Westminster, CA

Extended Care Hospital Of Westminster

5-star overall rating with 4-star inspections with 16 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle

206 Hospital Circle, Westminster, CA

(714) 891-2769

Compare this facility

Overall

5 / 5

CMS overall stars

Health inspections

4 / 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

97

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

No chain reported

Operator or chain grouping

Approved since

1985-09-05

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

Hours and turnover

RN hours / resident day

0.26

Registered nurse staffing · state 0.65 · national 0.68

LPN hours / resident day

1.07

Licensed practical nurse staffing · state 1.22 · national 0.87

Aide hours / resident day

2.41

Nurse aide staffing · state 2.64 · national 2.35

Total nurse hours

3.74

All reported nurse hours · state 4.51 · national 3.89

Licensed hours

1.34

RN + LPN hours · state 1.87 · national 1.54

Weekend hours

3.23

Weekend nurse staffing · state 4.08 · national 3.43

Weekend RN hours

0.18

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

0.33

CMS adjusted RN staffing hours

Adjusted total hours

4.75

CMS adjusted total nurse staffing hours

Case-mix index

1.08

Higher values indicate more complex resident acuity

RN turnover

0%

Annual RN turnover

Total nurse turnover

18%

Annual nurse turnover · state 38% · national 46%

SNF VBP

Value-based purchasing

Program rank

498

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

68.76

Composite VBP score used to determine payment impact.

Payment multiplier

1.0217

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Healthcare-associated infections

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Total nurse turnover

8.21

Baseline 23.66% · Performance 30.11% · Measure score 8.21 · Achievement 8.21 · Improvement 0

Adjusted total nurse staffing

5.54

Baseline 5.04 hours · Performance 4.65 hours · Measure score 5.54 · Achievement 5.54 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure Facility National Note
Potentially preventable 30-day readmission Not Available
10.72%
Not Available · Eligible stays 17 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Discharge to community Not Available
50.57%
Not Available · Eligible stays 4 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Medicare spending per beneficiary Not Available
1.02
Too few residents or stays to report publicly.
Drug regimen review with follow-up 100%
95.27%
4.7 pts better
Numerator 20 · Denominator 20
Falls with major injury 0%
0.77%
0.8 pts better
Numerator 0 · Denominator 20
Discharge self-care score Not Available
53.69%
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly.
Discharge mobility score Not Available
50.94%
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly.
Pressure ulcers or injuries, new or worsened 0%
2.29%
2.3 pts better
Numerator 0 · Denominator 20 · Adjusted rate 0%
Healthcare-associated infections requiring hospitalization Not Available
7.12%
Not Available · Eligible stays 14 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Staff COVID-19 vaccination coverage 21.92%
8.2%
13.7 pts better
Numerator 32 · Denominator 146
Staff flu vaccination coverage Not Available
42%
Numerator Not Available · Denominator Not Available · No data were submitted for this measure.
Discharge function score Not Available
56.45%
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly.
Transfer of health information to provider Not Available
95.95%
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly.
Transfer of health information to patient Not Available
96.28%
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report.
Resident COVID-19 vaccinations up to date Not Available
25.2%
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly.

Quality measures

Resident outcomes and process scores

Measure Facility State National Note
Number of hospitalizations per 1000 long-stay resident days 1.9
2.3
0.4 pts better
1.9
About the same
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.7 · Expected 1.7 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days 0.5
1.6
1.1 pts better
1.8
1.3 pts better
Long Stay · 20240701-20250630 · Adjusted 0.5 · Observed 0.4 · Expected 1.4 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine 97.6%
98.5%
0.9 pts worse
93.4%
4.2 pts better
Long Stay · 2024Q4-2025Q3 · Q1 96.9% · Q2 98.9% · Q3 96.7% · Q4 97.9% · 4Q avg 97.6%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine 96.1%
98.2%
2.1 pts worse
95.5%
0.6 pts better
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.1%
Percentage of long-stay residents experiencing one or more falls with major injury 0.3%
1.6%
1.3 pts better
3.3%
3 pts better
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.0% · 4Q avg 0.3% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms 0.6%
6.8%
6.2 pts better
11.4%
10.8 pts better
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.1% · Q4 1.1% · 4Q avg 0.6%
Percentage of long-stay residents who lose too much weight 3.3%
4.1%
0.8 pts better
5.4%
2.1 pts better
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 3.3% · Q3 3.4% · Q4 1.1% · 4Q avg 3.3%
Percentage of long-stay residents who received an antianxiety or hypnotic medication 10.8%
13.7%
2.9 pts better
19.6%
8.8 pts better
Long Stay · 2024Q4-2025Q3 · Q1 8.4% · Q2 9.9% · Q3 11.0% · Q4 13.8% · 4Q avg 10.8%
Percentage of long-stay residents who received an antipsychotic medication 34.6%
14.2%
20.4 pts worse
16.7%
17.9 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 34.0% · Q2 29.7% · Q3 39.6% · Q4 34.0% · 4Q avg 34.6% · Used in QM five-star
Percentage of long-stay residents who were physically restrained 1.1%
0.4%
0.7 pts worse
0.1%
1 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 1.1% · Q3 1.1% · Q4 1.0% · 4Q avg 1.1%
Percentage of long-stay residents whose ability to walk independently worsened 4.1%
11.0%
6.9 pts better
16.3%
12.2 pts better
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 6.5% · Q3 1.9% · Q4 3.6% · 4Q avg 4.1% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased 3.9%
10.7%
6.8 pts better
14.9%
11 pts better
Long Stay · 2024Q4-2025Q3 · Q1 5.5% · Q2 5.6% · Q3 4.4% · Q4 0.0% · 4Q avg 3.9% · 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 0.3%
1.2%
0.9 pts better
1.7%
1.4 pts better
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.1% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence 3.5%
10.9%
7.4 pts better
19.8%
16.3 pts better
Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 2.1% · Q3 1.0% · Q4 4.8% · 4Q avg 3.5%
Percentage of long-stay residents with pressure ulcers 1.4%
4.7%
3.3 pts better
5.1%
3.7 pts better
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 1.5% · Q3 0.0% · Q4 2.6% · 4Q avg 1.4% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine 90.3%
94.0%
3.7 pts worse
81.7%
8.6 pts better
Short Stay · 2024Q4-2025Q3 · Q2 95.7% · Q3 95.2% · 4Q avg 90.3%
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 92.0%
93.2%
1.2 pts worse
79.7%
12.3 pts better
Short Stay · 2024Q3-2025Q2 · 4Q avg 92.0%

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-07-01 · Fire 2025-07-01

16 health deficiencies

Top issue: Quality of Life and Care (4 deficiencies)

3 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)

Cycle 2 Health 2024-05-23 · Fire 2024-05-23

19 health deficiencies

Top issue: Quality of Life and Care (5 deficiencies)

3 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Cycle 3 Health 2022-09-07 · Fire 2022-09-07

12 health deficiencies

Top issue: Nutrition and Dietary (3 deficiencies)

4 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)

Fire safety

Fire-safety citations

E · Potential for more than minimal harm 2025-07-01

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-07-11

D · Potential for more than minimal harm 2025-07-01

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2025-07-11

C · Minimal harm 2025-07-01

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2025-07-11

D · Potential for more than minimal harm 2024-05-23

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2024-06-11

D · Potential for more than minimal harm 2024-05-23

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2024-06-11

D · Potential for more than minimal harm 2024-05-23

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2024-06-11

D · Potential for more than minimal harm 2022-09-07

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2022-09-19

D · Potential for more than minimal harm 2022-09-07

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2022-09-19

D · Potential for more than minimal harm 2022-09-07

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2022-09-19

D · Potential for more than minimal harm 2022-09-07

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2022-09-19

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-11-05

F552 · Resident Rights Deficiencies

Health

Ensure that residents are fully informed and understand their health status, care and treatments.

Corrected 2025-12-05

D · Potential for more than minimal harm 2025-07-01

F550 · Resident Rights Deficiencies

Health

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected 2025-07-28

D · Potential for more than minimal harm 2025-07-01

F552 · Resident Rights Deficiencies

Health

Ensure that residents are fully informed and understand their health status, care and treatments.

Corrected 2025-07-28

D · Potential for more than minimal harm 2025-07-01

F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

Corrected 2025-07-28

D · Potential for more than minimal harm 2025-07-01

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 2025-07-28

D · Potential for more than minimal harm 2025-07-01

F679 · Quality of Life and Care Deficiencies

Health

Provide activities to meet all resident's needs.

Corrected 2025-07-28

D · Potential for more than minimal harm 2025-07-01

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 2025-07-28

D · Potential for more than minimal harm 2025-07-01

F693 · Quality of Life and Care Deficiencies

Health

Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

Corrected 2025-07-28

D · Potential for more than minimal harm 2025-07-01

F697 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate pain management for a resident who requires such services.

Corrected 2025-07-28

D · Potential for more than minimal harm 2025-07-01

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 2025-07-28

D · Potential for more than minimal harm 2025-07-01

F755 · Pharmacy Service Deficiencies

Health

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected 2025-07-28

D · Potential for more than minimal harm 2025-07-01

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 2025-07-28

D · Potential for more than minimal harm 2025-07-01

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 2025-07-28

D · Potential for more than minimal harm 2025-07-01

F813 · Nutrition and Dietary Deficiencies

Health

Have a policy regarding use and storage of foods brought to residents by family and other visitors.

Corrected 2025-07-28

D · Potential for more than minimal harm 2025-07-01

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-07-28

B · Minimal harm 2025-07-01

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 2025-07-28

D · Potential for more than minimal harm 2024-08-06

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2024-09-04

D · Potential for more than minimal harm 2024-08-06

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 2024-08-16

E · Potential for more than minimal harm 2024-05-23

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 2024-05-30

E · Potential for more than minimal harm 2024-05-23

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-06-10

E · Potential for more than minimal harm 2024-05-23

F883 · Infection Control Deficiencies

Health

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Corrected 2024-06-06

D · Potential for more than minimal harm 2024-05-23

F644 · Resident Assessment and Care Planning Deficiencies

Health

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Corrected 2024-06-06

D · Potential for more than minimal harm 2024-05-23

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2024-06-09

D · Potential for more than minimal harm 2024-05-23

F700 · Quality of Life and Care Deficiencies

Health

Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.

Corrected 2024-06-06

D · Potential for more than minimal harm 2024-05-23

F727 · Nursing and Physician Services Deficiencies

Health

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

Corrected 2024-05-24

D · Potential for more than minimal harm 2024-05-23

F755 · Pharmacy Service Deficiencies

Health

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected 2024-06-09

D · Potential for more than minimal harm 2024-05-23

F757 · Pharmacy Service Deficiencies

Health

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Corrected 2024-06-09

D · Potential for more than minimal harm 2024-05-23

F758 · Pharmacy Service Deficiencies

Health

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Corrected 2024-06-09

D · Potential for more than minimal harm 2024-05-23

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 2024-06-11

D · Potential for more than minimal harm 2024-05-23

F770 · Administration Deficiencies

Health

Provide timely, quality laboratory services/tests to meet the needs of residents.

Corrected 2024-06-08

D · Potential for more than minimal harm 2024-05-23

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 2024-06-06

D · Potential for more than minimal harm 2024-05-23

F849 · Administration Deficiencies

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 2024-06-06

C · Minimal harm 2024-05-23

F814 · Nutrition and Dietary Deficiencies

Health

Dispose of garbage and refuse properly.

Corrected 2024-06-07

B · Minimal harm 2024-05-23

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2024-06-06

B · Minimal harm 2024-05-23

F908 · Environmental Deficiencies

Health

Keep all essential equipment working safely.

Corrected 2024-05-25

B · Minimal harm 2023-09-28

F550 · Resident Rights Deficiencies

Health

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected 2023-10-11

E · Potential for more than minimal harm 2022-09-07

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 2022-10-07

E · Potential for more than minimal harm 2022-09-07

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2022-10-07

D · Potential for more than minimal harm 2022-09-07

F578 · Resident Rights Deficiencies

Health

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Corrected 2022-10-07

D · Potential for more than minimal harm 2022-09-07

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2022-10-07

D · Potential for more than minimal harm 2022-09-07

F657 · Resident Assessment and Care Planning Deficiencies

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 2022-10-07

D · Potential for more than minimal harm 2022-09-07

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2022-10-07

D · Potential for more than minimal harm 2022-09-07

F758 · Pharmacy Service Deficiencies

Health

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Corrected 2022-10-07

D · Potential for more than minimal harm 2022-09-07

F804 · Nutrition and Dietary Deficiencies

Health

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Corrected 2022-10-07

D · Potential for more than minimal harm 2022-09-07

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 2022-10-07

D · Potential for more than minimal harm 2022-09-07

F921 · Environmental Deficiencies

Health

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Corrected 2022-10-07

B · Minimal harm 2022-09-07

F814 · Nutrition and Dietary Deficiencies

Health

Dispose of garbage and refuse properly.

Corrected 2022-10-07

Penalties and ownership

What sits behind the stars

Ownership

Landry, Marc

5% Or Greater Direct Ownership Interest · Individual

0% 1 facilities 1996-03-01
Lockhart, Ralph

5% Or Greater Direct Ownership Interest · Individual

0% 1 facilities 1996-03-01
Mark & Fred Enterprises

5% Or Greater Direct Ownership Interest · Organization

0% 1 facilities 1996-03-01
Meyer, Donna

W-2 Managing Employee · Individual

0% 1 facilities 1996-03-01
Riverside Magnolia Corp

5% Or Greater Direct Ownership Interest · Organization

0% 1 facilities 1996-03-01
Rodes, George

Corporate Officer · Individual

0% 1 facilities 1996-03-01
Rodes, George

W-2 Managing Employee · Individual

0% 1 facilities 1996-03-01

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