Cycle 1
Health 2025-01-09 · Fire 2025-01-09
7 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Martinez, CA
Legacy Post Acute Care
5-star overall rating with 5-star inspections with 7 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
1790 Muir Road, Martinez, CA
(925) 228-8383
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
96
Certified beds
Average residents
74
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1996-11-12
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
Hours and turnover
RN hours / resident day
0.53
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
0.81
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
4.19
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
1.34
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
3.78
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.43
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.54
CMS adjusted RN staffing hours
Adjusted total hours
4.26
CMS adjusted total nurse staffing hours
Case-mix index
1.35
Higher values indicate more complex resident acuity
RN turnover
27%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
32%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,884
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
38.23
Composite VBP score used to determine payment impact.
Payment multiplier
0.9913
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.90
Baseline 18.07% · Performance 19.62% · Measure score 3.90 · Achievement 3.90 · Improvement 0
Healthcare-associated infections
3.92
Baseline 5.09% · Performance 6.66% · Measure score 3.92 · Achievement 3.92 · Improvement 0
Total nurse turnover
4.05
Performance 47.13% · Measure score 4.05 · Achievement 4.05 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
3.42
Baseline 4.47 hours · Performance 4.05 hours · Measure score 3.42 · Achievement 3.42 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.83% |
10.72%
1.1 pts worse
|
No Different than the National Rate · Eligible stays 214 · Observed rate 12.62% · Lower 95% interval 7.88% |
| Discharge to community | 58.24% |
50.57%
7.7 pts better
|
Better than the National Rate · Eligible stays 218 · Observed rate 52.75% · Lower 95% interval 52.23% |
| Medicare spending per beneficiary | 1.07 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 191 · Denominator 191 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 191 |
| Discharge self-care score | 47.33% |
53.69%
6.4 pts worse
|
Numerator 62 · Denominator 131 |
| Discharge mobility score | 59.54% |
50.94%
8.6 pts better
|
Numerator 78 · Denominator 131 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 191 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.66% |
7.12%
0.5 pts better
|
No Different than the National Rate · Eligible stays 150 · Observed rate 6% · Lower 95% interval 4.35% |
| Staff COVID-19 vaccination coverage | 22.39% |
8.2%
14.2 pts better
|
Numerator 30 · Denominator 134 |
| Staff flu vaccination coverage | 59.02% |
42%
17 pts better
|
Numerator 108 · Denominator 183 |
| Discharge function score | 54.96% |
56.45%
1.5 pts worse
|
Numerator 72 · Denominator 131 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 55 · Denominator 55 |
| Transfer of health information to patient | 98.21% |
96.28%
1.9 pts better
|
Numerator 110 · Denominator 112 |
| Resident COVID-19 vaccinations up to date | 25.89% |
25.2%
0.7 pts better
|
Numerator 29 · Denominator 112 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.5 |
2.3
0.8 pts better
|
1.9
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 2.0 · Expected 2.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.8 |
1.6
0.2 pts worse
|
1.8
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 2.0 · Expected 1.8 · 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 | 0.5% |
1.6%
1.1 pts better
|
3.3%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 4.8% |
4.1%
0.7 pts worse
|
5.4%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.8% · Q2 9.5% · Q3 0.0% · Q4 0.0% · 4Q avg 4.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.8% |
13.7%
3.9 pts better
|
19.6%
9.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.6% · Q2 9.1% · Q3 9.5% · Q4 7.0% · 4Q avg 9.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 10.2% |
14.2%
4 pts better
|
16.7%
6.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.8% · Q2 11.8% · Q3 8.8% · Q4 8.6% · 4Q avg 10.2% · 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 | 15.9% |
11.0%
4.9 pts worse
|
16.3%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 15.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 7.5% |
10.7%
3.2 pts better
|
14.9%
7.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.8% · Q2 7.3% · Q3 7.7% · Q4 5.1% · 4Q avg 7.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.5% |
1.0%
0.5 pts better
|
1.0%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.6% |
1.2%
0.4 pts worse
|
1.7%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 4.7% · Q4 2.2% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 10.5% |
10.9%
0.4 pts better
|
19.8%
9.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.6% · Q2 4.6% · Q3 26.7% · Q4 7.0% · 4Q avg 10.5% |
| Percentage of long-stay residents with pressure ulcers | 1.8% |
4.7%
2.9 pts better
|
5.1%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 1.8% · Q3 0.0% · Q4 3.7% · 4Q avg 1.8% · 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 | 9.8% |
11.2%
1.4 pts better
|
12.0%
2.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.8% · Observed 10.2% · Expected 11.7% · 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 2.0% · Q2 4.7% · Q3 1.6% · Q4 0.8% · 4Q avg 2.2% · 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 | 26.5% |
23.2%
3.3 pts worse
|
23.9%
2.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.5% · Observed 27.8% · Expected 25.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-10-14 · Fire 2022-10-14
5 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
12 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Cycle 3
Health 2019-08-16 · Fire 2019-08-16
4 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
4 fire-safety deficiencies
Top issue: Emergency Preparedness (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-01-09
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-01-31
E · Potential for more than minimal harm
2025-01-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-01-27
D · Potential for more than minimal harm
2025-01-09
K342 · Smoke Deficiencies
Fire Safety
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
Corrected 2025-01-31
C · Minimal harm
2025-01-09
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-01-27
F · Potential for more than minimal harm
2022-10-14
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-11-29
E · Potential for more than minimal harm
2022-10-14
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2022-11-29
E · Potential for more than minimal harm
2022-10-14
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-11-29
E · Potential for more than minimal harm
2022-10-14
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2022-11-29
D · Potential for more than minimal harm
2022-10-14
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2022-11-29
D · Potential for more than minimal harm
2022-10-14
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2022-11-29
D · Potential for more than minimal harm
2022-10-14
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2022-11-29
D · Potential for more than minimal harm
2022-10-14
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-11-29
D · Potential for more than minimal harm
2022-10-14
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2022-11-29
D · Potential for more than minimal harm
2022-10-14
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2022-11-29
D · Potential for more than minimal harm
2022-10-14
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-11-29
D · Potential for more than minimal harm
2022-10-14
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2022-11-29
D · Potential for more than minimal harm
2019-08-16
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2019-10-13
D · Potential for more than minimal harm
2019-08-16
E32 · Emergency Preparedness Deficiencies
Fire Safety
Provide primary/alternate means for communication.
Corrected 2019-10-13
D · Potential for more than minimal harm
2019-08-16
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2019-10-13
D · Potential for more than minimal harm
2019-08-16
E9 · Emergency Preparedness Deficiencies
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2019-10-13
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-04
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 2026-01-03
D · Potential for more than minimal harm
2025-01-09
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 2025-02-06
D · Potential for more than minimal harm
2025-01-09
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2025-02-06
D · Potential for more than minimal harm
2025-01-09
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2025-02-06
D · Potential for more than minimal harm
2025-01-09
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-02-06
D · Potential for more than minimal harm
2025-01-09
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 2025-02-06
D · Potential for more than minimal harm
2025-01-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-06
F · Potential for more than minimal harm
2022-10-14
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 2022-11-14
E · Potential for more than minimal harm
2022-10-14
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 2022-11-14
E · Potential for more than minimal harm
2022-10-14
F803 · Nutrition and Dietary Deficiencies
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 2022-11-14
D · Potential for more than minimal harm
2022-10-14
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 2022-11-14
D · Potential for more than minimal harm
2022-10-14
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-11-14
E · Potential for more than minimal harm
2019-08-16
F803 · Nutrition and Dietary Deficiencies
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 2019-09-16
D · Potential for more than minimal harm
2019-08-16
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 2019-09-16
D · Potential for more than minimal harm
2019-08-16
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2019-09-16
D · Potential for more than minimal harm
2019-08-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-09-16
Penalties and ownership
What sits behind the stars
Ownership
Joseph, Tom
5% Or Greater Direct Ownership Interest · Individual
Broach, Jasmine
Operational/Managerial Control · Individual
Bughio, Sara
Operational/Managerial Control · Individual
Castillo, Myla
Operational/Managerial Control · Individual
Clement, Sharletta
Operational/Managerial Control · Individual
Cooper, Dustin
Operational/Managerial Control · Individual
Cruz, Marissa
Operational/Managerial Control · Individual
Dantes, Alvin
Operational/Managerial Control · Individual
Hernandez-Perdomo, Yesenia
Operational/Managerial Control · Individual
Joseph, April
Operational/Managerial Control · Individual
Joseph, April
Corporate Director · Individual
Joseph, April
Corporate Officer · Individual
Joseph, Tom
Operational/Managerial Control · Individual
Joseph, Tom
Corporate Director · Individual
Joseph, Tom
Corporate Officer · Individual
Kaur, Ramandeep
Operational/Managerial Control · Individual
Mcchesney, Stephanie
Operational/Managerial Control · Individual
Mcclendon, Cindy
Operational/Managerial Control · Individual
Roldan, Raquel
Operational/Managerial Control · Individual
Santoyo, Jennifer
Operational/Managerial Control · Individual
Vergara-Miestrup, Isabell
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Alhambra Post Acute
Martinez, CA
4-star overall rating with 3-star inspections with 11 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
#2
Bayberry Skilled Nursing & Healthcare Center
Concord, CA
5-star overall rating with 4-star inspections with 7 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Willow Pass Healthcare Center
Concord, CA
3-star overall rating with 2-star inspections with $45,702 in total fines with 20 recent health deficiencies with 15 fire-safety deficiencies in the latest cycle
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