Stonebrook Post Acute
4367 Concord Boulevard, Concord, CA 94521 · Contra Costa County · 120 certified beds · avg 110 residents/day · certified since May 24, 1990
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★★★☆4/5 · 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.
Most serious findings (actual harm or immediate jeopardy)
▲ Actual harm, one-off · Mar 23, 2026 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Apr 13, 2026 (Deficient, Provider has date of correction)
All citations in the current public record (25)
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 |
|---|---|---|
| Jun 25, 2026 | F · Potential for harm, facility-wide | 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. |
| Jun 25, 2026 | 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. |
| Jun 25, 2026 | D · Potential for harm, one-off | The facility did not make sure residents were fully informed about their own health, care, and treatments in a way they could understand. |
| Jun 25, 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. |
| Mar 23, 2026 | ▲ G · Actual 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. · from a complaint |
| Dec 29, 2025 | D · Potential for harm, one-off | The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care. · from a complaint |
| Dec 29, 2025 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Dec 22, 2025 | E · Potential for harm, repeated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint |
| Mar 6, 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. |
| Mar 6, 2025 | 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. |
| Mar 6, 2025 | D · Potential for harm, one-off | The facility used bed rails without first trying safer alternatives, or without assessing the resident's safety risk, discussing the risks and benefits with the resident or family, getting consent, and installing the rails correctly. |
| Mar 6, 2025 | D · Potential for harm, one-off | The facility did not provide the social services residents need — such as counseling, help with adjustment, or connecting to outside resources — to achieve the best possible quality of life. |
| Mar 6, 2025 | D · Potential for harm, one-off | 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. |
| Jan 16, 2025 | D · Potential for harm, one-off | The facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly. · from a complaint |
| Aug 27, 2024 | D · Potential for harm, one-off | 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 |
| Mar 5, 2024 | 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. · from a complaint |
| Aug 30, 2023 | 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. · from a complaint |
| Aug 30, 2023 | D · Potential for harm, one-off | The facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason. · from a complaint |
| Jun 28, 2023 | F · Potential for harm, facility-wide | 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. |
| Jun 28, 2023 | F · Potential for harm, facility-wide | The facility did not have enough support staff to safely and effectively run its food and nutrition service. |
| Jun 28, 2023 | F · Potential for harm, facility-wide | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. |
| Jun 28, 2023 | F · Potential for harm, facility-wide | 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. |
| Jun 28, 2023 | E · Potential for harm, repeated | 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. |
| Jun 28, 2023 | 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. |
| Jun 28, 2023 | D · Potential for harm, one-off | The facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline. |
Inspection trend by year
Citations from standard inspections stayed about the same across the last two inspection cycles (5 → 4).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 9 | 0 | F |
| 2024 | 2 | 0 | D |
| 2025 | 9 | 0 | E |
| 2026 | 5 | 1 | G ▲ |
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)
1 fine totaling $12,735.
| Date | Type | Amount / length |
|---|---|---|
| Mar 23, 2026 | Fine | $12,735 |
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) | 4.03 | 4.31 | 3.95 | bottom 44% in California; top 38% in the U.S. |
| Registered Nurse hours | 0.56 | 0.61 | 0.69 | top 37% in California; bottom 47% in the U.S. |
| Weekend total nurse staffing | 3.62 | 3.90 | 3.50 | bottom 40% in California; top 37% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.48 | 0.51 | 0.48 | top 34% in California; top 36% in the U.S. |
| Total nursing staff turnover (%) | 32.2 | 36.7 | 45.8 | top 38% in California; top 18% 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 4.71, RN 0.66, weekend 4.22. 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: 3/5 · long-stay residents: 4/5 · short-stay residents: 2/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Health Management INC | Organization | Direct Ownership Interest | NOT APPLICABLE | 01/01/2011 |
| Hightower, Todd | Individual | Direct Ownership Interest | NOT APPLICABLE | 01/01/2011 |
| Cooper, Lori | Individual | W-2 Managing Employee | NOT APPLICABLE | 12/02/1999 |
| Cooper, Lori | Individual | Corporate Officer | NOT APPLICABLE | 12/02/1999 |
| Cooper, Lori | Individual | Operational/Managerial Control | NOT APPLICABLE | 07/01/2016 |
| Cooper, Lori | Individual | ADP of the SNF | NOT APPLICABLE | 12/17/2024 |
| Health Management INC | Organization | Operational/Managerial Control | NOT APPLICABLE | 07/01/2016 |
| Health Management INC | Organization | ADP of the SNF | NOT APPLICABLE | 12/17/2024 |
| Hightower, Todd | Individual | Managing Control - Governing Body | NOT APPLICABLE | 01/01/2011 |
| Hightower, Todd | Individual | Corporate Director | NOT APPLICABLE | 01/01/2011 |
| Hightower, Todd | Individual | Corporate Officer | NOT APPLICABLE | 01/01/2011 |
| Hightower, Todd | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/01/2011 |
| Hightower, Todd | Individual | ADP of the SNF | NOT APPLICABLE | 12/17/2024 |
| Roncagliolo, Yvette | Individual | W-2 Managing Employee | NOT APPLICABLE | 07/01/2016 |
| Roncagliolo, Yvette | Individual | Operational/Managerial Control | NOT APPLICABLE | 11/07/2024 |
| Roncagliolo, Yvette | Individual | ADP of the SNF | NOT APPLICABLE | 12/17/2024 |
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 is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "How do you explain health changes and treatment options to residents and their families?"
- "How do you record and honor each resident's treatment wishes and advance directives, and how do staff know about them?"
- "When abuse or theft is suspected, who do you notify, how fast, and how do you inform the family?"
- "Can we tour the resident rooms, bathrooms, and common areas today, including areas not on the usual tour route?"
- "Who completes resident assessments here, and how do you check them for accuracy?"
- "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 |
|---|---|---|---|---|---|
| Diablo Valley Post Acute | 1.7 mi | Concord, CA | ★★☆☆☆ | 1/5 | abuse |
| Willow Pass Healthcare Center | 2.2 mi | Concord, CA | ★★★☆☆ | 2/5 | |
| Concord Post Acute | 3.0 mi | Concord, CA | ★★☆☆☆ | 2/5 | abuse |
| Bayberry Skilled Nursing & Healthcare Center | 3.3 mi | Concord, CA | ★★★★☆ | 3/5 | |
| Shadelands Post Acute | 3.8 mi | Walnut Creek, CA | ★★★★☆ | 3/5 | |
| Pleasant Hill Post Acute | 5.2 mi | Pleasant Hill, CA | ★★★★☆ | 3/5 | |
| Rosewood Post Acute | 5.7 mi | Pleasant Hill, CA | ★★★★☆ | 4/5 | |
| La Casa via Transitional Care Center | 5.8 mi | Walnut Creek, CA | ★★★★★ | 4/5 | |
| Tampico Healthcare Center | 5.8 mi | Walnut Creek, CA | ★★★★☆ | 3/5 | |
| Legacy Post Acute Care | 6.1 mi | Martinez, CA | ★★★★★ | 4/5 | |
| Pittsburg Skilled Nursing Center | 6.3 mi | Pittsburg, CA | ★☆☆☆☆ | 2/5 | |
| Diamond Ridge Healthcare Center | 6.3 mi | Pittsburg, CA | ★★☆☆☆ | 2/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 555421.