6 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
7 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Redwood City, CA
3-star overall rating with 4-star inspections with 6 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
3635 Jefferson Avenue, Redwood City, CA
(650) 366-9503
Overall
3 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Beds
38
Certified beds
Average residents
31
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2004-11-08
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
RN hours / resident day
0.00
Registered nurse staffing
LPN hours / resident day
0.00
Licensed practical nurse staffing
Aide hours / resident day
0.00
Nurse aide staffing
Total nurse hours
0.00
All reported nurse hours
Licensed hours
0.00
RN + LPN hours
Weekend hours
0.00
Weekend nurse staffing
Weekend RN hours
0.00
Weekend registered nurse coverage
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.00
CMS adjusted RN staffing hours
Adjusted total hours
0.00
CMS adjusted total nurse staffing hours
Case-mix index
0.00
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Program rank
4,834
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
38.41
Composite VBP score used to determine payment impact.
Payment multiplier
0.9915
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
0.64
Performance 21.14% · Measure score 0.64 · Achievement 0.64 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
6.90
Performance 5.77% · Measure score 6.90 · Achievement 6.90 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
1.99
Baseline 48.48% · Performance 55.56% · Measure score 1.99 · Achievement 1.99 · Improvement 0
Adjusted total nurse staffing
5.83
Baseline 5.09 hours · Performance 4.74 hours · Measure score 5.83 · Achievement 5.83 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.28% |
10.72%
1.6 pts worse
|
No Different than the National Rate · Eligible stays 64 · Observed rate 14.06% · Lower 95% interval 6.88% |
| Discharge to community | 60.25% |
50.57%
9.7 pts better
|
No Different than the National Rate · Eligible stays 61 · Observed rate 59.02% · Lower 95% interval 48.6% |
| Medicare spending per beneficiary | 0.87 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 90.38% |
95.27%
4.9 pts worse
|
Numerator 47 · Denominator 52 |
| Falls with major injury | 3.85% |
0.77%
3.1 pts worse
|
Numerator 2 · Denominator 52 |
| Discharge self-care score | 36.84% |
53.69%
16.8 pts worse
|
Numerator 14 · Denominator 38 |
| Discharge mobility score | 36.84% |
50.94%
14.1 pts worse
|
Numerator 14 · Denominator 38 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 52 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 5.77% |
7.12%
1.4 pts better
|
No Different than the National Rate · Eligible stays 42 · Observed rate 0% · Lower 95% interval 2.64% |
| Staff COVID-19 vaccination coverage | 38% |
8.2%
29.8 pts better
|
Numerator 19 · Denominator 50 |
| Staff flu vaccination coverage | 87.04% |
42%
45 pts better
|
Numerator 47 · Denominator 54 |
| Discharge function score | 44.74% |
56.45%
11.7 pts worse
|
Numerator 17 · Denominator 38 |
| Transfer of health information to provider | 85.71% |
95.95%
10.2 pts worse
|
Numerator 18 · Denominator 21 |
| Transfer of health information to patient | 95.45% |
96.28%
0.8 pts worse
|
Numerator 21 · Denominator 22 |
| Resident COVID-19 vaccinations up to date | 25.81% |
25.2%
0.6 pts better
|
Numerator 8 · Denominator 31 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.7% |
98.5%
1.8 pts worse
|
93.4%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 96.2% · Q3 95.8% · Q4 95.5% · 4Q avg 96.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 85.7% |
98.2%
12.5 pts worse
|
95.5%
9.8 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 85.7% |
| 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 · 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 | 2.8% |
6.8%
4 pts better
|
11.4%
8.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 4.8% · 4Q avg 2.8% |
| Percentage of long-stay residents who lose too much weight | 9.6% |
4.1%
5.5 pts worse
|
5.4%
4.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 0.0% · Q3 18.2% · Q4 13.6% · 4Q avg 9.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 8.3% |
13.7%
5.4 pts better
|
19.6%
11.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 8.7% · Q3 9.1% · Q4 9.1% · 4Q avg 8.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 6.7% |
14.2%
7.5 pts better
|
16.7%
10 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 6.7% · 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% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 10.3% |
11.0%
0.7 pts better
|
16.3%
6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 10.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.3% |
10.7%
2.4 pts better
|
14.9%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 15.0% · Q4 5.0% · 4Q avg 8.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.9% |
1.0%
0.9 pts worse
|
1.0%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 3.2% · Q3 0.0% · Q4 4.3% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.1% |
1.2%
0.1 pts better
|
1.7%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 0.0% · Q3 0.0% · Q4 4.5% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 15.7% |
10.9%
4.8 pts worse
|
19.8%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 16.5% · Q3 7.6% · Q4 13.7% · 4Q avg 15.7% |
| Percentage of long-stay residents with pressure ulcers | 2.2% |
4.7%
2.5 pts better
|
5.1%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 0.0% · Q3 0.0% · Q4 4.8% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 79.3% |
94.0%
14.7 pts worse
|
81.7%
2.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 78.4% · Q2 80.3% · Q3 76.2% · Q4 83.0% · 4Q avg 79.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.0% |
11.2%
4.8 pts worse
|
12.0%
4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 16.0% · Observed 13.9% · Expected 9.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.3% |
1.5%
0.2 pts better
|
1.6%
0.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 2.4% · Q3 0.0% · Q4 0.0% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 79.1% |
93.2%
14.1 pts worse
|
79.7%
0.6 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 79.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.6% |
23.2%
0.6 pts better
|
23.9%
1.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.6% · Observed 19.4% · Expected 20.5% · Used in QM five-star |
Survey summary
Top issue: Resident Assessment and Care Planning (2 deficiencies)
7 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Top issue: Nutrition and Dietary (5 deficiencies)
19 fire-safety deficiencies
Top issue: Smoke (9 deficiencies)
Top issue: Nutrition and Dietary (3 deficiencies)
13 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Fire safety
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2025-02-13
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-02-27
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2025-02-20
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-02-20
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-01-30
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-02-07
Fire Safety
Use approved construction type or materials.
Corrected 2025-02-13
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-02-18
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-02-18
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-01-23
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-01-23
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2023-12-13
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-12-13
Fire Safety
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Corrected 2023-12-13
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-12-13
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-12-13
Fire Safety
Use approved construction type or materials.
Corrected 2023-12-13
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-12-13
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-12-13
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-12-13
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 2023-12-13
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-12-13
Fire Safety
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
Corrected 2023-12-13
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-12-13
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2023-12-13
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2023-12-13
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-12-13
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2021-12-13
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2021-12-13
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2021-12-13
Fire Safety
Establish policies and procedures for medical documentation.
Corrected 2021-12-13
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2021-12-13
Fire Safety
Provide a means of sharing information on occupancy/needs.
Corrected 2021-12-13
Fire Safety
Use approved construction type or materials.
Corrected 2021-12-13
Fire Safety
Provide properly protected cooking facilities.
Corrected 2021-12-13
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2021-12-13
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2021-12-13
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2021-12-13
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2021-12-13
Inspection history
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-03-01
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2025-03-01
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-03-01
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-03-01
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-03-01
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2025-03-01
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-11-24
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2023-10-30
Health
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Corrected 2023-11-02
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 2023-11-28
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-11-23
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-10-30
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2023-11-29
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-10-27
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2023-10-27
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-01-15
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2023-10-30
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-10-30
Health
Post nurse staffing information every day.
Corrected 2023-10-30
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 2023-10-30
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2023-11-02
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-09-01
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2021-12-14
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2021-12-14
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2021-12-14
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2021-12-14
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2021-12-14
Health
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Corrected 2021-12-14
Penalties and ownership
5% Or Greater Direct Ownership Interest · Individual
5% Or Greater Direct Ownership Interest · Individual
General Partnership Interest · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
W-2 Managing Employee · Individual
5% Or Greater Direct Ownership Interest · Organization
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