10 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Hollister, CA
4-star overall rating with 3-star inspections with 10 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
911 Sunset Drive, Hollister, CA
(831) 637-5711
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Beds
119
Certified beds
Average residents
87
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1968-07-01
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
Hospital-based
Yes
CMS reports the provider resides in a hospital
Staffing
RN hours / resident day
0.95
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
0.71
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
2.86
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
4.52
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
1.66
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
3.80
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.72
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
1.00
CMS adjusted RN staffing hours
Adjusted total hours
4.75
CMS adjusted total nurse staffing hours
Case-mix index
1.30
Higher values indicate more complex resident acuity
RN turnover
21%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
9%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Program rank
1,026
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
61
Composite VBP score used to determine payment impact.
Payment multiplier
1.0161
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
3.54
Baseline 22.35% · Performance 20.20% · Measure score 3.54 · Achievement 2.66 · Improvement 3.54
Healthcare-associated infections
5.57
Baseline 6.55% · Performance 6.17% · Measure score 5.57 · Achievement 5.57 · Improvement 1.96
Total nurse turnover
10
Baseline 25.71% · Performance 21.50% · Measure score 10 · Achievement 10 · Improvement 9
Adjusted total nurse staffing
5.29
Baseline 5.34 hours · Performance 4.58 hours · Measure score 5.29 · Achievement 5.29 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.57% |
10.72%
1.2 pts better
|
No Different than the National Rate · Eligible stays 219 · Observed rate 6.85% · Lower 95% interval 7.01% |
| Discharge to community | 55.53% |
50.57%
5 pts better
|
No Different than the National Rate · Eligible stays 209 · Observed rate 53.59% · Lower 95% interval 49.61% |
| Medicare spending per beneficiary | 0.9 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 125 · Denominator 125 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 125 |
| Discharge self-care score | 43.69% |
53.69%
10 pts worse
|
Numerator 45 · Denominator 103 |
| Discharge mobility score | 63.11% |
50.94%
12.2 pts better
|
Numerator 65 · Denominator 103 |
| Pressure ulcers or injuries, new or worsened | 0.8% |
2.29%
1.5 pts better
|
Numerator 1 · Denominator 125 · Adjusted rate 0.64% |
| Healthcare-associated infections requiring hospitalization | 6.17% |
7.12%
1 pts better
|
No Different than the National Rate · Eligible stays 106 · Observed rate 2.83% · Lower 95% interval 3.26% |
| Staff COVID-19 vaccination coverage | 2.63% |
8.2%
5.6 pts worse
|
Numerator 4 · Denominator 152 |
| Staff flu vaccination coverage | 72.12% |
42%
30.1 pts better
|
Numerator 119 · Denominator 165 |
| Discharge function score | 41.75% |
56.45%
14.7 pts worse
|
Numerator 43 · Denominator 103 |
| Transfer of health information to provider | 97.83% |
95.95%
1.9 pts better
|
Numerator 90 · Denominator 92 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 8.96% |
25.2%
16.2 pts worse
|
Numerator 6 · Denominator 67 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.7 |
2.3
0.6 pts better
|
1.9
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.3 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.6 |
1.6
1 pts worse
|
1.8
0.8 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.6 · Observed 2.2 · Expected 1.4 · 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 | 1.7% |
1.6%
0.1 pts worse
|
3.3%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.4% · Q3 2.7% · Q4 2.6% · 4Q avg 1.7% · 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 | 3.3% |
4.1%
0.8 pts better
|
5.4%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 6.2% · Q3 0.0% · Q4 1.4% · 4Q avg 3.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 8.2% |
13.7%
5.5 pts better
|
19.6%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.3% · Q2 5.8% · Q3 7.5% · Q4 7.0% · 4Q avg 8.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 10.4% |
14.2%
3.8 pts better
|
16.7%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.5% · Q2 13.2% · Q3 10.3% · Q4 6.9% · 4Q avg 10.4% · 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 | 23.9% |
11.0%
12.9 pts worse
|
16.3%
7.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.2% · Q2 16.7% · Q3 19.1% · Q4 30.5% · 4Q avg 23.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.1% |
10.7%
1.6 pts better
|
14.9%
5.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.1% · Q2 7.7% · Q3 7.3% · Q4 9.1% · 4Q avg 9.1% · 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 | 3.1% |
1.2%
1.9 pts worse
|
1.7%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.8% · Q2 1.4% · Q3 4.1% · Q4 0.0% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 12.9% |
10.9%
2 pts worse
|
19.8%
6.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.8% · Q2 9.8% · Q3 13.6% · Q4 18.3% · 4Q avg 12.9% |
| Percentage of long-stay residents with pressure ulcers | 2.4% |
4.7%
2.3 pts better
|
5.1%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 4.1% · Q3 0.0% · Q4 1.0% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.2% |
94.0%
2.2 pts better
|
81.7%
14.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.0% · Q2 96.1% · Q3 96.7% · Q4 95.3% · 4Q avg 96.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.2% |
11.2%
2 pts better
|
12.0%
2.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.2% · Observed 8.2% · Expected 9.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.5% |
1.5%
1 pts better
|
1.6%
1.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 94.9% |
93.2%
1.7 pts better
|
79.7%
15.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 94.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.1% |
23.2%
2.9 pts worse
|
23.9%
2.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.1% · Observed 21.1% · Expected 19.2% · Used in QM five-star |
Survey summary
Top issue: Resident Assessment and Care Planning (3 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Top issue: Quality of Life and Care (4 deficiencies)
12 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Top issue: Nutrition and Dietary (2 deficiencies)
10 fire-safety deficiencies
Top issue: Emergency Preparedness (5 deficiencies)
Fire safety
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2025-12-01
Fire Safety
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
Corrected 2025-12-01
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2025-12-01
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2025-12-01
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-12-01
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-12-01
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 2025-12-01
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-12-01
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-12-01
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-12-01
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-05-03
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-05-03
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-05-03
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2024-05-03
Fire Safety
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
Corrected 2024-05-03
Fire Safety
Use approved construction type or materials.
Corrected 2024-05-03
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 2024-05-03
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-05-03
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-05-03
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-05-03
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-05-03
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-05-03
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2022-07-26
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2022-07-26
Fire Safety
Establish policies and procedures for sheltering.
Corrected 2022-07-26
Fire Safety
Provide a means of sharing information on occupancy/needs.
Corrected 2022-07-26
Fire Safety
Provide family notifications of emergency plan.
Corrected 2022-07-26
Fire Safety
Use approved construction type or materials.
Corrected 2022-07-26
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 2022-07-26
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2022-07-26
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-07-26
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2022-07-26
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 2025-10-10
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-10-10
Health
Provide and implement an infection prevention and control program.
Corrected 2025-10-10
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2025-10-10
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-10-10
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2025-10-10
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 2025-10-10
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-10-10
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 2025-10-10
Health
Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.
Corrected 2025-10-10
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-12-30
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 2024-06-26
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-04-15
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-05-10
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2024-04-15
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-04-26
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-04-14
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-04-14
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 2024-04-14
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2024-04-14
Health
Provide and implement an infection prevention and control program.
Corrected 2024-04-14
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2023-12-19
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 2022-07-21
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-07-21
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-07-21
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-07-21
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 2022-07-21
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2022-07-21
Penalties and ownership
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Corporate Officer · Individual
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