Cycle 1
Health 2025-04-08 · Fire 2025-04-08
5 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Santa Maria, CA
Marian Regional Medical Center D/P SNF
5-star overall rating with 4-star inspections with 5 recent health deficiencies
1530 East Cypress Way, Santa Maria, CA
(805) 739-3650
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
95
Certified beds
Average residents
87
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Commonspirit Health
Operator or chain grouping
Approved since
1986-09-15
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
19 facilities
Chain averages 3 overall / 3 health / 3 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
Hospital-based
Yes
CMS reports the provider resides in a hospital
Staffing
Hours and turnover
RN hours / resident day
2.11
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
0.87
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
3.17
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
6.15
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
2.99
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
5.58
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
1.79
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
1.95
CMS adjusted RN staffing hours
Adjusted total hours
5.68
CMS adjusted total nurse staffing hours
Case-mix index
1.48
Higher values indicate more complex resident acuity
RN turnover
23%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
24%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Value-based purchasing
Program rank
35
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
94.94
Composite VBP score used to determine payment impact.
Payment multiplier
1.0276
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
10
Baseline 17.82% · Performance 15.86% · Measure score 10 · Achievement 10 · Improvement 9
Healthcare-associated infections
10
Baseline 4.47% · Performance 3.53% · Measure score 10 · Achievement 10 · Improvement 9
Total nurse turnover
8.97
Performance 27.03% · Measure score 8.97 · Achievement 8.97 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
9.01
Baseline 5.68 hours · Performance 5.64 hours · Measure score 9.01 · Achievement 9.01 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.31% |
10.72%
1.4 pts better
|
No Different than the National Rate · Eligible stays 619 · Observed rate 7.92% · Lower 95% interval 7.54% |
| Discharge to community | 70.77% |
50.57%
20.2 pts better
|
Better than the National Rate · Eligible stays 656 · Observed rate 67.99% · Lower 95% interval 67.32% |
| Medicare spending per beneficiary | 0.77 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 99.47% |
95.27%
4.2 pts better
|
Numerator 375 · Denominator 377 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 377 |
| Discharge self-care score | 46.5% |
53.69%
7.2 pts worse
|
Numerator 153 · Denominator 329 |
| Discharge mobility score | 44.07% |
50.94%
6.9 pts worse
|
Numerator 145 · Denominator 329 |
| Pressure ulcers or injuries, new or worsened | 2.39% |
2.29%
0.1 pts worse
|
Numerator 9 · Denominator 377 · Adjusted rate 3.23% |
| Healthcare-associated infections requiring hospitalization | 3.53% |
7.12%
3.6 pts better
|
Better than the National Rate · Eligible stays 379 · Observed rate 1.06% · Lower 95% interval 2.19% |
| Staff COVID-19 vaccination coverage | 5.94% |
8.2%
2.3 pts worse
|
Numerator 13 · Denominator 219 |
| Staff flu vaccination coverage | 86.23% |
42%
44.2 pts better
|
Numerator 238 · Denominator 276 |
| Discharge function score | 51.06% |
56.45%
5.4 pts worse
|
Numerator 168 · Denominator 329 |
| Transfer of health information to provider | 99.66% |
95.95%
3.7 pts better
|
Numerator 296 · Denominator 297 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 51 · Denominator 51 |
| Resident COVID-19 vaccinations up to date | 17.44% |
25.2%
7.8 pts worse
|
Numerator 34 · Denominator 195 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.9 |
2.3
1.4 pts better
|
1.9
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.8 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.8 |
1.6
0.8 pts better
|
1.8
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.7 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.0% |
98.5%
0.5 pts better
|
93.4%
5.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.0% · Q2 98.1% · Q3 100.0% · Q4 100.0% · 4Q avg 99.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.2% |
98.2%
About the same
|
95.5%
2.7 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.5% |
1.6%
1.1 pts better
|
3.3%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.0% · 4Q avg 0.5% · 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 | 6.5% |
4.1%
2.4 pts worse
|
5.4%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 4.3% · Q3 8.7% · Q4 9.1% · 4Q avg 6.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.7% |
13.7%
About the same
|
19.6%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.0% · Q2 12.5% · Q3 14.9% · Q4 13.3% · 4Q avg 13.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.6% |
14.2%
1.4 pts worse
|
16.7%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.5% · Q2 15.4% · Q3 15.4% · Q4 13.9% · 4Q avg 15.6% · 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 | 15.2% |
11.0%
4.2 pts worse
|
16.3%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 15.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 17.3% |
10.7%
6.6 pts worse
|
14.9%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 34.1% · Q3 20.9% · Q4 7.5% · 4Q avg 17.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.7% |
1.0%
2.7 pts worse
|
1.0%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 6.3% · Q3 2.0% · Q4 2.8% · 4Q avg 3.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.0% |
1.2%
1.8 pts worse
|
1.7%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 7.8% · Q3 0.0% · Q4 2.1% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 14.9% |
10.9%
4 pts worse
|
19.8%
4.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.8% · Q2 20.9% · Q3 11.8% · Q4 15.2% · 4Q avg 14.9% |
| Percentage of long-stay residents with pressure ulcers | 3.3% |
4.7%
1.4 pts better
|
5.1%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.8% · Q2 3.1% · Q3 2.9% · Q4 1.4% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 90.2% |
94.0%
3.8 pts worse
|
81.7%
8.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 88.5% · Q2 85.3% · Q3 91.0% · Q4 96.3% · 4Q avg 90.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.9% |
11.2%
0.3 pts better
|
12.0%
1.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.9% · Observed 9.8% · Expected 10.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.0% |
1.5%
0.5 pts worse
|
1.6%
0.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 0.9% · Q3 2.4% · Q4 3.3% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 85.6% |
93.2%
7.6 pts worse
|
79.7%
5.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 85.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 16.9% |
23.2%
6.3 pts better
|
23.9%
7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 16.9% · Observed 14.2% · Expected 20.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-15 · Fire 2024-02-15
7 health deficiencies
Top issue: Nutrition and Dietary (4 deficiencies)
6 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
Cycle 3
Health 2023-03-23 · Fire 2023-03-23
7 health deficiencies
Top issue: Nutrition and Dietary (3 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-02-15
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-03-01
E · Potential for more than minimal harm
2024-02-15
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-03-01
D · Potential for more than minimal harm
2024-02-15
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2024-03-01
D · Potential for more than minimal harm
2024-02-15
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2024-03-01
D · Potential for more than minimal harm
2024-02-15
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2024-03-01
D · Potential for more than minimal harm
2024-02-15
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-03-01
D · Potential for more than minimal harm
2023-03-23
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-04-13
D · Potential for more than minimal harm
2023-03-23
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-04-13
D · Potential for more than minimal harm
2023-03-23
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-04-13
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-06-13
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 2025-07-13
D · Potential for more than minimal harm
2025-06-13
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-07-13
F · Potential for more than minimal harm
2025-04-08
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 2025-05-13
E · Potential for more than minimal harm
2025-04-08
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2025-05-13
D · Potential for more than minimal harm
2025-04-08
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 2025-05-13
F · Potential for more than minimal harm
2024-02-15
F801 · Nutrition and Dietary Deficiencies
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2024-03-15
D · Potential for more than minimal harm
2024-02-15
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2024-03-15
D · Potential for more than minimal harm
2024-02-15
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 2024-03-15
D · Potential for more than minimal harm
2024-02-15
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 2024-03-15
D · Potential for more than minimal harm
2024-02-15
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2024-03-15
D · Potential for more than minimal harm
2024-02-15
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2024-03-15
D · Potential for more than minimal harm
2024-02-15
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 2024-03-15
F · Potential for more than minimal harm
2023-03-23
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 2023-04-23
F · Potential for more than minimal harm
2023-03-23
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 2023-04-23
D · Potential for more than minimal harm
2023-03-23
F551 · Resident Rights Deficiencies
Health
Give the resident's representative the ability to exercise the resident's rights.
Corrected 2023-04-23
D · Potential for more than minimal harm
2023-03-23
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2023-04-23
D · Potential for more than minimal harm
2023-03-23
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 2023-04-23
D · Potential for more than minimal harm
2023-03-23
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2023-04-23
D · Potential for more than minimal harm
2023-03-23
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 2023-04-23
Penalties and ownership
What sits behind the stars
Ownership
Commonspirit Health
5% Or Greater Indirect Ownership Interest · Organization
Dignity Health
5% Or Greater Direct Ownership Interest · Organization
Carswell, Scott
Corporate Director · Individual
Melfi, Mitch
Corporate Director · Individual
Melfi, Mitch
Corporate Officer · Individual
Morissette, Daniel
Corporate Officer · Individual
O'quinn, Marvin
Corporate Director · Individual
O'quinn, Marvin
Corporate Officer · Individual
Petersdorf, John
Corporate Officer · Individual
Petersdorf, John
W-2 Managing Employee · Individual
Scharmann, Steven
Corporate Officer · Individual
Scharmann, Steven
W-2 Managing Employee · Individual
Shih, Elizabeth
Corporate Director · Individual
Shih, Elizabeth
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Valley Oaks Post Acute
Santa Maria, CA
3-star overall rating with 3-star inspections with 9 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#2
Villa Maria Post Acute
Santa Maria, CA
5-star overall rating with 5-star inspections with 4 recent health deficiencies with 14 fire-safety deficiencies in the latest cycle
#3
Santa Maria Post Acute
Santa Maria, CA
3-star overall rating with 3-star inspections with 15 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
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