Lone Tree Post Acute
4001 Lone Tree Way · Antioch, CA · 94509 · 9257540470
99 certified beds For profit - Limited Liability company Chain: Pacs Group
Why this verdict
- Inspection results are getting worse cycle over cycle, not better.
- No federal fines or payment denials in CMS’s 3-year window.
Red flags
No red flags in the current CMS record. Genuinely good news — pair it with an in-person tour before deciding.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 5 of 5 Inspections: 4 of 5 Staffing: 2 of 5 Quality measures: 5 of 5
| Total nurse hours / resident-day | 3.94 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.56 | 0.55–0.75 |
| Weekend hours / resident-day | 3.57 | ≈ weekday level |
| Nursing turnover / year | 33% | median 45% |
| Fines (3-yr window) | none |
Inspection citations (25 in the current record)
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Potential for harm · E April 27, 2026 · found via complaint
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Deficient, Provider has no plan of correction · Pharmacy Service
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Potential for harm · F April 27, 2026 · found via complaint
Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.
Deficient, Provider has no plan of correction · Administration
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Potential for harm · D April 10, 2025
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected May 11, 2025 · Resident Rights
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Potential for harm · D April 10, 2025
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Corrected May 11, 2025 · Resident Rights
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Potential for harm · D April 10, 2025
Ensure each resident receives an accurate assessment.
Corrected May 11, 2025 · Resident Assessment and Care Planning
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Potential for harm · D April 10, 2025
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected May 11, 2025 · Quality of Life and Care
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Potential for harm · D April 10, 2025
Provide appropriate foot care.
Corrected May 11, 2025 · Quality of Life and Care
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Potential for harm · D April 10, 2025
Provide safe and appropriate respiratory care for a resident when needed.
Corrected May 11, 2025 · Quality of Life and Care
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Potential for harm · F April 10, 2025
Post nurse staffing information every day.
Corrected May 11, 2025 · Nursing and Physician Services
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Potential for harm · E April 10, 2025
Ensure medication error rates are not 5 percent or greater.
Corrected May 11, 2025 · Pharmacy Service
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Potential for harm · E April 10, 2025
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 May 11, 2025 · Pharmacy Service
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Potential for harm · E April 10, 2025
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected May 11, 2025 · Nutrition and Dietary
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Potential for harm · E April 10, 2025
Provide and implement an infection prevention and control program.
Corrected May 11, 2025 · Infection Control
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Potential for harm · D December 6, 2023
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected January 6, 2024 · Resident Assessment and Care Planning
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Potential for harm · D December 6, 2023
Ensure medication error rates are not 5 percent or greater.
Corrected January 6, 2024 · Pharmacy Service
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Actual harm · G April 15, 2021
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected June 30, 2021 · Quality of Life and Care
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Potential for harm · D April 15, 2021
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected June 30, 2021 · Resident Rights
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Potential for harm · D April 15, 2021
Reasonably accommodate the needs and preferences of each resident.
Corrected June 30, 2021 · Resident Rights
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Potential for harm · D April 15, 2021
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected June 30, 2021 · Quality of Life and Care
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Potential for harm · E April 15, 2021
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected June 30, 2021 · Quality of Life and Care
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Potential for harm · D April 15, 2021
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 June 30, 2021 · Quality of Life and Care
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Potential for harm · D April 15, 2021
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected June 30, 2021 · Quality of Life and Care
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Potential for harm · D April 15, 2021
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 June 30, 2021 · Pharmacy Service
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Potential for harm · E April 15, 2021
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected June 30, 2021 · Nutrition and Dietary
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Potential for harm · D April 15, 2021
Provide and implement an infection prevention and control program.
Corrected June 30, 2021 · Infection Control
Family & resident reviews — a separate signal, never mixed into the score
No approved reviews yet. If your family has experience with this facility, yours could be the review that helps the next family decide.
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 056021 · certified since November 7, 1979. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.