Lone Tree Post Acute

Name: Lone Tree Post Acute
Address: 4001 LONE TREE WAY, Antioch, CA, 94509, US
Telephone: 9257540470

4001 Lone Tree Way, Antioch, CA 94509 · Contra Costa County · 99 certified beds · avg 95 residents/day · certified since Nov 7, 1979

Part of chain: PACS GROUP (274 facilities, chain avg rating 2.9★)

3/5

Health inspection rating (on-site)

Serious findings on record

Fines, last 3 years

3.59

Nurse hours/resident/day (adjusted)

What health inspectors found (on-site government inspections — the most independent evidence available)

Health inspection rating: ★★★☆☆3/5 · CMS overall rating: 4/5

The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.

All citations in the current public record (29)

CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.

Date	Severity	What the facility was cited for
May 1, 2026	E · Potential for harm, repeated	The facility gave residents unnecessary mind-altering (psychotropic) medications, or used drugs in a way that restrained residents by dulling their ability to think, move, or function.
May 1, 2026	E · Potential for harm, repeated	The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
May 1, 2026	E · Potential for harm, repeated	The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration.
May 1, 2026	E · Potential for harm, repeated	The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it.
May 1, 2026	E · Potential for harm, repeated	The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time.
May 1, 2026	E · Potential for harm, repeated	The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
May 1, 2026	D · Potential for harm, one-off	The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights.
May 1, 2026	D · Potential for harm, one-off	The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups.
May 1, 2026	D · Potential for harm, one-off	The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away.
May 1, 2026	D · Potential for harm, one-off	The facility did not coordinate resident assessments with the state's pre-admission screening program for mental illness and intellectual disabilities, or failed to refer residents for the special services they need.
May 1, 2026	D · Potential for harm, one-off	The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines.
May 1, 2026	D · Potential for harm, one-off	The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
May 1, 2026	D · Potential for harm, one-off	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
May 1, 2026	D · Potential for harm, one-off	The facility did not provide safe and appropriate pain management for a resident who needed it.
Apr 27, 2026	F · Potential for harm, facility-wide	The facility was not properly licensed, or did not operate in compliance with federal, state, and local laws, regulations, and accepted professional standards. · from a complaint
Apr 27, 2026	E · Potential for harm, repeated	The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint
Apr 10, 2025	F · Potential for harm, facility-wide	The facility did not post its nurse staffing information every day. Nursing homes must publicly display how many nurses and aides are on duty each day.
Apr 10, 2025	E · Potential for harm, repeated	The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time.
Apr 10, 2025	E · Potential for harm, repeated	The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock.
Apr 10, 2025	E · Potential for harm, repeated	The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Apr 10, 2025	E · Potential for harm, repeated	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Apr 10, 2025	D · Potential for harm, one-off	The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights.
Apr 10, 2025	D · Potential for harm, one-off	The facility did not honor residents' right to share a room with their spouse or a roommate of their choosing, or moved residents to a different room without written notice beforehand.
Apr 10, 2025	D · Potential for harm, one-off	The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives.
Apr 10, 2025	D · Potential for harm, one-off	The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own.
Apr 10, 2025	D · Potential for harm, one-off	The facility did not provide proper foot care for residents. Foot care includes routine care like nail trimming and attention to foot problems, which matter greatly for older adults.
Apr 10, 2025	D · Potential for harm, one-off	The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it.
Dec 6, 2023	D · Potential for harm, one-off	The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable.
Dec 6, 2023	D · Potential for harm, one-off	The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time.

Inspection trend by year

Citations from standard inspections increased between the last two inspection cycles (11 → 14).

Year	Citations	Worst severity that year
2023	2	D
2025	11	F
2026	16	F

Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.

Fines and enforcement (last 3 years)

No fines or payment denials in the published 3-year window.

Nurse staffing (from payroll records, adjusted for how much care residents need)

Measure	This facility	California avg	U.S. avg	Where it stands
Total nurse staffing (hours per resident per day)	3.59	4.31	3.95	bottom 15% in California; bottom 41% in the U.S.
Registered Nurse hours	0.53	0.61	0.69	top 42% in California; bottom 42% in the U.S.
Weekend total nurse staffing	3.22	3.90	3.50	bottom 12% in California; bottom 43% in the U.S.
Weekend RN hours (not acuity-adjusted)	0.49	0.51	0.48	top 32% in California; top 34% in the U.S.
Total nursing staff turnover (%)	33.0	36.7	45.8	top 40% in California; top 20% in the U.S.
RN turnover (%)	33.3	38.1	42.9	top 40% in California; top 33% in the U.S.

Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 4.03, RN 0.59, weekend 3.61. Staffing rating: 3/5.

Self-reported quality measures

Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.

Quality measures rating: 5/5 · long-stay residents: 5/5 · short-stay residents: 5/5

Who owns this facility

For profit - Limited Liability company

Owner / manager	Type	Role	Stake	Since
Apt, Frederick	Individual	Corporate Officer	NOT APPLICABLE	02/10/2021
Dhugga, Gurpreet	Individual	Contracted Managing Employee	NOT APPLICABLE	01/01/2015
Hadley, Matthew	Individual	W-2 Managing Employee	NOT APPLICABLE	05/01/2023
Hancock, Mark	Individual	Corporate Officer	NOT APPLICABLE	05/01/2020
Jergensen, Joshua	Individual	Corporate Officer	NOT APPLICABLE	01/01/2024
Mitchell, John	Individual	Corporate Officer	NOT APPLICABLE	02/10/2021
Murray, Jason	Individual	Corporate Officer	NOT APPLICABLE	05/01/2020

Questions to ask on your visit

Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.

"What percentage of your residents are on antipsychotic or sedating medications, and how do you work to reduce that?"
"How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
"How do you monitor residents' weight and eating, and what happens when someone starts losing weight?"
"How many residents here use oxygen or breathing equipment, and who checks that equipment each shift?"
"What is your current medication error rate, and what have you changed to bring errors down?"
"What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
"Can you give me examples of how your staff protect residents' dignity in everyday care, like bathing and dressing?"
"Can you give me examples of how you adjust daily routines and room setups to fit each resident's preferences?"
"What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
"Can I see the results and plan of correction from your most recent state inspection?"

Nearby facilities (within 20 miles)

Facility	Distance	City	Overall	Inspection	Flags
Delta View Post Acute	3.1 mi	Antioch, CA	★★★★☆	3/5
Diamond Ridge Healthcare Center	5.1 mi	Pittsburg, CA	★★☆☆☆	2/5
Pittsburg Skilled Nursing Center	6.1 mi	Pittsburg, CA	★☆☆☆☆	2/5
Stonebrook Post Acute	10.4 mi	Concord, CA	★★★★☆	4/5
Diablo Valley Post Acute	12.0 mi	Concord, CA	★★☆☆☆	1/5	abuse
Willow Pass Healthcare Center	12.6 mi	Concord, CA	★★★☆☆	2/5
Shadelands Post Acute	12.8 mi	Walnut Creek, CA	★★★★☆	3/5
Concord Post Acute	13.1 mi	Concord, CA	★★☆☆☆	2/5	abuse
The Reutlinger Community	13.1 mi	Danville, CA	★★★★☆	4/5
Bayberry Skilled Nursing & Healthcare Center	13.6 mi	Concord, CA	★★★★☆	3/5

Compare this facility with the 3 closest →

All facilities in Antioch →

Facility data as of CMS processing date 2026-08-01. CCN 056021.

The Care File

Visit checklist — Lone Tree Post Acute

4001 Lone Tree Way, Antioch, CA 94509 · 9257540470

Health inspection rating 3/5 · CMS overall 4/5· Fines (3y): $0

Questions for the administrator:

☐ "What percentage of your residents are on antipsychotic or sedating medications, and how do you work to reduce that?"
☐ "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
☐ "How do you monitor residents' weight and eating, and what happens when someone starts losing weight?"
☐ "How many residents here use oxygen or breathing equipment, and who checks that equipment each shift?"
☐ "What is your current medication error rate, and what have you changed to bring errors down?"
☐ "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
☐ "Can you give me examples of how your staff protect residents' dignity in everyday care, like bathing and dressing?"
☐ "Can you give me examples of how you adjust daily routines and room setups to fit each resident's preferences?"
☐ "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
☐ "Can I see the results and plan of correction from your most recent state inspection?"

While you're there, notice:

☐ Smell and cleanliness in hallways, not just the lobby
☐ How staff speak to residents; call lights answered promptly
☐ Residents up, dressed, and engaged (visit mealtimes and a weekend if you can)

Data: CMS Provider Data Catalog, version 2026-08-01 · CCN 056021 · Verify at medicare.gov/care-compare · Printed from The Care File (thecarefile.com)