Cycle 1
Health 2025-08-15 · Fire 2025-08-15
14 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
4 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Pleasant Hill, CA
Pleasant Hill Post Acute
4-star overall rating with 3-star inspections with 14 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
1625 Oak Park Boulevard, Pleasant Hill, CA
(925) 935-5222
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
51
Certified beds
Average residents
48
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Pacs Group
Operator or chain grouping
Approved since
1971-07-01
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
0.54
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.31
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
2.26
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
4.10
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
1.85
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
3.76
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.41
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.25
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.45
CMS adjusted RN staffing hours
Adjusted total hours
3.42
CMS adjusted total nurse staffing hours
Case-mix index
1.64
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
44%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Value-based purchasing
Program rank
880
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
62.55
Composite VBP score used to determine payment impact.
Payment multiplier
1.0174
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
10
Baseline 17.74% · Performance 15.06% · Measure score 10 · Achievement 10 · Improvement 9
Healthcare-associated infections
8.07
Baseline 6.38% · Performance 5.42% · Measure score 8.07 · Achievement 8.07 · Improvement 6.42
Total nurse turnover
6.94
Baseline 53.03% · Performance 35.29% · Measure score 6.94 · Achievement 6.94 · Improvement 5.79
Adjusted total nurse staffing
0
Baseline 3.88 hours · Performance 3.10 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.56% |
10.72%
1.2 pts better
|
No Different than the National Rate · Eligible stays 449 · Observed rate 8.69% · Lower 95% interval 7.73% |
| Discharge to community | 63.01% |
50.57%
12.4 pts better
|
Better than the National Rate · Eligible stays 396 · Observed rate 57.32% · Lower 95% interval 56.91% |
| Medicare spending per beneficiary | 1.06 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 272 · Denominator 272 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 272 |
| Discharge self-care score | 44% |
53.69%
9.7 pts worse
|
Numerator 44 · Denominator 100 |
| Discharge mobility score | 63% |
50.94%
12.1 pts better
|
Numerator 63 · Denominator 100 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 272 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 5.42% |
7.12%
1.7 pts better
|
No Different than the National Rate · Eligible stays 270 · Observed rate 4.07% · Lower 95% interval 3.62% |
| Staff COVID-19 vaccination coverage | 37.65% |
8.2%
29.4 pts better
|
Numerator 32 · Denominator 85 |
| Staff flu vaccination coverage | 49.44% |
42%
7.4 pts better
|
Numerator 44 · Denominator 89 |
| Discharge function score | 62% |
56.45%
5.5 pts better
|
Numerator 62 · Denominator 100 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 91 · Denominator 91 |
| Transfer of health information to patient | 97.13% |
96.28%
0.8 pts better
|
Numerator 169 · Denominator 174 |
| Resident COVID-19 vaccinations up to date | 50.97% |
25.2%
25.8 pts better
|
Numerator 79 · Denominator 155 |
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 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
1.6%
1.6 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · 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 · 4Q avg 0.0% |
| 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 · 4Q avg 0.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 10.0% |
13.7%
3.7 pts better
|
19.6%
9.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 10.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 0.0% |
14.2%
14.2 pts better
|
16.7%
16.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · 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 · 4Q avg 0.0% |
| Percentage of long-stay residents whose need for help with daily activities has increased | 1.9% |
10.7%
8.8 pts better
|
14.9%
13 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 1.9% · 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 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 1.7% |
10.9%
9.2 pts better
|
19.8%
18.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 1.7% |
| Percentage of long-stay residents with pressure ulcers | 3.2% |
4.7%
1.5 pts better
|
5.1%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 3.2% · 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 | 5.6% |
11.2%
5.6 pts better
|
12.0%
6.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.6% · Observed 5.4% · Expected 10.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.8% |
1.5%
0.3 pts worse
|
1.6%
0.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.7% · Q2 1.9% · Q3 1.9% · Q4 2.4% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 99.6% |
93.2%
6.4 pts better
|
79.7%
19.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 99.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.9% |
23.2%
0.3 pts better
|
23.9%
1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.9% · Observed 20.3% · Expected 21.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-16 · Fire 2024-05-16
5 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
16 fire-safety deficiencies
Top issue: Smoke (7 deficiencies)
Cycle 3
Health 2022-06-16 · Fire 2022-06-16
2 health deficiencies
Top issue: Nursing and Physician Services (1 deficiency)
8 fire-safety deficiencies
Top issue: Emergency Preparedness (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-08-15
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-09-04
D · Potential for more than minimal harm
2025-08-15
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2025-09-04
C · Minimal harm
2025-08-15
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-08-19
C · Minimal harm
2025-08-15
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-08-19
F · Potential for more than minimal harm
2024-05-16
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-06-24
F · Potential for more than minimal harm
2024-05-16
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-06-24
F · Potential for more than minimal harm
2024-05-16
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-06-24
E · Potential for more than minimal harm
2024-05-16
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-06-24
E · Potential for more than minimal harm
2024-05-16
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-06-24
E · Potential for more than minimal harm
2024-05-16
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-06-24
E · Potential for more than minimal harm
2024-05-16
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2024-06-24
E · Potential for more than minimal harm
2024-05-16
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-06-24
E · Potential for more than minimal harm
2024-05-16
K500 · Services Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2024-06-24
E · Potential for more than minimal harm
2024-05-16
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 2024-06-24
E · Potential for more than minimal harm
2024-05-16
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-06-24
E · Potential for more than minimal harm
2024-05-16
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-06-24
D · Potential for more than minimal harm
2024-05-16
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2024-06-24
D · Potential for more than minimal harm
2024-05-16
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 2024-06-24
D · Potential for more than minimal harm
2024-05-16
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-06-24
D · Potential for more than minimal harm
2024-05-16
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-06-24
D · Potential for more than minimal harm
2022-06-16
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2022-07-28
D · Potential for more than minimal harm
2022-06-16
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2022-07-28
D · Potential for more than minimal harm
2022-06-16
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2022-07-28
D · Potential for more than minimal harm
2022-06-16
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2022-07-28
D · Potential for more than minimal harm
2022-06-16
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 2022-07-28
D · Potential for more than minimal harm
2022-06-16
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2022-07-28
D · Potential for more than minimal harm
2022-06-16
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-07-28
D · Potential for more than minimal harm
2022-06-16
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-07-28
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-08-15
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 2025-09-23
E · Potential for more than minimal harm
2025-08-15
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-09-23
E · Potential for more than minimal harm
2025-08-15
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-09-23
E · Potential for more than minimal harm
2025-08-15
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-09-23
E · Potential for more than minimal harm
2025-08-15
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 2025-09-23
E · Potential for more than minimal harm
2025-08-15
F813 · Nutrition and Dietary Deficiencies
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2025-09-23
E · Potential for more than minimal harm
2025-08-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-09-23
D · Potential for more than minimal harm
2025-08-15
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 2025-09-23
D · Potential for more than minimal harm
2025-08-15
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 2025-09-23
D · Potential for more than minimal harm
2025-08-15
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2025-09-23
D · Potential for more than minimal harm
2025-08-15
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2025-09-23
D · Potential for more than minimal harm
2025-08-15
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-09-23
D · Potential for more than minimal harm
2025-08-15
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2025-09-23
B · Minimal harm
2025-08-15
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 2025-09-23
E · Potential for more than minimal harm
2024-05-16
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 2024-06-12
E · Potential for more than minimal harm
2024-05-16
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 2024-06-12
E · Potential for more than minimal harm
2024-05-16
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 2024-06-12
D · Potential for more than minimal harm
2024-05-16
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-06-12
B · Minimal harm
2024-05-16
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 2024-06-12
E · Potential for more than minimal harm
2022-06-16
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 2022-06-16
D · Potential for more than minimal harm
2022-06-16
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2022-06-16
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
Bills, Craig
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
Rosewood Post Acute
Pleasant Hill, CA
4-star overall rating with 4-star inspections with 8 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#2
La Casa Via Transitional Care Center
Walnut Creek, CA
5-star overall rating with 4-star inspections with 9 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Tampico Healthcare Center
Walnut Creek, CA
3-star overall rating with 3-star inspections with 15 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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