14 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Tracy, CA
3-star overall rating with 3-star inspections with 14 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
545 West Beverly Place, Tracy, CA
(209) 835-6034
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Beds
62
Certified beds
Average residents
57
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Aspen Skilled Healthcare
Operator or chain grouping
Approved since
1978-02-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
34 facilities
Chain averages 4 overall / 3 health / 3 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
0.68
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.21
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
2.61
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
4.50
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
1.89
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
3.88
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.35
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.65
CMS adjusted RN staffing hours
Adjusted total hours
4.32
CMS adjusted total nurse staffing hours
Case-mix index
1.43
Higher values indicate more complex resident acuity
RN turnover
75%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
53%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Program rank
6,684
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
32.04
Composite VBP score used to determine payment impact.
Payment multiplier
0.9868
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
0
Baseline 19.22% · Performance 21.29% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
1.81
Baseline 7.69% · Performance 7.29% · Measure score 1.81 · Achievement 1.81 · Improvement 0.98
Total nurse turnover
6.84
Baseline 38.03% · Performance 35.71% · Measure score 6.84 · Achievement 6.84 · Improvement 1.26
Adjusted total nurse staffing
4.17
Baseline 4.32 hours · Performance 4.26 hours · Measure score 4.17 · Achievement 4.17 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.44% |
10.72%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 295 · Observed rate 13.9% · Lower 95% interval 9.18% |
| Discharge to community | 66.97% |
50.57%
16.4 pts better
|
Better than the National Rate · Eligible stays 274 · Observed rate 61.68% · Lower 95% interval 60.07% |
| Medicare spending per beneficiary | 0.99 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 97.4% |
95.27%
2.1 pts better
|
Numerator 187 · Denominator 192 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 192 |
| Discharge self-care score | 44.12% |
53.69%
9.6 pts worse
|
Numerator 60 · Denominator 136 |
| Discharge mobility score | 58.82% |
50.94%
7.9 pts better
|
Numerator 80 · Denominator 136 |
| Pressure ulcers or injuries, new or worsened | 0.52% |
2.29%
1.8 pts better
|
Numerator 1 · Denominator 192 · Adjusted rate 0.4% |
| Healthcare-associated infections requiring hospitalization | 7.29% |
7.12%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 169 · Observed rate 8.28% · Lower 95% interval 4.94% |
| Staff COVID-19 vaccination coverage | 21.43% |
8.2%
13.2 pts better
|
Numerator 21 · Denominator 98 |
| Staff flu vaccination coverage | 72.32% |
42%
30.3 pts better
|
Numerator 128 · Denominator 177 |
| Discharge function score | 57.35% |
56.45%
0.9 pts better
|
Numerator 78 · Denominator 136 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 54 · Denominator 54 |
| Transfer of health information to patient | 98.26% |
96.28%
2 pts better
|
Numerator 113 · Denominator 115 |
| Resident COVID-19 vaccinations up to date | 10.42% |
25.2%
14.8 pts worse
|
Numerator 10 · Denominator 96 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.6 |
2.3
0.3 pts worse
|
1.9
0.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.6 · Observed 1.8 · Expected 1.3 · 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 1.9 · Expected 1.2 · 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 | 1.3% |
1.6%
0.3 pts better
|
3.3%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 2.6% · Q3 0.0% · Q4 0.0% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.5% |
6.8%
5.3 pts better
|
11.4%
9.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 3.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.5% |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.7% |
13.7%
3 pts worse
|
19.6%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.6% · Q2 15.6% · Q3 16.7% · Q4 13.3% · 4Q avg 16.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 9.1% |
14.2%
5.1 pts better
|
16.7%
7.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.7% · Q2 8.0% · Q3 8.7% · Q4 8.7% · 4Q avg 9.1% · 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 | 18.1% |
11.0%
7.1 pts worse
|
16.3%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 18.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.3% |
10.7%
0.4 pts better
|
14.9%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.7% · Q2 14.3% · Q3 12.0% · Q4 3.8% · 4Q avg 10.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.9% |
1.0%
0.9 pts worse
|
1.0%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.5% · Q3 2.5% · Q4 2.5% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.1% |
1.2%
0.9 pts worse
|
1.7%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 2.7% · Q3 0.0% · Q4 0.0% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 12.1% |
10.9%
1.2 pts worse
|
19.8%
7.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 21.6% · Q3 13.2% · Q4 10.6% · 4Q avg 12.1% |
| Percentage of long-stay residents with pressure ulcers | 0.9% |
4.7%
3.8 pts better
|
5.1%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 1.7% · Q3 0.0% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.4% |
94.0%
4.4 pts better
|
81.7%
16.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.2% · Q2 97.9% · Q3 98.6% · Q4 98.1% · 4Q avg 98.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 15.7% |
11.2%
4.5 pts worse
|
12.0%
3.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 15.7% · Observed 15.6% · Expected 11.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.2% |
1.5%
0.7 pts worse
|
1.6%
0.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 4.1% · Q3 2.9% · Q4 0.9% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 97.2% |
93.2%
4 pts better
|
79.7%
17.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 97.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 31.1% |
23.2%
7.9 pts worse
|
23.9%
7.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 31.1% · Observed 31.2% · Expected 23.9% · Used in QM five-star |
Survey summary
Top issue: Resident Assessment and Care Planning (4 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Top issue: Quality of Life and Care (5 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Top issue: Quality of Life and Care (4 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-12-26
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-12-26
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2025-12-26
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-12-26
Fire Safety
Use approved construction type or materials.
Corrected 2024-09-18
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-09-18
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-09-18
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-08-22
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2024-08-22
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2024-08-22
Fire Safety
Provide primary/alternate means for communication.
Corrected 2023-09-05
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-09-05
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-09-05
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-09-05
Inspection history
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Not marked corrected
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Not marked corrected
Health
Provide and implement an infection prevention and control program.
Not marked corrected
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2026-01-05
Health
Provide and implement an infection prevention and control program.
Corrected 2026-01-05
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2026-01-05
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2026-01-05
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2026-01-05
Health
Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.
Corrected 2026-01-05
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2026-01-05
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 2026-01-05
Health
Post nurse staffing information every day.
Corrected 2026-01-05
Health
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Corrected 2026-01-05
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2025-11-14
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2024-09-08
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-09-08
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-09-08
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 2024-09-08
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-09-08
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2024-09-08
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-09-08
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-09-08
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2024-09-08
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-09-08
Health
Provide or obtain dental services for each resident.
Corrected 2024-09-08
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-09-08
Health
Provide and implement an infection prevention and control program.
Corrected 2024-09-08
Health
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Corrected 2024-09-08
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-02-28
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-02-28
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-03-04
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-01-22
Health
Provide and implement an infection prevention and control program.
Corrected 2023-09-29
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2023-09-14
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-09-14
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 2023-09-14
Health
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Corrected 2023-09-14
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-09-14
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-09-14
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-09-14
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-09-14
Health
Provide and implement an infection prevention and control program.
Corrected 2023-09-14
Health
Implement a program that monitors antibiotic use.
Corrected 2023-09-14
Health
Keep all essential equipment working safely.
Corrected 2023-09-14
Health
Post nurse staffing information every day.
Corrected 2023-09-14
Penalties and ownership
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Mortgage Interest · Organization
5% Or Greater Direct Ownership Interest · Organization
Operational/Managerial Control · Organization
5% Or Greater Indirect Ownership Interest · Individual
Corporate Officer · Individual
5% Or Greater Indirect Ownership Interest · Individual
Corporate Officer · Individual
5% Or Greater Indirect Ownership Interest · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
5% Or Greater Indirect Ownership Interest · Organization
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