Cycle 1
Health 2024-08-08 · Fire 2024-08-08
3 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Mariposa, CA
John C. Fremont Healthcare District Dp/Snf
5-star overall rating with 5-star inspections with 3 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
5189 Hospital Road, Mariposa, CA
(209) 966-3631
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
16
Certified beds
Average residents
16
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1967-01-01
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
Hours and turnover
RN hours / resident day
0.56
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
2.09
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
3.54
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
6.19
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
2.65
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
4.86
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.02
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.00
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.64
CMS adjusted RN staffing hours
Adjusted total hours
7.08
CMS adjusted total nurse staffing hours
Case-mix index
1.20
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · No data were submitted for this measure. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · No data were submitted for this measure. |
| Medicare spending per beneficiary | Not Available |
1.02
|
No data were submitted for this measure. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator Not Available · Adjusted rate Not Available · No data were submitted for this measure. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · No data were submitted for this measure. |
| Staff COVID-19 vaccination coverage | 34.38% |
8.2%
26.2 pts better
|
Numerator 11 · Denominator 32 |
| Staff flu vaccination coverage | 80.65% |
42%
38.7 pts better
|
Numerator 25 · Denominator 31 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.8% |
98.5%
1.7 pts worse
|
93.4%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 96.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.8% |
1.6%
3.2 pts worse
|
3.3%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 4.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.7% |
6.8%
5.1 pts better
|
11.4%
9.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 1.7% |
| Percentage of long-stay residents who lose too much weight | 0.0% |
4.1%
4.1 pts better
|
5.4%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 4.8% |
13.7%
8.9 pts better
|
19.6%
14.8 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 4.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 25.4% |
14.2%
11.2 pts worse
|
16.7%
8.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 25.4% · 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 · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 7.9% |
11.0%
3.1 pts better
|
16.3%
8.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 7.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 18.2% |
10.7%
7.5 pts worse
|
14.9%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 18.2% · 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 · 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 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 30.7% |
10.9%
19.8 pts worse
|
19.8%
10.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 30.7% |
| Percentage of long-stay residents with pressure ulcers | 4.1% |
4.7%
0.6 pts better
|
5.1%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 4.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-10-20 · Fire 2022-10-20
2 health deficiencies
Top issue: Nursing and Physician Services (1 deficiency)
7 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Cycle 3
Health 2019-11-15 · Fire 2019-11-15
1 health deficiencies
Top issue: Environmental (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-08-08
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2024-08-21
D · Potential for more than minimal harm
2024-08-08
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 2024-08-21
D · Potential for more than minimal harm
2024-08-08
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-08-21
D · Potential for more than minimal harm
2024-08-08
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2024-08-21
F · Potential for more than minimal harm
2022-10-20
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-11-07
D · Potential for more than minimal harm
2022-10-20
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2022-11-07
D · Potential for more than minimal harm
2022-10-20
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2022-11-07
D · Potential for more than minimal harm
2022-10-20
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 2022-11-07
D · Potential for more than minimal harm
2022-10-20
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-11-07
D · Potential for more than minimal harm
2022-10-20
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2022-11-07
D · Potential for more than minimal harm
2022-10-20
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-11-07
E · Potential for more than minimal harm
2019-11-15
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2020-01-03
D · Potential for more than minimal harm
2019-11-15
E18 · Emergency Preparedness Deficiencies
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2020-01-03
D · Potential for more than minimal harm
2019-11-15
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2020-01-03
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-08-08
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 2024-09-03
E · Potential for more than minimal harm
2024-08-08
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 2024-09-03
E · Potential for more than minimal harm
2024-08-08
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-09-03
F · Potential for more than minimal harm
2022-10-20
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 2022-11-21
D · Potential for more than minimal harm
2022-10-20
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 2022-11-21
D · Potential for more than minimal harm
2019-11-15
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 2019-12-02
Penalties and ownership
What sits behind the stars
Ownership
Clark, Ginger
Operational/Managerial Control · Individual
Clark, Ginger
W-2 Managing Employee · Individual
Debry, Philip
Corporate Director · Individual
Forrest Sweeney, Brenda
Corporate Director · Individual
John C Fremont Healthcare District
Operational/Managerial Control · Organization
Mathiesen, Mathew
Operational/Managerial Control · Individual
Mathiesen, Mathew
Corporate Officer · Individual
Mathiesen, Mathew
W-2 Managing Employee · Individual
O'donel-Brown, Candy
Corporate Director · Individual
Rogers, Joseph
Corporate Director · Individual
Woertz Pribyl, Linda
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Majestic Mountain Care Center
Oakhurst, CA
1-star overall rating with 1-star inspections with Special Focus status with $252,683 in total fines with 22 recent health deficiencies with 16 fire-safety deficiencies in the latest cycle
#2
Franciscan Post-Acute Care Center
Merced, CA
4-star overall rating with 4-star inspections with $9,110 in total fines with 3 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Golden Merced Care Center
Merced, CA
2-star overall rating with 2-star inspections with $103,467 in total fines with 15 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
Jump out