2 health deficiencies
Top issue: Nursing and Physician Services (1 deficiency)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
San Luis Obispo, CA
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
1425 Woodside Drive, San Luis Obispo, CA
(805) 543-0210
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Beds
162
Certified beds
Average residents
105
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Compass Health, Inc.
Operator or chain grouping
Approved since
1967-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
7 facilities
Chain averages 5 overall / 5 health / 4 staffing / 5 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
0.80
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.03
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
3.40
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
5.23
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
1.83
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
4.99
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.68
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.24
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.89
CMS adjusted RN staffing hours
Adjusted total hours
5.86
CMS adjusted total nurse staffing hours
Case-mix index
1.22
Higher values indicate more complex resident acuity
RN turnover
47%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
38%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Program rank
650
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
65.92
Composite VBP score used to determine payment impact.
Payment multiplier
1.0200
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
7.51
Baseline 18.19% · Performance 17.95% · Measure score 7.51 · Achievement 7.51 · Improvement 1.55
Healthcare-associated infections
1.97
Baseline 8.17% · Performance 7.39% · Measure score 1.97 · Achievement 1.49 · Improvement 1.97
Total nurse turnover
6.89
Baseline 25.42% · Performance 35.50% · Measure score 6.89 · Achievement 6.89 · Improvement 0
Adjusted total nurse staffing
10
Baseline 4.49 hours · Performance 5.85 hours · Measure score 10 · Achievement 10 · Improvement 9
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.4% |
10.72%
0.3 pts better
|
No Different than the National Rate · Eligible stays 376 · Observed rate 9.57% · Lower 95% interval 8.14% |
| Discharge to community | 59.92% |
50.57%
9.4 pts better
|
Better than the National Rate · Eligible stays 385 · Observed rate 54.29% · Lower 95% interval 54.41% |
| Medicare spending per beneficiary | 0.99 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 270 · Denominator 270 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 270 |
| Discharge self-care score | 60.28% |
53.69%
6.6 pts better
|
Numerator 129 · Denominator 214 |
| Discharge mobility score | 59.35% |
50.94%
8.4 pts better
|
Numerator 127 · Denominator 214 |
| Pressure ulcers or injuries, new or worsened | 0.37% |
2.29%
1.9 pts better
|
Numerator 1 · Denominator 270 · Adjusted rate 0.45% |
| Healthcare-associated infections requiring hospitalization | 7.39% |
7.12%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 245 · Observed rate 6.94% · Lower 95% interval 5.03% |
| Staff COVID-19 vaccination coverage | 43.26% |
8.2%
35.1 pts better
|
Numerator 77 · Denominator 178 |
| Staff flu vaccination coverage | 54.49% |
42%
12.5 pts better
|
Numerator 97 · Denominator 178 |
| Discharge function score | 67.29% |
56.45%
10.8 pts better
|
Numerator 144 · Denominator 214 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 48 · Denominator 48 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 170 · Denominator 170 |
| Resident COVID-19 vaccinations up to date | 34.29% |
25.2%
9.1 pts better
|
Numerator 48 · Denominator 140 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.2 |
2.3
1.1 pts better
|
1.9
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.1 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.9 |
1.6
0.7 pts better
|
1.8
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.7 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.7% |
98.5%
1.2 pts better
|
93.4%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 98.7% · Q3 100.0% · Q4 100.0% · 4Q avg 99.7% |
| 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 | 0.7% |
1.6%
0.9 pts better
|
3.3%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 1.3% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.3% |
6.8%
6.5 pts better
|
11.4%
11.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.4% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% |
| Percentage of long-stay residents who lose too much weight | 5.1% |
4.1%
1 pts worse
|
5.4%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 6.3% · Q3 5.2% · Q4 4.6% · 4Q avg 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.8% |
13.7%
6.1 pts worse
|
19.6%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.6% · Q2 23.4% · Q3 20.0% · Q4 18.2% · 4Q avg 19.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 23.2% |
14.2%
9 pts worse
|
16.7%
6.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.4% · Q2 24.0% · Q3 23.6% · Q4 18.9% · 4Q avg 23.2% · 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 | 8.5% |
11.0%
2.5 pts better
|
16.3%
7.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 11.9% · Q3 6.2% · Q4 12.3% · 4Q avg 8.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 6.3% |
10.7%
4.4 pts better
|
14.9%
8.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 3.2% · Q3 5.2% · Q4 13.8% · 4Q avg 6.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.4% |
1.0%
0.6 pts better
|
1.0%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.3% |
1.2%
1.1 pts worse
|
1.7%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 2.7% · Q3 2.7% · Q4 1.3% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 0.6% |
10.9%
10.3 pts better
|
19.8%
19.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.3% · Q3 1.3% · Q4 0.0% · 4Q avg 0.6% |
| Percentage of long-stay residents with pressure ulcers | 5.1% |
4.7%
0.4 pts worse
|
5.1%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 6.6% · Q3 3.6% · Q4 6.1% · 4Q avg 5.1% · Used in QM five-star |
| 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 | 13.2% |
11.2%
2 pts worse
|
12.0%
1.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.2% · Observed 12.3% · Expected 10.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.4% |
1.5%
0.1 pts better
|
1.6%
0.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 1.5% · Q3 0.0% · Q4 0.0% · 4Q avg 1.4% · 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 | 17.7% |
23.2%
5.5 pts better
|
23.9%
6.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 17.7% · Observed 16.0% · Expected 21.6% · Used in QM five-star |
Survey summary
Top issue: Nursing and Physician Services (1 deficiency)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Top issue: Infection Control (1 deficiency)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Top issue: Pharmacy Service (2 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2026-01-15
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2026-01-15
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2026-01-15
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2026-01-15
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2026-01-15
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2024-10-18
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-10-18
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-10-18
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2021-12-23
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2021-12-23
Fire Safety
Meet other general requirements that are deficient.
Corrected 2021-12-23
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2021-12-23
Inspection history
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2026-01-16
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2025-08-14
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-31
Health
Keep all essential equipment working safely.
Corrected 2021-12-29
Health
Ensure each resident receives an accurate assessment.
Corrected 2021-12-29
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2021-12-29
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 2021-12-29
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 2021-12-29
Penalties and ownership
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Individual
Operational/Managerial Control · Individual
5% Or Greater Direct Ownership Interest · Organization
Operational/Managerial Control · Organization
5% Or Greater Direct Ownership Interest · Organization
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
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