Cycle 1
Health 2024-10-11 · Fire 2024-10-11
14 health deficiencies
Top issue: Pharmacy Service (4 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Danville, CA
Danville Post-Acute Rehab
4-star overall rating with 3-star inspections with 14 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
336 Diablo Road, Danville, CA
(925) 837-4566
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
54
Certified beds
Average residents
43
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
1989-05-01
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
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.54
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.30
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
2.42
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
4.27
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
1.84
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
3.80
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
0.05
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.47
CMS adjusted RN staffing hours
Adjusted total hours
3.71
CMS adjusted total nurse staffing hours
Case-mix index
1.57
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
35%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,797
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
47.68
Composite VBP score used to determine payment impact.
Payment multiplier
1.0013
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.24
Baseline 19.48% · Performance 20.39% · Measure score 2.24 · Achievement 2.24 · Improvement 0
Healthcare-associated infections
4.55
Baseline 5.97% · Performance 6.47% · Measure score 4.55 · Achievement 4.55 · Improvement 0
Total nurse turnover
9.32
Baseline 20.00% · Performance 25.58% · Measure score 9.32 · Achievement 9.32 · Improvement 0
Adjusted total nurse staffing
2.95
Baseline 3.57 hours · Performance 3.92 hours · Measure score 2.95 · Achievement 2.95 · Improvement 1.07
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.5% |
10.72%
0.2 pts better
|
No Different than the National Rate · Eligible stays 324 · Observed rate 8.95% · Lower 95% interval 8.22% |
| Discharge to community | 63.03% |
50.57%
12.5 pts better
|
Better than the National Rate · Eligible stays 323 · Observed rate 60.06% · Lower 95% interval 57.9% |
| Medicare spending per beneficiary | 1.01 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 99.45% |
95.27%
4.2 pts better
|
Numerator 182 · Denominator 183 |
| Falls with major injury | 1.09% |
0.77%
0.3 pts worse
|
Numerator 2 · Denominator 183 |
| Discharge self-care score | 49.64% |
53.69%
4 pts worse
|
Numerator 68 · Denominator 137 |
| Discharge mobility score | 57.66% |
50.94%
6.7 pts better
|
Numerator 79 · Denominator 137 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 183 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.47% |
7.12%
0.7 pts better
|
No Different than the National Rate · Eligible stays 198 · Observed rate 5.05% · Lower 95% interval 3.81% |
| Staff COVID-19 vaccination coverage | 27.38% |
8.2%
19.2 pts better
|
Numerator 23 · Denominator 84 |
| Staff flu vaccination coverage | 83.51% |
42%
41.5 pts better
|
Numerator 81 · Denominator 97 |
| Discharge function score | 56.93% |
56.45%
0.5 pts better
|
Numerator 78 · Denominator 137 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 37 · Denominator 37 |
| Transfer of health information to patient | 96.3% |
96.28%
About the same
|
Numerator 130 · Denominator 135 |
| Resident COVID-19 vaccinations up to date | 33.8% |
25.2%
8.6 pts better
|
Numerator 24 · Denominator 71 |
Quality measures
Resident outcomes and process scores
| 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 · Q1 100.0% · Q2 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 | 4.9% |
1.6%
3.3 pts worse
|
3.3%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 4.3% · 4Q avg 4.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 6.8% |
6.8%
About the same
|
11.4%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 10.0% · 4Q avg 6.8% |
| 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 · Q2 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 22.1% |
13.7%
8.4 pts worse
|
19.6%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 28.6% · 4Q avg 22.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 8.3% |
14.2%
5.9 pts better
|
16.7%
8.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 8.3% · 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% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 4.4% |
11.0%
6.6 pts better
|
16.3%
11.9 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 4.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 7.0% |
10.7%
3.7 pts better
|
14.9%
7.9 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 7.0% · 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 · Q2 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 18.4% |
10.9%
7.5 pts worse
|
19.8%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 18.4% |
| Percentage of long-stay residents with pressure ulcers | 2.9% |
4.7%
1.8 pts better
|
5.1%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 5.1% · 4Q avg 2.9% · 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 | 9.6% |
11.2%
1.6 pts better
|
12.0%
2.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.6% · Observed 8.2% · Expected 9.6% · 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 | 92.1% |
93.2%
1.1 pts worse
|
79.7%
12.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 92.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.2% |
23.2%
2 pts better
|
23.9%
2.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.2% · Observed 18.6% · Expected 20.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-11-04 · Fire 2022-11-04
2 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
4 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Cycle 3
Health 2019-02-13 · Fire 2019-02-13
1 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-10-11
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2024-11-13
E · Potential for more than minimal harm
2024-10-11
E32 · Emergency Preparedness Deficiencies
Fire Safety
Provide primary/alternate means for communication.
Corrected 2024-11-13
E · Potential for more than minimal harm
2024-10-11
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-11-13
D · Potential for more than minimal harm
2024-10-11
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-11-13
D · Potential for more than minimal harm
2024-10-11
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2024-11-13
C · Minimal harm
2024-10-11
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2024-11-13
D · Potential for more than minimal harm
2022-11-04
E18 · Emergency Preparedness Deficiencies
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2022-11-28
D · Potential for more than minimal harm
2022-11-04
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2022-11-28
D · Potential for more than minimal harm
2022-11-04
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-11-28
D · Potential for more than minimal harm
2022-11-04
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-11-28
E · Potential for more than minimal harm
2019-02-13
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2019-05-20
D · Potential for more than minimal harm
2019-02-13
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2019-05-20
D · Potential for more than minimal harm
2019-02-13
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2019-05-20
D · Potential for more than minimal harm
2019-02-13
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2019-05-20
D · Potential for more than minimal harm
2019-02-13
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2019-05-20
D · Potential for more than minimal harm
2019-02-13
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2019-05-20
D · Potential for more than minimal harm
2019-02-13
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2019-05-20
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-06-11
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 2025-06-27
D · Potential for more than minimal harm
2024-12-30
F573 · Resident Rights Deficiencies
Health
Let each resident or the resident's legal representative access or purchase copies of all the resident's records.
Corrected 2025-01-11
E · Potential for more than minimal harm
2024-10-11
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-10-31
E · Potential for more than minimal harm
2024-10-11
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 2024-10-31
E · Potential for more than minimal harm
2024-10-11
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 2024-10-31
E · Potential for more than minimal harm
2024-10-11
F758 · Pharmacy Service Deficiencies
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 2024-10-31
E · Potential for more than minimal harm
2024-10-11
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-10-31
E · Potential for more than minimal harm
2024-10-11
F761 · Pharmacy Service Deficiencies
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 2024-10-31
E · Potential for more than minimal harm
2024-10-11
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 2024-10-31
E · Potential for more than minimal harm
2024-10-11
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 2024-10-31
D · Potential for more than minimal harm
2024-10-11
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-10-31
D · Potential for more than minimal harm
2024-10-11
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-10-31
D · Potential for more than minimal harm
2024-10-11
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 2024-10-31
D · Potential for more than minimal harm
2024-10-11
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2024-10-31
D · Potential for more than minimal harm
2024-10-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-31
D · Potential for more than minimal harm
2024-05-20
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 2024-05-29
E · Potential for more than minimal harm
2019-02-13
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 2019-03-13
Penalties and ownership
What sits behind the stars
Ownership
Flagstone Healthcare North LLC
5% Or Greater Direct Ownership Interest · Organization
The Ensign Group Inc
5% Or Greater Indirect Ownership Interest · Organization
Burnam, Soon
Corporate Officer · Individual
Fitch, Craig
Corporate Officer · Individual
Monette, Cory
Corporate Officer · Individual
Valle, Leon
Operational/Managerial Control · Individual
Valle, Leon
W-2 Managing Employee · Individual
Willits, Adam
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Tice Valley Post Acute
Walnut Creek, CA
5-star overall rating with 4-star inspections with 7 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#2
Rossmoor Post Acute
Walnut Creek, CA
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
Walnut Creek Skilled Nursing & Rehabilitation Cent
Walnut Creek, CA
3-star overall rating with 3-star inspections with 12 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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