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
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
0.74
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.23
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
2.32
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
4.30
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
1.98
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
0.63
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.40
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.49
CMS adjusted RN staffing hours
Adjusted total hours
2.80
CMS adjusted total nurse staffing hours
Case-mix index
2.10
Higher values indicate more complex resident acuity
RN turnover
31%
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
1,302
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
57.77
Composite VBP score used to determine payment impact.
Payment multiplier
1.0130
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
10
Performance 14.87% · Measure score 10 · Achievement 10 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
9.06
Performance 5.13% · Measure score 9.06 · Achievement 9.06 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
4.05
Performance 47.14% · Measure score 4.05 · Achievement 4.05 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
0
Performance 2.77 hours · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.67% |
10.72%
2.1 pts better
|
No Different than the National Rate · Eligible stays 818 · Observed rate 7.21% · Lower 95% interval 7.12% |
| Discharge to community | 68.32% |
50.57%
17.7 pts better
|
Better than the National Rate · Eligible stays 890 · Observed rate 64.72% · Lower 95% interval 65.19% |
| Medicare spending per beneficiary | 1.27 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 511 · Denominator 511 |
| Falls with major injury | 0.2% |
0.77%
0.6 pts better
|
Numerator 1 · Denominator 511 |
| Discharge self-care score | 59.04% |
53.69%
5.4 pts better
|
Numerator 111 · Denominator 188 |
| Discharge mobility score | 70.74% |
50.94%
19.8 pts better
|
Numerator 133 · Denominator 188 |
| Pressure ulcers or injuries, new or worsened | 0.59% |
2.29%
1.7 pts better
|
Numerator 3 · Denominator 511 · Adjusted rate 0.55% |
| Healthcare-associated infections requiring hospitalization | 5.13% |
7.12%
2 pts better
|
Better than the National Rate · Eligible stays 573 · Observed rate 4.01% · Lower 95% interval 3.58% |
| Staff COVID-19 vaccination coverage | 18.09% |
8.2%
9.9 pts better
|
Numerator 17 · Denominator 94 |
| Staff flu vaccination coverage | 57.27% |
42%
15.3 pts better
|
Numerator 63 · Denominator 110 |
| Discharge function score | 67.55% |
56.45%
11.1 pts better
|
Numerator 127 · Denominator 188 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 86 · Denominator 86 |
| Transfer of health information to patient | 99.29% |
96.28%
3 pts better
|
Numerator 422 · Denominator 425 |
| Resident COVID-19 vaccinations up to date | 34.77% |
25.2%
9.6 pts better
|
Numerator 89 · Denominator 256 |
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 · 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 | 9.8% |
11.2%
1.4 pts better
|
12.0%
2.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.8% · Observed 8.3% · Expected 9.5% · Used in QM five-star |
| 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 · Q1 0.5% · Q2 0.5% · Q3 1.4% · Q4 2.3% · 4Q avg 1.2% · 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 15.0% · Expected 20.9% · Used in QM five-star |
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
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