7 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
2 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Richmond, CA
5-star overall rating with 4-star inspections with $36,343 in total fines with 7 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
955 23rd Street, Richmond, CA
(510) 237-5182
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
Beds
35
Certified beds
Average residents
27
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1999-03-16
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
Staffing
RN hours / resident day
1.58
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.09
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
3.31
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
5.98
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
2.67
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
4.82
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
1.53
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.23
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
1.56
CMS adjusted RN staffing hours
Adjusted total hours
5.90
CMS adjusted total nurse staffing hours
Case-mix index
1.39
Higher values indicate more complex resident acuity
RN turnover
46%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
34%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Program rank
1,464
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
56.51
Composite VBP score used to determine payment impact.
Payment multiplier
1.0116
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
2.08
Baseline 21.07% · Performance 20.47% · Measure score 2.08 · Achievement 2.08 · Improvement 0.99
Healthcare-associated infections
3.51
Baseline 10.37% · Performance 8.21% · Measure score 3.51 · Achievement 0 · Improvement 3.51
Total nurse turnover
7.02
Baseline 13.33% · Performance 35.00% · Measure score 7.02 · Achievement 7.02 · Improvement 0
Adjusted total nurse staffing
10
Baseline 5.41 hours · Performance 5.91 hours · Measure score 10 · Achievement 10 · Improvement 9
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.86% |
10.72%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 73 · Observed rate 13.7% · Lower 95% interval 7.26% |
| Discharge to community | 68.75% |
50.57%
18.2 pts better
|
Better than the National Rate · Eligible stays 83 · Observed rate 57.83% · Lower 95% interval 54.67% |
| Medicare spending per beneficiary | 1.14 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 94.34% |
95.27%
0.9 pts worse
|
Numerator 50 · Denominator 53 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 53 |
| Discharge self-care score | 60% |
53.69%
6.3 pts better
|
Numerator 18 · Denominator 30 |
| Discharge mobility score | 73.33% |
50.94%
22.4 pts better
|
Numerator 22 · Denominator 30 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 53 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 8.21% |
7.12%
1.1 pts worse
|
No Different than the National Rate · Eligible stays 43 · Observed rate 13.95% · Lower 95% interval 5.44% |
| Staff COVID-19 vaccination coverage | 36.11% |
8.2%
27.9 pts better
|
Numerator 13 · Denominator 36 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 80% |
56.45%
23.5 pts better
|
Numerator 24 · Denominator 30 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 81.25% |
96.28%
15 pts worse
|
Numerator 26 · Denominator 32 |
| Resident COVID-19 vaccinations up to date | 31.03% |
25.2%
5.8 pts better
|
Numerator 9 · Denominator 29 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| 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 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
1.6%
1.6 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · 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 · 4Q avg 0.0% |
| 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 · 4Q avg 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 0.0% |
13.7%
13.7 pts better
|
19.6%
19.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 9.5% |
14.2%
4.7 pts better
|
16.7%
7.2 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 9.5% · 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 | 5.7% |
11.0%
5.3 pts better
|
16.3%
10.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 5.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 2.6% |
10.7%
8.1 pts better
|
14.9%
12.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 2.6% · 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 | 11.1% |
10.9%
0.2 pts worse
|
19.8%
8.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 11.1% |
| Percentage of long-stay residents with pressure ulcers | 12.5% |
4.7%
7.8 pts worse
|
5.1%
7.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 12.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.7% |
94.0%
3.7 pts better
|
81.7%
16 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.8% · Q2 100.0% · Q3 98.0% · Q4 94.2% · 4Q avg 97.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 21.7% |
11.2%
10.5 pts worse
|
12.0%
9.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 21.7% · Observed 21.2% · Expected 10.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short 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 short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.9% |
93.2%
3.7 pts better
|
79.7%
17.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 96.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 28.0% |
23.2%
4.8 pts worse
|
23.9%
4.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 28.0% · Observed 27.3% · Expected 23.3% · Used in QM five-star |
Survey summary
Top issue: Pharmacy Service (2 deficiencies)
2 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Top issue: Environmental (2 deficiencies)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Top issue: Nutrition and Dietary (7 deficiencies)
6 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Fire safety
Fire Safety
Use approved construction type or materials.
Corrected 2025-01-23
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2025-01-23
Fire Safety
Use approved construction type or materials.
Corrected 2023-12-20
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-12-20
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-12-20
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-12-20
Fire Safety
Establish policies and procedures including evacuation.
Corrected 2022-08-08
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2022-08-08
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 2022-08-08
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-08-08
Fire Safety
Meet other general requirements that are deficient.
Corrected 2022-08-08
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2022-08-08
Inspection history
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2025-02-25
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 2025-02-25
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-02-25
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 2025-02-25
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-02-25
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-25
Health
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Corrected 2025-02-25
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 2024-01-31
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-01-31
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-01-31
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-01-31
Health
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Corrected 2024-01-31
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
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2022-07-21
Health
Dispose of garbage and refuse properly.
Corrected 2022-07-21
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2022-07-21
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 2022-07-21
Health
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Corrected 2022-07-21
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 2022-07-21
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 2022-07-21
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2022-07-21
Health
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Corrected 2022-07-21
Penalties and ownership
Fine · fine $4,587
Fine
Fine · fine $4,587
Fine
Fine · fine $4,235
Fine
Fine · fine $3,882
Fine
Fine · fine $3,529
Fine
Fine · fine $3,176
Fine
Fine · fine $7,409
Fine
Fine · fine $1,764
Fine
Fine · fine $3,174
Fine
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
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