11 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fillmore, CA
4-star overall rating with 3-star inspections with $8,018 in total fines with 11 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
118 B Street, Fillmore, CA
(805) 524-5250
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Beds
99
Certified beds
Average residents
67
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Eva Care Group
Operator or chain grouping
Approved since
1977-05-20
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
9 facilities
Chain averages 3 overall / 3 health / 4 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
RN hours / resident day
0.95
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.39
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
2.90
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
5.24
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
2.34
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
4.71
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.87
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.75
CMS adjusted RN staffing hours
Adjusted total hours
4.11
CMS adjusted total nurse staffing hours
Case-mix index
1.74
Higher values indicate more complex resident acuity
RN turnover
42%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
37%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Program rank
7,859
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
28.58
Composite VBP score used to determine payment impact.
Payment multiplier
0.9851
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
1.31
Baseline 20.27% · Performance 20.83% · Measure score 1.31 · Achievement 1.31 · Improvement 0
Healthcare-associated infections
2.11
Baseline 5.88% · Performance 7.20% · Measure score 2.11 · Achievement 2.11 · Improvement 0
Total nurse turnover
5.24
Baseline 36.67% · Performance 42.25% · Measure score 5.24 · Achievement 5.24 · Improvement 0
Adjusted total nurse staffing
2.77
Baseline 3.83 hours · Performance 3.87 hours · Measure score 2.77 · Achievement 2.77 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.74% |
10.72%
1 pts better
|
No Different than the National Rate · Eligible stays 80 · Observed rate 7.5% · Lower 95% interval 6.64% |
| Discharge to community | 62.77% |
50.57%
12.2 pts better
|
No Different than the National Rate · Eligible stays 69 · Observed rate 53.62% · Lower 95% interval 47.24% |
| Medicare spending per beneficiary | 0.92 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 58 · Denominator 58 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 58 |
| Discharge self-care score | 60.53% |
53.69%
6.8 pts better
|
Numerator 23 · Denominator 38 |
| Discharge mobility score | 63.16% |
50.94%
12.2 pts better
|
Numerator 24 · Denominator 38 |
| Pressure ulcers or injuries, new or worsened | 1.72% |
2.29%
0.6 pts better
|
Numerator 1 · Denominator 58 · Adjusted rate 1.38% |
| Healthcare-associated infections requiring hospitalization | 7.2% |
7.12%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 54 · Observed rate 9.26% · Lower 95% interval 4.01% |
| Staff COVID-19 vaccination coverage | 23.93% |
8.2%
15.7 pts better
|
Numerator 28 · Denominator 117 |
| Staff flu vaccination coverage | 60.39% |
42%
18.4 pts better
|
Numerator 93 · Denominator 154 |
| Discharge function score | 60.53% |
56.45%
4.1 pts better
|
Numerator 23 · Denominator 38 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 32 · Denominator 32 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 32.43% |
25.2%
7.2 pts better
|
Numerator 12 · Denominator 37 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.4 |
2.3
0.9 pts better
|
1.9
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.7 · Expected 2.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.7 |
1.6
0.9 pts better
|
1.8
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.8 · Expected 1.9 · 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 | 3.0% |
1.6%
1.4 pts worse
|
3.3%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 1.8% · Q3 3.4% · Q4 3.1% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
6.8%
6.8 pts better
|
11.4%
11.4 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 who lose too much weight | 6.3% |
4.1%
2.2 pts worse
|
5.4%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 13.5% · Q3 1.9% · Q4 3.3% · 4Q avg 6.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 32.2% |
13.7%
18.5 pts worse
|
19.6%
12.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.1% · Q2 35.8% · Q3 29.8% · Q4 28.3% · 4Q avg 32.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 27.6% |
14.2%
13.4 pts worse
|
16.7%
10.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.8% · Q2 33.3% · Q3 27.9% · Q4 19.4% · 4Q avg 27.6% · 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 | 13.1% |
11.0%
2.1 pts worse
|
16.3%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 9.8% · 4Q avg 13.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.9% |
10.7%
0.8 pts better
|
14.9%
5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.2% · Q2 14.6% · Q3 6.4% · Q4 7.0% · 4Q avg 9.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.9% |
1.0%
2.9 pts worse
|
1.0%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 4.8% · Q3 1.6% · Q4 5.2% · 4Q avg 3.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.9% |
1.2%
2.7 pts worse
|
1.7%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.9% · Q3 3.6% · Q4 9.4% · 4Q avg 3.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 20.4% |
10.9%
9.5 pts worse
|
19.8%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.7% · Q2 22.3% · Q3 21.4% · Q4 24.8% · 4Q avg 20.4% |
| Percentage of long-stay residents with pressure ulcers | 8.9% |
4.7%
4.2 pts worse
|
5.1%
3.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.3% · Q2 9.8% · Q3 6.4% · Q4 11.8% · 4Q avg 8.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.6% |
94.0%
5.6 pts better
|
81.7%
17.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.9% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 3.6% |
11.2%
7.6 pts better
|
12.0%
8.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 3.6% · Observed 4.0% · Expected 12.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.1% |
1.5%
0.6 pts worse
|
1.6%
0.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 0.0% · Q3 2.6% · Q4 3.7% · 4Q avg 2.1% · 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 | 13.5% |
23.2%
9.7 pts better
|
23.9%
10.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 13.5% · Observed 14.0% · Expected 24.7% · Used in QM five-star |
Survey summary
Top issue: Pharmacy Service (3 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Top issue: Resident Assessment and Care Planning (5 deficiencies)
6 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Top issue: Resident Assessment and Care Planning (5 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-06-25
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-03-19
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-03-17
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-03-18
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-03-20
Fire Safety
Provide emergency officials' contact information.
Corrected 2025-03-17
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2023-12-08
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-12-08
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-12-08
Fire Safety
Use approved construction type or materials.
Corrected 2023-12-08
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2023-12-08
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-12-08
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-04-21
Inspection history
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-04-07
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-04-07
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-04-07
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-04-07
Health
Keep all essential equipment working safely.
Corrected 2025-04-07
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-04-07
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2025-04-07
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-04-07
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 2025-04-07
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-04-07
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-07
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2025-03-11
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-12-17
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-06-20
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-06-03
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-05-08
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-05-08
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-05-08
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-04-17
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 2023-12-13
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-12-13
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
Health
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Corrected 2023-12-13
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
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
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-10-27
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2023-05-02
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2023-05-08
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-05-08
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-03-15
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 2023-03-15
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2022-05-25
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 2022-05-25
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2022-05-25
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-05-25
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2022-05-25
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2022-05-25
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 2022-05-25
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 2022-05-25
Health
Provide and implement an infection prevention and control program.
Corrected 2022-05-25
Penalties and ownership
Fine · fine $8,018
Fine
5% Or Greater Direct Ownership Interest · Individual
5% Or Greater Direct Ownership Interest · Individual
Operational/Managerial Control · Individual
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