Cycle 1
Health 2025-02-27 · Fire 2025-02-27
9 health deficiencies
Top issue: Resident Assessment and Care Planning (5 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Ventura, CA
Victoria Care Center
5-star overall rating with 4-star inspections with 9 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
5445 Everglades Street, Ventura, CA
(805) 642-1736
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
188
Certified beds
Average residents
177
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
1991-09-18
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
329 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.47
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.10
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
2.85
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
4.42
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
1.57
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
4.04
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.39
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.16
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.46
CMS adjusted RN staffing hours
Adjusted total hours
4.29
CMS adjusted total nurse staffing hours
Case-mix index
1.41
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
34%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,422
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
56.79
Composite VBP score used to determine payment impact.
Payment multiplier
1.0119
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.82
Baseline 21.16% · Performance 19.20% · Measure score 4.82 · Achievement 4.82 · Improvement 4.24
Healthcare-associated infections
7.47
Baseline 5.80% · Performance 5.60% · Measure score 7.47 · Achievement 7.47 · Improvement 1.91
Total nurse turnover
7.92
Baseline 36.14% · Performance 31.32% · Measure score 7.92 · Achievement 7.92 · Improvement 3.77
Adjusted total nurse staffing
2.52
Baseline 3.96 hours · Performance 3.79 hours · Measure score 2.52 · Achievement 2.52 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.11% |
10.72%
1.4 pts worse
|
No Different than the National Rate · Eligible stays 418 · Observed rate 11.24% · Lower 95% interval 9.38% |
| Discharge to community | 56.83% |
50.57%
6.3 pts better
|
Better than the National Rate · Eligible stays 365 · Observed rate 55.89% · Lower 95% interval 53.14% |
| Medicare spending per beneficiary | 1.2 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 321 · Denominator 321 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 321 |
| Discharge self-care score | 83.59% |
53.69%
29.9 pts better
|
Numerator 219 · Denominator 262 |
| Discharge mobility score | 56.49% |
50.94%
5.6 pts better
|
Numerator 148 · Denominator 262 |
| Pressure ulcers or injuries, new or worsened | 2.18% |
2.29%
0.1 pts better
|
Numerator 7 · Denominator 321 · Adjusted rate 2.15% |
| Healthcare-associated infections requiring hospitalization | 5.6% |
7.12%
1.5 pts better
|
No Different than the National Rate · Eligible stays 277 · Observed rate 3.97% · Lower 95% interval 3.9% |
| Staff COVID-19 vaccination coverage | 3.5% |
8.2%
4.7 pts worse
|
Numerator 11 · Denominator 314 |
| Staff flu vaccination coverage | 11.33% |
42%
30.7 pts worse
|
Numerator 40 · Denominator 353 |
| Discharge function score | 53.82% |
56.45%
2.6 pts worse
|
Numerator 141 · Denominator 262 |
| Transfer of health information to provider | 98.15% |
95.95%
2.2 pts better
|
Numerator 53 · Denominator 54 |
| Transfer of health information to patient | 95.96% |
96.28%
0.3 pts worse
|
Numerator 190 · Denominator 198 |
| Resident COVID-19 vaccinations up to date | 14.92% |
25.2%
10.3 pts worse
|
Numerator 27 · Denominator 181 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.8 |
2.3
0.5 pts better
|
1.9
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.4 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.9 |
1.6
0.3 pts worse
|
1.8
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.5 · Expected 1.4 · 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 0.0% · Q2 0.8% · Q3 2.3% · Q4 2.2% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.0% |
6.8%
5.8 pts better
|
11.4%
10.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 0.8% · Q3 0.0% · Q4 1.6% · 4Q avg 1.0% |
| Percentage of long-stay residents who lose too much weight | 1.3% |
4.1%
2.8 pts better
|
5.4%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 0.0% · Q3 0.9% · Q4 1.7% · 4Q avg 1.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.3% |
13.7%
1.4 pts better
|
19.6%
7.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 10.4% · Q3 11.8% · Q4 10.5% · 4Q avg 12.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 7.6% |
14.2%
6.6 pts better
|
16.7%
9.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.2% · Q2 8.6% · Q3 8.7% · Q4 7.8% · 4Q avg 7.6% · 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 | 8.4% |
11.0%
2.6 pts better
|
16.3%
7.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.5% · Q2 9.0% · Q3 4.2% · Q4 10.4% · 4Q avg 8.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 6.1% |
10.7%
4.6 pts better
|
14.9%
8.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 6.5% · Q3 6.3% · Q4 6.9% · 4Q avg 6.1% · 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.8% |
1.2%
0.4 pts better
|
1.7%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 0.8% · Q3 0.0% · Q4 0.8% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 10.3% |
10.9%
0.6 pts better
|
19.8%
9.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.5% · Q2 5.2% · Q3 7.3% · Q4 10.0% · 4Q avg 10.3% |
| Percentage of long-stay residents with pressure ulcers | 3.8% |
4.7%
0.9 pts better
|
5.1%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 5.2% · Q3 1.5% · Q4 3.0% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.9% |
94.0%
5.9 pts better
|
81.7%
18.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.7% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.3% |
11.2%
0.1 pts worse
|
12.0%
0.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.3% · Observed 12.0% · Expected 11.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.0% |
1.5%
0.5 pts better
|
1.6%
0.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.8% · Q2 0.4% · Q3 0.8% · Q4 2.0% · 4Q avg 1.0% · 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 | 17.8% |
23.2%
5.4 pts better
|
23.9%
6.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 17.8% · Observed 16.3% · Expected 21.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-10-19 · Fire 2023-10-19
11 health deficiencies
Top issue: Resident Assessment and Care Planning (5 deficiencies)
9 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Cycle 3
Health 2021-04-15 · Fire 2021-04-15
5 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-02-27
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-03-24
D · Potential for more than minimal harm
2025-02-27
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-03-24
D · Potential for more than minimal harm
2025-02-27
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2025-03-24
D · Potential for more than minimal harm
2025-02-27
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-03-24
D · Potential for more than minimal harm
2025-02-27
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2025-03-24
D · Potential for more than minimal harm
2025-02-27
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-03-24
F · Potential for more than minimal harm
2023-10-19
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2023-11-16
F · Potential for more than minimal harm
2023-10-19
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-11-16
E · Potential for more than minimal harm
2023-10-19
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-11-16
E · Potential for more than minimal harm
2023-10-19
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-11-16
D · Potential for more than minimal harm
2023-10-19
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-11-16
D · Potential for more than minimal harm
2023-10-19
K223 · Egress Deficiencies
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 2023-11-16
D · Potential for more than minimal harm
2023-10-19
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 2023-11-16
D · Potential for more than minimal harm
2023-10-19
K500 · Services Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2023-11-16
D · Potential for more than minimal harm
2023-10-19
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-11-16
F · Potential for more than minimal harm
2023-03-03
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-05-09
E · Potential for more than minimal harm
2021-04-15
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2021-05-27
D · Potential for more than minimal harm
2021-04-15
K223 · Egress Deficiencies
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 2021-05-27
D · Potential for more than minimal harm
2021-04-15
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2021-05-27
D · Potential for more than minimal harm
2021-04-15
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2021-05-27
D · Potential for more than minimal harm
2021-04-15
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2021-05-27
D · Potential for more than minimal harm
2021-04-15
K500 · Services Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2021-05-27
D · Potential for more than minimal harm
2021-04-15
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2021-05-27
D · Potential for more than minimal harm
2021-04-15
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2021-05-27
D · Potential for more than minimal harm
2021-04-15
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2021-05-27
C · Minimal harm
2021-04-15
E22 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for sheltering.
Corrected 2021-05-27
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-07-10
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-07-15
D · Potential for more than minimal harm
2025-04-11
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-04-22
E · Potential for more than minimal harm
2025-02-27
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 2025-03-31
D · Potential for more than minimal harm
2025-02-27
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-03-25
D · Potential for more than minimal harm
2025-02-27
F578 · Resident Rights Deficiencies
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 2025-03-25
D · Potential for more than minimal harm
2025-02-27
F657 · Resident Assessment and Care Planning Deficiencies
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 2025-03-31
D · Potential for more than minimal harm
2025-02-27
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 2025-03-31
D · Potential for more than minimal harm
2025-02-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-31
D · Potential for more than minimal harm
2025-02-27
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 2025-03-31
D · Potential for more than minimal harm
2025-01-31
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-02-18
D · Potential for more than minimal harm
2025-01-31
F713 · Nursing and Physician Services Deficiencies
Health
Provide or arrange emergency care by a doctor 24 hours a day.
Corrected 2025-02-18
D · Potential for more than minimal harm
2025-01-28
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-02-19
D · Potential for more than minimal harm
2025-01-28
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-02-19
D · Potential for more than minimal harm
2024-10-17
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 2024-11-13
D · Potential for more than minimal harm
2024-10-17
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 2024-11-13
D · Potential for more than minimal harm
2024-07-19
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-09-05
D · Potential for more than minimal harm
2024-07-02
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 2024-07-16
D · Potential for more than minimal harm
2024-06-25
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-07-11
D · Potential for more than minimal harm
2023-12-03
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2023-12-07
D · Potential for more than minimal harm
2023-10-19
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-11-01
D · Potential for more than minimal harm
2023-10-19
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-11-01
D · Potential for more than minimal harm
2023-07-14
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-07-26
D · Potential for more than minimal harm
2023-05-31
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-06-07
D · Potential for more than minimal harm
2021-04-15
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 2021-05-13
D · Potential for more than minimal harm
2021-04-15
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 2021-05-13
Penalties and ownership
What sits behind the stars
Ownership
Flagstone Healthcare Central LLC
5% Or Greater Indirect Ownership Interest · Organization
Burnam, Soon
Corporate Officer · Individual
Cullifer, Jared
Corporate Officer · Individual
Gardner, John
Operational/Managerial Control · Individual
Keetch, Chad
Corporate Officer · Individual
Sato, Ami
Corporate Officer · Individual
Valiveti, Vinod
Operational/Managerial Control · Individual
Willits, Adam
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Coastal View Healthcare Center
Ventura, CA
5-star overall rating with 4-star inspections with $8,278 in total fines with 10 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Ventura Post Acute
Ventura, CA
4-star overall rating with 4-star inspections with 6 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Oxnard Manor Healthcare Center
Oxnard, CA
5-star overall rating with 4-star inspections with 7 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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