8 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
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
1911 Oak Park Boulevard, Pleasant Hill, CA
(925) 935-6630
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Beds
113
Certified beds
Average residents
97
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Windsor
Operator or chain grouping
Approved since
1977-07-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
19 facilities
Chain averages 2 overall / 2 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
RN hours / resident day
0.89
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.41
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
2.07
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
4.37
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
2.29
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
4.13
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.70
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.65
CMS adjusted RN staffing hours
Adjusted total hours
3.21
CMS adjusted total nurse staffing hours
Case-mix index
1.86
Higher values indicate more complex resident acuity
RN turnover
48%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
46%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Program rank
6,640
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
32.19
Composite VBP score used to determine payment impact.
Payment multiplier
0.9869
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
4.71
Baseline 22.49% · Performance 19.64% · Measure score 4.71 · Achievement 3.86 · Improvement 4.71
Healthcare-associated infections
2.35
Baseline 8.53% · Performance 7.53% · Measure score 2.35 · Achievement 1.03 · Improvement 2.35
Total nurse turnover
4.94
Performance 43.48% · Measure score 4.94 · Achievement 4.94 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
0.87
Baseline 3.25 hours · Performance 3.33 hours · Measure score 0.87 · Achievement 0.87 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.86% |
10.72%
1.1 pts worse
|
No Different than the National Rate · Eligible stays 48 · Observed rate 22.92% · Lower 95% interval 8.52% |
| Discharge to community | 43.25% |
50.57%
7.3 pts worse
|
No Different than the National Rate · Eligible stays 46 · Observed rate 21.74% · Lower 95% interval 26.67% |
| Medicare spending per beneficiary | 1.17 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 96% |
95.27%
0.7 pts better
|
Numerator 48 · Denominator 50 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 50 |
| Discharge self-care score | 55.17% |
53.69%
1.5 pts better
|
Numerator 16 · Denominator 29 |
| Discharge mobility score | 51.72% |
50.94%
0.8 pts better
|
Numerator 15 · Denominator 29 |
| Pressure ulcers or injuries, new or worsened | 2% |
2.29%
0.3 pts better
|
Numerator 1 · Denominator 50 · Adjusted rate 1.12% |
| Healthcare-associated infections requiring hospitalization | 7.53% |
7.12%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 46 · Observed rate 15.22% · Lower 95% interval 4.87% |
| Staff COVID-19 vaccination coverage | 9.92% |
8.2%
1.7 pts better
|
Numerator 13 · Denominator 131 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 51.72% |
56.45%
4.7 pts worse
|
Numerator 15 · Denominator 29 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 13.04% |
25.2%
12.2 pts worse
|
Numerator 3 · Denominator 23 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.4 |
2.3
0.1 pts worse
|
1.9
0.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.4 · Observed 2.9 · Expected 2.3 · 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 1.9 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.7% |
98.5%
1.8 pts worse
|
93.4%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 96.8% · Q3 95.2% · Q4 94.3% · 4Q avg 96.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.1% |
98.2%
0.1 pts worse
|
95.5%
2.6 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.3% |
1.6%
1.3 pts better
|
3.3%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.1% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.8% |
6.8%
3 pts better
|
11.4%
7.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.2% · Q2 5.5% · Q3 3.0% · Q4 1.4% · 4Q avg 3.8% |
| 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 3.3% · Q2 6.0% · Q3 6.5% · Q4 3.7% · 4Q avg 4.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 11.9% |
13.7%
1.8 pts better
|
19.6%
7.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.9% · Q2 13.8% · Q3 11.1% · Q4 11.8% · 4Q avg 11.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.4% |
14.2%
1.8 pts better
|
16.7%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.8% · Q2 12.5% · Q3 14.0% · Q4 14.5% · 4Q avg 12.4% · 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 | 6.3% |
11.0%
4.7 pts better
|
16.3%
10 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 6.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.4% |
10.7%
5.3 pts better
|
14.9%
9.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 4.4% · Q3 7.5% · Q4 6.5% · 4Q avg 5.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
1.0%
0.7 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.1% · Q4 0.0% · 4Q avg 0.3% · 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 | 11.7% |
10.9%
0.8 pts worse
|
19.8%
8.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.3% · Q2 11.5% · Q3 14.4% · Q4 14.9% · 4Q avg 11.7% |
| Percentage of long-stay residents with pressure ulcers | 4.8% |
4.7%
0.1 pts worse
|
5.1%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 6.7% · Q3 5.5% · Q4 4.4% · 4Q avg 4.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 76.6% |
94.0%
17.4 pts worse
|
81.7%
5.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 87.7% · Q2 74.6% · Q3 76.2% · Q4 69.2% · 4Q avg 76.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 22.1% |
11.2%
10.9 pts worse
|
12.0%
10.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 22.1% · Observed 26.3% · Expected 13.3% · 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 | 71.4% |
93.2%
21.8 pts worse
|
79.7%
8.3 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 71.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.0% |
23.2%
1.8 pts worse
|
23.9%
1.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.0% · Observed 34.2% · Expected 32.6% · Used in QM five-star |
Survey summary
Top issue: Pharmacy Service (2 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Top issue: Quality of Life and Care (5 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Top issue: Resident Rights (3 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire Safety
Establish staff and initial training requirements.
Corrected 2023-10-16
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-10-16
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-10-16
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-10-16
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-10-16
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-10-16
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2023-10-16
Fire Safety
Provide emergency officials' contact information.
Corrected 2020-09-14
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2020-09-14
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2020-09-14
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2020-09-14
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2020-09-14
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2019-05-20
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2019-05-20
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2019-05-20
Fire Safety
Provide properly protected cooking facilities.
Corrected 2019-05-20
Inspection history
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2026-01-29
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Not marked corrected
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-06-23
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-08-28
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-08-28
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-08-24
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-08-24
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-10-19
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-10-19
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 2023-10-19
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-10-19
Health
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Corrected 2023-10-19
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2020-04-10
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2020-04-10
Health
Dispose of garbage and refuse properly.
Corrected 2020-04-10
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 2020-04-10
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2020-04-10
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2020-04-10
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2020-04-10
Health
Provide appropriate foot care.
Corrected 2020-04-10
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2020-04-10
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 2020-04-10
Health
Provide or get specialized rehabilitative services as required for a resident.
Corrected 2020-04-10
Health
Provide and implement an infection prevention and control program.
Corrected 2020-04-10
Health
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Corrected 2020-04-10
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 2019-03-01
Health
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Corrected 2019-03-01
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2019-03-01
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2019-03-01
Health
Ensure each resident receives an accurate assessment.
Corrected 2019-03-01
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2019-03-01
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2019-03-01
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2019-03-01
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2019-03-01
Health
Provide and implement an infection prevention and control program.
Corrected 2019-03-01
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2019-03-01
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2019-03-01
Penalties and ownership
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
Operational/Managerial Control · Individual
Operational/Managerial Control · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
5% Or Greater Indirect Ownership Interest · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
Nearby options
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5-star overall rating with 4-star inspections with 9 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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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