11
D · Potential for more than minimal harm
2024-11-17
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-12-11
D · Potential for more than minimal harm
2024-11-17
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-12-11
D · Potential for more than minimal harm
2023-11-19
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-12-13
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-15
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2026-01-31
D · Potential for more than minimal harm
2026-01-15
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2026-01-31
D · Potential for more than minimal harm
2026-01-15
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 2026-01-20
E · Potential for more than minimal harm
2024-11-17
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-12-11
E · Potential for more than minimal harm
2024-11-17
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 2024-11-22
D · Potential for more than minimal harm
2024-11-17
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-12-11
D · Potential for more than minimal harm
2024-11-17
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2024-12-11
D · Potential for more than minimal harm
2024-11-17
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-12-11
D · Potential for more than minimal harm
2024-11-17
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-12-11
D · Potential for more than minimal harm
2024-11-17
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-12-11
D · Potential for more than minimal harm
2024-11-17
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-12-11
D · Potential for more than minimal harm
2024-11-17
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-12-11
D · Potential for more than minimal harm
2024-11-17
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-12-09
D · Potential for more than minimal harm
2024-11-17
F847 · Administration Deficiencies
Health
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Corrected 2024-12-11
D · Potential for more than minimal harm
2024-05-30
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 2024-06-17
D · Potential for more than minimal harm
2023-12-08
F573 · Resident Rights Deficiencies
Health
Let each resident or the resident's legal representative access or purchase copies of all the resident's records.
Corrected 2023-12-18
E · Potential for more than minimal harm
2023-11-19
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 2023-12-13
E · Potential for more than minimal harm
2023-11-19
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2023-12-13
E · Potential for more than minimal harm
2023-11-19
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2023-12-13
D · Potential for more than minimal harm
2023-11-19
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-12-13
D · Potential for more than minimal harm
2023-11-19
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-12-13
D · Potential for more than minimal harm
2023-11-19
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-12-13
D · Potential for more than minimal harm
2023-11-19
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 2023-12-13
D · Potential for more than minimal harm
2023-11-19
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 2023-12-13
D · Potential for more than minimal harm
2023-11-19
F803 · Nutrition and Dietary Deficiencies
Health
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.
Corrected 2023-12-13
D · Potential for more than minimal harm
2023-11-19
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 2023-12-13
D · Potential for more than minimal harm
2023-11-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-12-13
D · Potential for more than minimal harm
2023-05-16
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-07-07
Penalties and ownership
What sits behind the stars
Ownership
Nahs Southeast, Inc.
5% Or Greater Direct Ownership Interest · Organization
Dahl, Brenden
Operational/Managerial Control · Individual
Dahl, Brenden
Corporate Director · Individual
Dahl, Brenden
Corporate Officer · Individual
Dahl, Brenden
W-2 Managing Employee · Individual
Ellis-Sherinian, James
Corporate Director · Individual
Johnson, Marc
Corporate Officer · Individual
Lane, Joanne
Corporate Director · Individual
Lundquist, Victor
Corporate Officer · Individual
Nahs Employee Stock Ownership Trust
5% Or Greater Indirect Ownership Interest · Organization
Nahs Holding Inc
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Other facilities in reach
#1
Garden View Post Acute Rehabilitation
Baldwin Park, CA
4-star overall rating with 3-star inspections with 12 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
West Covina Healthcare Center
West Covina, CA
3-star overall rating with 3-star inspections with $86,320 in total fines with 13 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
West Haven Healthcare
West Covina, CA
3-star overall rating with 2-star inspections with 19 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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