Cycle 1
Health 2024-10-10 · Fire 2024-10-10
2 health deficiencies
Top issue: Environmental (1 deficiency)
8 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fremont, CA
Mission Valley Post Acute
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
2400 Parkside Drive, Fremont, CA
(510) 793-7222
Overall
5 / 5
CMS overall stars
Health inspections
5 / 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
85
Certified beds
Average residents
82
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Pacs Group
Operator or chain grouping
Approved since
1969-02-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
264 facilities
Chain averages 3 overall / 3 health / 2 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
0.76
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
0.93
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
2.38
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
4.07
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
1.69
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
3.74
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.63
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
0.65
CMS adjusted RN staffing hours
Adjusted total hours
3.47
CMS adjusted total nurse staffing hours
Case-mix index
1.60
Higher values indicate more complex resident acuity
RN turnover
42%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
40%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,947
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
31.25
Composite VBP score used to determine payment impact.
Payment multiplier
0.9864
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.43
Baseline 26.71% · Performance 20.97% · Measure score 5.43 · Achievement 0.99 · Improvement 5.43
Healthcare-associated infections
0
Baseline 6.87% · Performance 9.26% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
5.51
Baseline 53.62% · Performance 41.18% · Measure score 5.51 · Achievement 5.51 · Improvement 3.83
Adjusted total nurse staffing
1.56
Baseline 3.52 hours · Performance 3.52 hours · Measure score 1.56 · Achievement 1.56 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 15.18% |
10.72%
4.5 pts worse
|
Worse than the National Rate · Eligible stays 267 · Observed rate 19.1% · Lower 95% interval 12.56% |
| Discharge to community | 55.07% |
50.57%
4.5 pts better
|
No Different than the National Rate · Eligible stays 249 · Observed rate 48.19% · Lower 95% interval 47.97% |
| Medicare spending per beneficiary | 1.23 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 206 · Denominator 206 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 206 |
| Discharge self-care score | 66.34% |
53.69%
12.7 pts better
|
Numerator 67 · Denominator 101 |
| Discharge mobility score | 62.38% |
50.94%
11.4 pts better
|
Numerator 63 · Denominator 101 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 206 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 9.26% |
7.12%
2.1 pts worse
|
No Different than the National Rate · Eligible stays 204 · Observed rate 10.78% · Lower 95% interval 6.94% |
| Staff COVID-19 vaccination coverage | 37.27% |
8.2%
29.1 pts better
|
Numerator 41 · Denominator 110 |
| Staff flu vaccination coverage | 60.9% |
42%
18.9 pts better
|
Numerator 81 · Denominator 133 |
| Discharge function score | 71.29% |
56.45%
14.8 pts better
|
Numerator 72 · Denominator 101 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 65 · Denominator 65 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 112 · Denominator 112 |
| Resident COVID-19 vaccinations up to date | 37.86% |
25.2%
12.7 pts better
|
Numerator 39 · Denominator 103 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.1 |
2.3
0.8 pts worse
|
1.9
1.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.1 · Observed 3.1 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.2 |
1.6
0.4 pts better
|
1.8
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.2 · Expected 1.6 · 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 | 2.6% |
1.6%
1 pts worse
|
3.3%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 4.2% · Q3 2.0% · Q4 0.0% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 17.0% |
6.8%
10.2 pts worse
|
11.4%
5.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.2% · Q2 16.7% · Q3 14.9% · Q4 22.7% · 4Q avg 17.0% |
| Percentage of long-stay residents who lose too much weight | 4.0% |
4.1%
0.1 pts better
|
5.4%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 2.2% · Q3 0.0% · Q4 2.2% · 4Q avg 4.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 8.3% |
13.7%
5.4 pts better
|
19.6%
11.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.8% · Q2 8.7% · Q3 8.5% · Q4 6.4% · 4Q avg 8.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 3.0% |
14.2%
11.2 pts better
|
16.7%
13.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 3.2% · Q3 2.6% · Q4 2.9% · 4Q avg 3.0% · 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 | 12.2% |
11.0%
1.2 pts worse
|
16.3%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 12.2% · 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 · Q1 10.8% · Q2 5.1% · Q3 7.5% · Q4 4.9% · 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 · 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 | 0.0% |
1.2%
1.2 pts better
|
1.7%
1.7 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 new or worsened bowel or bladder incontinence | 13.3% |
10.9%
2.4 pts worse
|
19.8%
6.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.5% · Q2 9.1% · Q3 17.9% · Q4 14.5% · 4Q avg 13.3% |
| Percentage of long-stay residents with pressure ulcers | 3.0% |
4.7%
1.7 pts better
|
5.1%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 1.6% · Q3 1.5% · Q4 1.6% · 4Q avg 3.0% · 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 | 8.5% |
11.2%
2.7 pts better
|
12.0%
3.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.5% · Observed 7.8% · Expected 10.3% · 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 | 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 | 17.2% |
23.2%
6 pts better
|
23.9%
6.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 17.2% · Observed 17.5% · Expected 24.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-10-21 · Fire 2021-10-21
17 health deficiencies
Top issue: Pharmacy Service (5 deficiencies)
6 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Cycle 3
Health 2019-11-21 · Fire 2019-11-21
2 health deficiencies
Top issue: Environmental (1 deficiency)
18 fire-safety deficiencies
Top issue: Emergency Preparedness (8 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-10-10
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2024-10-22
F · Potential for more than minimal harm
2024-10-10
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-10-22
E · Potential for more than minimal harm
2024-10-10
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-10-22
D · Potential for more than minimal harm
2024-10-10
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2024-10-22
D · Potential for more than minimal harm
2024-10-10
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-10-22
D · Potential for more than minimal harm
2024-10-10
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-10-22
D · Potential for more than minimal harm
2024-10-10
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2024-10-22
D · Potential for more than minimal harm
2024-10-10
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2024-10-22
D · Potential for more than minimal harm
2021-10-21
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2021-11-15
D · Potential for more than minimal harm
2021-10-21
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 2021-11-15
D · Potential for more than minimal harm
2021-10-21
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2021-11-15
D · Potential for more than minimal harm
2021-10-21
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-11-15
D · Potential for more than minimal harm
2021-10-21
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2021-11-15
D · Potential for more than minimal harm
2021-10-21
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2021-11-15
E · Potential for more than minimal harm
2019-11-21
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2020-02-18
E · Potential for more than minimal harm
2019-11-21
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2020-02-18
E · Potential for more than minimal harm
2019-11-21
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2020-02-18
D · Potential for more than minimal harm
2019-11-21
E23 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for medical documentation.
Corrected 2020-02-18
D · Potential for more than minimal harm
2019-11-21
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2020-02-18
D · Potential for more than minimal harm
2019-11-21
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2020-02-18
D · Potential for more than minimal harm
2019-11-21
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2020-02-18
D · Potential for more than minimal harm
2019-11-21
E32 · Emergency Preparedness Deficiencies
Fire Safety
Provide primary/alternate means for communication.
Corrected 2020-02-18
D · Potential for more than minimal harm
2019-11-21
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2020-02-18
D · Potential for more than minimal harm
2019-11-21
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2020-02-18
D · Potential for more than minimal harm
2019-11-21
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2020-02-18
D · Potential for more than minimal harm
2019-11-21
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2020-02-18
D · Potential for more than minimal harm
2019-11-21
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2020-02-18
D · Potential for more than minimal harm
2019-11-21
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2020-02-18
D · Potential for more than minimal harm
2019-11-21
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2020-02-18
D · Potential for more than minimal harm
2019-11-21
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2020-02-18
D · Potential for more than minimal harm
2019-11-21
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2020-02-18
D · Potential for more than minimal harm
2019-11-21
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2020-02-18
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-10-10
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-10-28
B · Minimal harm
2024-10-10
F912 · Environmental Deficiencies
Health
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Corrected 2024-10-28
D · Potential for more than minimal harm
2024-03-27
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-06-06
E · Potential for more than minimal harm
2021-10-21
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2021-12-15
E · Potential for more than minimal harm
2021-10-21
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2021-12-15
E · Potential for more than minimal harm
2021-10-21
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 2021-12-15
E · Potential for more than minimal harm
2021-10-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-12-15
D · Potential for more than minimal harm
2021-10-21
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2021-12-15
D · Potential for more than minimal harm
2021-10-21
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2021-12-15
D · Potential for more than minimal harm
2021-10-21
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2021-12-15
D · Potential for more than minimal harm
2021-10-21
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2021-12-15
D · Potential for more than minimal harm
2021-10-21
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2021-12-15
D · Potential for more than minimal harm
2021-10-21
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2021-12-15
D · Potential for more than minimal harm
2021-10-21
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2021-12-15
D · Potential for more than minimal harm
2021-10-21
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 2021-12-15
D · Potential for more than minimal harm
2021-10-21
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2021-12-15
D · Potential for more than minimal harm
2021-10-21
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 2021-12-15
D · Potential for more than minimal harm
2021-10-21
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 2021-12-15
B · Minimal harm
2021-10-21
F912 · Environmental Deficiencies
Health
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Corrected 2021-12-10
E · Potential for more than minimal harm
2019-11-21
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 2019-11-22
B · Minimal harm
2019-11-21
F912 · Environmental Deficiencies
Health
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Corrected 2019-11-22
Penalties and ownership
What sits behind the stars
Ownership
Providence Group Nh, LLC
5% Or Greater Direct Ownership Interest · Organization
Apt, Frederick
Corporate Officer · Individual
Bills, Kelly
Operational/Managerial Control · Individual
Bills, Kelly
W-2 Managing Employee · Individual
Dhugga, Gurpreet
Contracted Managing Employee · Individual
Hancock, Mark
5% Or Greater Indirect Ownership Interest · Individual
Hancock, Mark
Corporate Officer · Individual
Jergensen, Joshua
Corporate Officer · Individual
Mitchell, John
Corporate Officer · Individual
Murray, Jason
5% Or Greater Indirect Ownership Interest · Individual
Pacs Group, Inc.
5% Or Greater Indirect Ownership Interest · Organization
Pacs Holdings, LLC
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Other facilities in reach
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We Care Skilled Nursing - Fremont
Fremont, CA
3-star overall rating with 3-star inspections with 10 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
#2
Country Drive Post Acute
Fremont, CA
4-star overall rating with 4-star inspections with 7 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#3
Crestwood Treatment Center
Fremont, CA
5-star overall rating with 5-star inspections with 4 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
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