Cycle 1
Health 2024-08-01 · Fire 2024-08-01
5 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
11 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (4 deficiencies)
Walnut Creek, CA
Shadelands Post Acute
5-star overall rating with 5-star inspections with 5 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
2765 Mitchell Dr, Walnut Creek, CA
(925) 296-5547
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
59
Certified beds
Average residents
59
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Pacs Group
Operator or chain grouping
Approved since
2022-07-29
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.74
Registered nurse staffing
LPN hours / resident day
1.23
Licensed practical nurse staffing
Aide hours / resident day
2.32
Nurse aide staffing
Weekend hours
3.76
Weekend nurse staffing
RN turnover
31%
Annual RN turnover
Total nurse turnover
46%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| 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 |
| 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 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.2% |
1.5%
0.3 pts better
|
1.6%
0.4 pts better
|
Short Stay · 2024Q4-2025Q3 |
| 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 |
| 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 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-07-13 · Fire 2022-07-13
0 health deficiencies
No concentrated health issue counts in this cycle.
4 fire-safety deficiencies
Top issue: Electrical (1 deficiency)
Cycle 3
Health · Fire
2 health deficiencies
Top issue: Resident Assessment and Care Planning (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-08-01
E24 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2024-09-07
F · Potential for more than minimal harm
2024-08-01
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-09-07
F · Potential for more than minimal harm
2024-08-01
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2024-09-07
F · Potential for more than minimal harm
2024-08-01
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2024-09-07
F · Potential for more than minimal harm
2024-08-01
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-09-07
F · Potential for more than minimal harm
2024-08-01
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-09-07
F · Potential for more than minimal harm
2024-08-01
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-09-07
F · Potential for more than minimal harm
2024-08-01
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-09-07
D · Potential for more than minimal harm
2024-08-01
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-09-07
D · Potential for more than minimal harm
2024-08-01
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2024-09-07
D · Potential for more than minimal harm
2024-08-01
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-09-07
D · Potential for more than minimal harm
2022-07-13
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2022-07-29
D · Potential for more than minimal harm
2022-07-13
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-07-29
D · Potential for more than minimal harm
2022-07-13
K901 · Electrical Deficiencies
Fire Safety
Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.
Corrected 2022-07-29
D · Potential for more than minimal harm
2022-07-13
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-07-29
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-08-01
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-09-01
E · Potential for more than minimal harm
2024-08-01
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 2024-09-01
E · Potential for more than minimal harm
2024-08-01
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-09-01
D · Potential for more than minimal harm
2024-08-01
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 2024-09-01
D · Potential for more than minimal harm
2024-08-01
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 2024-09-01
E · Potential for more than minimal harm
2023-10-19
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2023-10-31
E · Potential for more than minimal harm
2023-10-19
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 2023-10-31
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, Craig
Operational/Managerial Control · Individual
Bills, Craig
W-2 Managing Employee · Individual
Hancock, Mark
5% Or Greater Indirect Ownership Interest · Individual
Hancock, Mark
Corporate Officer · Individual
Mitchell, John
Corporate Officer · Individual
Murray, Jason
5% Or Greater Indirect Ownership Interest · Individual
Murray, Jason
Corporate Officer · 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
#1
Concord Post Acute
Concord, CA
4-star overall rating with 4-star inspections with 5 recent health deficiencies with 11 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
Jump out