Cycle 1
Health 2025-08-15 · Fire 2025-08-15
4 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Glendale, CA
Glendale Adventist Medical Center Dp/Snf
5-star overall rating with 5-star inspections with 4 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
1509 Wilson Ter, Glendale, CA
(818) 409-8000
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
40
Certified beds
Average residents
35
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Adventist Health
Operator or chain grouping
Approved since
2019-04-18
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
5 facilities
Chain averages 4 overall / 4 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Hospital-based
Yes
CMS reports the provider resides in a hospital
Staffing
Hours and turnover
RN hours / resident day
2.73
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.68
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
2.82
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
7.23
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
4.40
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
6.31
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
2.69
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.22
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
2.01
CMS adjusted RN staffing hours
Adjusted total hours
5.33
CMS adjusted total nurse staffing hours
Case-mix index
1.85
Higher values indicate more complex resident acuity
RN turnover
25%
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
956
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
61.70
Composite VBP score used to determine payment impact.
Payment multiplier
1.0167
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.69
Baseline 24.66% · Performance 20.70% · Measure score 4.69 · Achievement 1.58 · Improvement 4.69
Healthcare-associated infections
8.10
Baseline 5.56% · Performance 5.41% · Measure score 8.10 · Achievement 8.10 · Improvement 2.05
Total nurse turnover
5.65
Baseline 42.47% · Performance 40.58% · Measure score 5.65 · Achievement 5.65 · Improvement 0.57
Adjusted total nurse staffing
6.24
Baseline 5.65 hours · Performance 4.85 hours · Measure score 6.24 · Achievement 6.24 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 13.43% |
10.72%
2.7 pts worse
|
Worse than the National Rate · Eligible stays 1451 · Observed rate 13.23% · Lower 95% interval 11.91% |
| Discharge to community | 64.07% |
50.57%
13.5 pts better
|
Better than the National Rate · Eligible stays 1015 · Observed rate 59.7% · Lower 95% interval 61.06% |
| Medicare spending per beneficiary | 0.98 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 98.8% |
95.27%
3.5 pts better
|
Numerator 826 · Denominator 836 |
| Falls with major injury | 0.12% |
0.77%
0.7 pts better
|
Numerator 1 · Denominator 836 |
| Discharge self-care score | 39.25% |
53.69%
14.4 pts worse
|
Numerator 241 · Denominator 614 |
| Discharge mobility score | 15.64% |
50.94%
35.3 pts worse
|
Numerator 96 · Denominator 614 |
| Pressure ulcers or injuries, new or worsened | 0.24% |
2.29%
2 pts better
|
Numerator 2 · Denominator 836 · Adjusted rate 0.22% |
| Healthcare-associated infections requiring hospitalization | 5.41% |
7.12%
1.7 pts better
|
Better than the National Rate · Eligible stays 770 · Observed rate 4.55% · Lower 95% interval 3.98% |
| Staff COVID-19 vaccination coverage | 7.84% |
8.2%
0.4 pts worse
|
Numerator 4 · Denominator 51 |
| Staff flu vaccination coverage | 98.41% |
42%
56.4 pts better
|
Numerator 62 · Denominator 63 |
| Discharge function score | 32.9% |
56.45%
23.6 pts worse
|
Numerator 202 · Denominator 614 |
| Transfer of health information to provider | 94.8% |
95.95%
1.2 pts worse
|
Numerator 729 · Denominator 769 |
| Transfer of health information to patient | 91.04% |
96.28%
5.2 pts worse
|
Numerator 61 · Denominator 67 |
| Resident COVID-19 vaccinations up to date | 1.77% |
25.2%
23.4 pts worse
|
Numerator 8 · Denominator 452 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| 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 | 2.7% |
11.2%
8.5 pts better
|
12.0%
9.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 2.7% · Observed 2.7% · Expected 11.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 5.5% |
1.5%
4 pts worse
|
1.6%
3.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 3.6% · Q3 6.9% · Q4 7.6% · 4Q avg 5.5% · 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 | 22.4% |
23.2%
0.8 pts better
|
23.9%
1.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.4% · Observed 22.2% · Expected 23.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-08-18 · Fire 2024-08-18
4 health deficiencies
Top issue: Infection Control (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-08-06 · Fire 2023-08-06
6 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-08-15
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-09-05
E · Potential for more than minimal harm
2025-08-15
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-09-05
D · Potential for more than minimal harm
2025-08-15
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-09-05
D · Potential for more than minimal harm
2025-08-15
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-09-05
D · Potential for more than minimal harm
2025-08-15
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-09-05
D · Potential for more than minimal harm
2025-08-15
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-09-05
F · Potential for more than minimal harm
2024-08-18
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-09-18
D · Potential for more than minimal harm
2024-08-18
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-09-18
D · Potential for more than minimal harm
2024-08-18
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-09-18
F · Potential for more than minimal harm
2023-08-06
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2023-08-10
F · Potential for more than minimal harm
2023-08-06
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2023-08-10
E · Potential for more than minimal harm
2023-08-06
K331 · Smoke Deficiencies
Fire Safety
Construct fire resistant interior walls.
Corrected 2023-08-10
E · Potential for more than minimal harm
2023-08-06
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-08-10
D · Potential for more than minimal harm
2023-08-06
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-08-10
D · Potential for more than minimal harm
2023-08-06
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 2023-08-10
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-08-15
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 2025-09-05
D · Potential for more than minimal harm
2025-08-15
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-09-05
D · Potential for more than minimal harm
2025-08-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-09-05
D · Potential for more than minimal harm
2025-08-12
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-09-18
E · Potential for more than minimal harm
2024-08-18
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 2024-09-05
E · Potential for more than minimal harm
2024-08-18
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 2024-09-05
D · Potential for more than minimal harm
2024-08-18
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-09-05
D · Potential for more than minimal harm
2024-08-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-09-05
E · Potential for more than minimal harm
2023-08-06
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 2023-08-29
E · Potential for more than minimal harm
2023-08-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-08-29
D · Potential for more than minimal harm
2023-08-06
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-08-29
D · Potential for more than minimal harm
2023-08-06
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 2023-08-29
D · Potential for more than minimal harm
2023-08-06
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-08-29
D · Potential for more than minimal harm
2023-08-06
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-08-29
Penalties and ownership
What sits behind the stars
Ownership
Adventist Health System/West
5% Or Greater Direct Ownership Interest · Organization
Adventist Health System/West
Operational/Managerial Control · Organization
Banks, David
Corporate Director · Individual
Bonner, Robert
Corporate Officer · Individual
Bonner, Robert
W-2 Managing Employee · Individual
Cherry, Robert
Corporate Director · Individual
Davis, Andrew
Corporate Director · Individual
Freedman, John
Corporate Director · Individual
Gabriel, Melody
Corporate Director · Individual
Graham, Ricardo
Corporate Director · Individual
Heinrich, Kerry
Corporate Director · Individual
Innocent, Larry
Corporate Director · Individual
Issai, Alice
Corporate Officer · Individual
Issai, Alice
W-2 Managing Employee · Individual
Jobe, Meredith
Corporate Officer · Individual
Pedersen, James
Corporate Director · Individual
Reiner, Brian
Corporate Director · Individual
Reiner, Brian
Corporate Officer · Individual
Reiner, Richard
Corporate Director · Individual
Rippey, Wesley
Corporate Director · Individual
Salazar, Velino
Corporate Director · Individual
Tetz, Warren
Corporate Officer · Individual
Tetz, Warren
W-2 Managing Employee · Individual
Wagner, Jack
Corporate Officer · Individual
Wing, Billy
Corporate Director · Individual
Wing, Billy
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Glendale Post Acute Center
Glendale, CA
1-star overall rating with 1-star inspections with $161,982 in total fines with 30 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Autumn Hills Health Care Center
Glendale, CA
2-star overall rating with 2-star inspections with $14,387 in total fines with 11 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Ararat Convalescent Hospital
Los Angeles, CA
4-star overall rating with 3-star inspections with $10,039 in total fines with 14 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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