Cycle 1
Health 2024-11-08 · Fire 2024-11-08
1 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
17 fire-safety deficiencies
Top issue: Smoke (7 deficiencies)
Moraga, CA
Moraga Post Acute
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 17 fire-safety deficiencies in the latest cycle
348 Rheem Boulevard, Moraga, CA
(925) 376-5995
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
49
Certified beds
Average residents
47
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Pacs Group
Operator or chain grouping
Approved since
1970-02-13
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
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.25
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.51
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
2.36
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
4.12
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
1.76
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
3.67
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.22
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.20
CMS adjusted RN staffing hours
Adjusted total hours
3.31
CMS adjusted total nurse staffing hours
Case-mix index
1.70
Higher values indicate more complex resident acuity
RN turnover
80%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
46%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,977
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
21.87
Composite VBP score used to determine payment impact.
Payment multiplier
0.9827
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0.96
Baseline 17.83% · Performance 20.99% · Measure score 0.96 · Achievement 0.96 · Improvement 0
Healthcare-associated infections
0
Baseline 5.53% · Performance 7.71% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
4.90
Baseline 59.38% · Performance 43.64% · Measure score 4.90 · Achievement 4.90 · Improvement 4.06
Adjusted total nurse staffing
2.88
Baseline 3.49 hours · Performance 3.90 hours · Measure score 2.88 · Achievement 2.88 · Improvement 1.29
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.07% |
10.72%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 237 · Observed rate 10.55% · Lower 95% interval 8.21% |
| Discharge to community | 63.12% |
50.57%
12.5 pts better
|
Better than the National Rate · Eligible stays 237 · Observed rate 57.38% · Lower 95% interval 55.96% |
| Medicare spending per beneficiary | 1.09 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 130 · Denominator 130 |
| Falls with major injury | 0.77% |
0.77%
About the same
|
Numerator 1 · Denominator 130 |
| Discharge self-care score | 64.71% |
53.69%
11 pts better
|
Numerator 55 · Denominator 85 |
| Discharge mobility score | 64.71% |
50.94%
13.8 pts better
|
Numerator 55 · Denominator 85 |
| Pressure ulcers or injuries, new or worsened | 1.54% |
2.29%
0.8 pts better
|
Numerator 2 · Denominator 130 · Adjusted rate 1.76% |
| Healthcare-associated infections requiring hospitalization | 7.71% |
7.12%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 136 · Observed rate 8.09% · Lower 95% interval 4.85% |
| Staff COVID-19 vaccination coverage | 26.51% |
8.2%
18.3 pts better
|
Numerator 22 · Denominator 83 |
| Staff flu vaccination coverage | 49.56% |
42%
7.6 pts better
|
Numerator 56 · Denominator 113 |
| Discharge function score | 72.94% |
56.45%
16.5 pts better
|
Numerator 62 · Denominator 85 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 44 · Denominator 44 |
| Transfer of health information to patient | 88.75% |
96.28%
7.5 pts worse
|
Numerator 71 · Denominator 80 |
| Resident COVID-19 vaccinations up to date | 28.07% |
25.2%
2.9 pts better
|
Numerator 16 · Denominator 57 |
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% · 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 | 2.1% |
1.6%
0.5 pts worse
|
3.3%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 4.2% · Q3 0.0% · Q4 0.0% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 11.4% |
6.8%
4.6 pts worse
|
11.4%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 8.7% · Q2 4.5% · Q3 5.0% · Q4 26.1% · 4Q avg 11.4% |
| 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% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 11.2% |
13.7%
2.5 pts better
|
19.6%
8.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.5% · Q2 13.6% · Q3 9.5% · Q4 12.0% · 4Q avg 11.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 5.9% |
14.2%
8.3 pts better
|
16.7%
10.8 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 5.9% · 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 | 6.1% |
11.0%
4.9 pts better
|
16.3%
10.2 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 6.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 1.4% |
10.7%
9.3 pts better
|
14.9%
13.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q4 4.8% · 4Q avg 1.4% · 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% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.2% |
1.2%
About the same
|
1.7%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 1.4% |
10.9%
9.5 pts better
|
19.8%
18.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · 4Q avg 1.4% |
| Percentage of long-stay residents with pressure ulcers | 2.5% |
4.7%
2.2 pts better
|
5.1%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q3 0.0% · Q4 0.0% · 4Q avg 2.5% · 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 | 10.5% |
11.2%
0.7 pts better
|
12.0%
1.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.5% · Observed 9.4% · Expected 10.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.9% |
1.5%
0.6 pts better
|
1.6%
0.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 0.9% · Q3 0.8% · Q4 1.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.7% |
93.2%
5.5 pts better
|
79.7%
19 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 32.9% |
23.2%
9.7 pts worse
|
23.9%
9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 32.9% · Observed 31.2% · Expected 22.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-03 · Fire 2023-11-03
9 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
1 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Cycle 3
Health 2021-07-09 · Fire 2021-07-09
12 health deficiencies
Top issue: Nutrition and Dietary (5 deficiencies)
6 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-11-08
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2024-11-29
F · Potential for more than minimal harm
2024-11-08
E18 · Emergency Preparedness Deficiencies
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2024-11-29
F · Potential for more than minimal harm
2024-11-08
K352 · Smoke Deficiencies
Fire Safety
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Corrected 2024-11-29
F · Potential for more than minimal harm
2024-11-08
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-11-29
F · Potential for more than minimal harm
2024-11-08
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-11-29
D · Potential for more than minimal harm
2024-11-08
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-11-29
D · Potential for more than minimal harm
2024-11-08
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 2024-11-29
D · Potential for more than minimal harm
2024-11-08
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-11-29
D · Potential for more than minimal harm
2024-11-08
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2024-11-29
D · Potential for more than minimal harm
2024-11-08
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-11-29
D · Potential for more than minimal harm
2024-11-08
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-11-29
D · Potential for more than minimal harm
2024-11-08
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2024-11-29
D · Potential for more than minimal harm
2024-11-08
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2024-11-29
D · Potential for more than minimal harm
2024-11-08
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-11-29
D · Potential for more than minimal harm
2024-11-08
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-11-29
C · Minimal harm
2024-11-08
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2024-11-29
C · Minimal harm
2024-11-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-11-29
C · Minimal harm
2023-11-03
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-11-16
D · Potential for more than minimal harm
2021-07-09
E23 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for medical documentation.
Corrected 2021-08-03
D · Potential for more than minimal harm
2021-07-09
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2021-08-03
D · Potential for more than minimal harm
2021-07-09
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 2021-08-03
D · Potential for more than minimal harm
2021-07-09
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2021-08-03
D · Potential for more than minimal harm
2021-07-09
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2021-08-03
D · Potential for more than minimal harm
2021-07-09
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2021-08-03
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-11-08
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 2024-12-04
F · Potential for more than minimal harm
2023-11-03
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 2023-12-06
F · Potential for more than minimal harm
2023-11-03
F801 · Nutrition and Dietary Deficiencies
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2023-12-06
F · Potential for more than minimal harm
2023-11-03
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 2023-12-06
E · Potential for more than minimal harm
2023-11-03
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 2023-12-06
E · Potential for more than minimal harm
2023-11-03
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 2023-12-06
E · Potential for more than minimal harm
2023-11-03
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-12-06
D · Potential for more than minimal harm
2023-11-03
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-12-06
D · Potential for more than minimal harm
2023-11-03
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2023-12-06
D · Potential for more than minimal harm
2023-11-03
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 2023-12-06
D · Potential for more than minimal harm
2023-08-01
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 2023-09-25
D · Potential for more than minimal harm
2023-08-01
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-09-25
F · Potential for more than minimal harm
2021-07-09
F801 · Nutrition and Dietary Deficiencies
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2021-08-20
F · Potential for more than minimal harm
2021-07-09
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 2021-08-20
F · Potential for more than minimal harm
2021-07-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-08-20
E · Potential for more than minimal harm
2021-07-09
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 2021-08-20
D · Potential for more than minimal harm
2021-07-09
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 2021-08-20
D · Potential for more than minimal harm
2021-07-09
F688 · Quality of Life and Care Deficiencies
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 2021-08-20
D · Potential for more than minimal harm
2021-07-09
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2021-08-20
D · Potential for more than minimal harm
2021-07-09
F802 · Nutrition and Dietary Deficiencies
Health
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Corrected 2021-08-20
D · Potential for more than minimal harm
2021-07-09
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2021-08-20
D · Potential for more than minimal harm
2021-07-09
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2021-08-20
Penalties and ownership
What sits behind the stars
Ownership
Providence Group North LLC
5% Or Greater Direct Ownership Interest · Organization
Apt, Frederick
Corporate Officer · Individual
Cook, Ian
W-2 Managing Employee · Individual
Hancock, Mark
5% Or Greater Indirect Ownership Interest · 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
Providence Group Inc
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Other facilities in reach
#1
Orinda Care Center, LLC
Orinda, CA
2-star overall rating with 2-star inspections with 24 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#2
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
#3
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
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