Cycle 1
Health 2024-11-21 · Fire 2024-11-21
2 health deficiencies
Top issue: Infection Control (1 deficiency)
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Oakland, CA
Excell Health Care Center
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
3025 High Street, Oakland, CA
(510) 261-5200
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
99
Certified beds
Average residents
92
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
David & Frank Johnson
Operator or chain grouping
Approved since
1970-03-04
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
45 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 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
0.51
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
0.94
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
2.44
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
3.89
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
1.45
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
3.57
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.33
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.49
CMS adjusted RN staffing hours
Adjusted total hours
3.75
CMS adjusted total nurse staffing hours
Case-mix index
1.42
Higher values indicate more complex resident acuity
RN turnover
11%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
25%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,083
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
41.37
Composite VBP score used to determine payment impact.
Payment multiplier
0.9943
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.53
Baseline 19.57% · Performance 20.26% · Measure score 2.53 · Achievement 2.53 · Improvement 0
Healthcare-associated infections
2.86
Baseline 7.57% · Performance 6.98% · Measure score 2.86 · Achievement 2.86 · Improvement 1.78
Total nurse turnover
8.85
Baseline 27.94% · Performance 27.50% · Measure score 8.85 · Achievement 8.85 · Improvement 0.93
Adjusted total nurse staffing
2.31
Baseline 2.77 hours · Performance 3.62 hours · Measure score 2.31 · Achievement 1.90 · Improvement 2.31
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.89% |
10.72%
0.8 pts better
|
No Different than the National Rate · Eligible stays 140 · Observed rate 9.29% · Lower 95% interval 7.52% |
| Discharge to community | 39.48% |
50.57%
11.1 pts worse
|
Worse than the National Rate · Eligible stays 177 · Observed rate 29.94% · Lower 95% interval 32.43% |
| Medicare spending per beneficiary | 1.55 |
1.02
0.5 pts worse
|
|
| Drug regimen review with follow-up | 98.52% |
95.27%
3.2 pts better
|
Numerator 133 · Denominator 135 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 135 |
| Discharge self-care score | 72.15% |
53.69%
18.5 pts better
|
Numerator 57 · Denominator 79 |
| Discharge mobility score | 73.42% |
50.94%
22.5 pts better
|
Numerator 58 · Denominator 79 |
| Pressure ulcers or injuries, new or worsened | 3.7% |
2.29%
1.4 pts worse
|
Numerator 5 · Denominator 135 · Adjusted rate 2.7% |
| Healthcare-associated infections requiring hospitalization | 6.98% |
7.12%
0.1 pts better
|
No Different than the National Rate · Eligible stays 132 · Observed rate 7.58% · Lower 95% interval 4.34% |
| Staff COVID-19 vaccination coverage | 27.52% |
8.2%
19.3 pts better
|
Numerator 30 · Denominator 109 |
| Staff flu vaccination coverage | 66.96% |
42%
25 pts better
|
Numerator 75 · Denominator 112 |
| Discharge function score | 75.95% |
56.45%
19.5 pts better
|
Numerator 60 · Denominator 79 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 82 · Denominator 82 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 30.14% |
25.2%
4.9 pts better
|
Numerator 22 · Denominator 73 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.2 |
2.3
0.1 pts better
|
1.9
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 2.7 · Expected 2.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.5 |
1.6
0.1 pts better
|
1.8
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.5 · Expected 1.6 · 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 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
98.2%
1.8 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.2% |
1.6%
0.6 pts worse
|
3.3%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 2.7% · Q3 1.3% · Q4 1.2% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 6.8% |
6.8%
About the same
|
11.4%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 7.0% · Q3 8.0% · Q4 7.9% · 4Q avg 6.8% |
| Percentage of long-stay residents who lose too much weight | 3.4% |
4.1%
0.7 pts better
|
5.4%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 1.5% · Q3 2.8% · Q4 6.2% · 4Q avg 3.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 3.6% |
13.7%
10.1 pts better
|
19.6%
16 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 2.7% · Q3 3.9% · Q4 4.9% · 4Q avg 3.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 3.0% |
14.2%
11.2 pts better
|
16.7%
13.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 4.5% · Q3 4.2% · Q4 0.0% · 4Q avg 3.0% · 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 3.4% |
11.0%
7.6 pts better
|
16.3%
12.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 4.7% · Q4 3.6% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 4.5% |
10.7%
6.2 pts better
|
14.9%
10.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 1.6% · Q3 6.2% · Q4 8.3% · 4Q avg 4.5% · 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 4.6% |
10.9%
6.3 pts better
|
19.8%
15.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.6% · Q2 6.1% · Q3 5.5% · Q4 2.4% · 4Q avg 4.6% |
| Percentage of long-stay residents with pressure ulcers | 3.0% |
4.7%
1.7 pts better
|
5.1%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 1.5% · Q3 2.5% · Q4 3.8% · 4Q avg 3.0% · 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 | 9.6% |
11.2%
1.6 pts better
|
12.0%
2.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.6% · Observed 10.2% · Expected 12.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.2% |
1.5%
0.3 pts better
|
1.6%
0.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 2.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
93.2%
6.8 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.5% |
23.2%
4.7 pts better
|
23.9%
5.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 18.5% · Observed 20.5% · Expected 26.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-12-21 · Fire 2022-12-21
3 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2019-12-05 · Fire 2019-12-05
6 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-11-21
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2024-12-05
E · Potential for more than minimal harm
2024-11-21
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-12-05
D · Potential for more than minimal harm
2024-11-21
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-12-05
D · Potential for more than minimal harm
2024-11-21
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-11-27
D · Potential for more than minimal harm
2024-11-21
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2024-12-05
D · Potential for more than minimal harm
2024-11-21
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2024-11-27
C · Minimal harm
2024-11-21
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2024-11-26
E · Potential for more than minimal harm
2022-12-21
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-01-20
D · Potential for more than minimal harm
2022-12-21
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2023-01-20
D · Potential for more than minimal harm
2022-12-21
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2023-01-20
D · Potential for more than minimal harm
2022-12-21
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2023-01-20
D · Potential for more than minimal harm
2022-12-21
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-01-20
D · Potential for more than minimal harm
2022-12-21
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-01-20
D · Potential for more than minimal harm
2022-12-21
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-01-20
D · Potential for more than minimal harm
2019-12-05
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2020-02-18
D · Potential for more than minimal harm
2019-12-05
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 2020-02-18
D · Potential for more than minimal harm
2019-12-05
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2020-02-18
D · Potential for more than minimal harm
2019-12-05
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2020-02-18
D · Potential for more than minimal harm
2019-12-05
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2020-02-18
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-11-21
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 2025-01-22
E · Potential for more than minimal harm
2024-11-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-22
E · Potential for more than minimal harm
2022-12-21
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 2023-01-25
E · Potential for more than minimal harm
2022-12-21
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 2023-01-25
D · Potential for more than minimal harm
2022-12-21
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-01-25
E · Potential for more than minimal harm
2019-12-05
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2019-12-19
E · Potential for more than minimal harm
2019-12-05
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2019-12-19
D · Potential for more than minimal harm
2019-12-05
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2019-12-19
D · Potential for more than minimal harm
2019-12-05
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2019-12-19
D · Potential for more than minimal harm
2019-12-05
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 2019-12-19
D · Potential for more than minimal harm
2019-12-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-12-19
Penalties and ownership
What sits behind the stars
Ownership
Excell Post Acute LLC
5% Or Greater Direct Ownership Interest · Organization
Johnson, David
5% Or Greater Indirect Ownership Interest · Individual
Johnson, Frank
5% Or Greater Indirect Ownership Interest · Individual
Conway, Elma
W-2 Managing Employee · Individual
Dehghanmanesh, Adrian
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Redwood Healthcare Center LLC
Oakland, CA
4-star overall rating with 4-star inspections with 4 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
#2
Princeton Manor Healthcare Center, LLC
Oakland, CA
5-star overall rating with 4-star inspections with 11 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#3
Mercy Retirement & Care Center
Oakland, CA
3-star overall rating with 3-star inspections with $47,447 in total fines with 11 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
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