Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Greenridge Post Acute during CMS and state inspections, most recent first.
Delayed pain medication administration: A resident admitted with sickle cell disease and acute chest syndrome had severe pain with a documented pain score of 10, but hydromorphone was not given until nearly 2 1/2 hours later. Nursing notes described difficulty obtaining the order needed to access the E-kit, delays in getting the medication, and the resident requesting IV pain medication and transfer to the ED. The DON stated it was not acceptable for a resident with a pain score of 10 to wait that long for pain medication.
Delay in Accessing Emergency Pain Medication: A resident admitted with sickle cell disease and severe pain had orders for hydromorphone, but staff had difficulty obtaining the pharmacy code needed to access the E-kit because the resident’s medication supply had not yet arrived and there were problems securing a controlled-med order. The resident reported pain rated 10/10, waited almost 2 1/2 hours for pain medication to become available, received oral hydromorphone late, and requested transfer to the ED for IV pain relief.
A resident with multiple medical conditions experienced a significant drop in blood pressure and oxygen saturation, which went unaddressed for over 12 hours by an LVN. The resident was later transferred to a hospital with altered mental status and hyponatremia. Facility staff acknowledged the need for reassessment and documentation, which were not performed as per policy.
Delayed Pain Medication Administration
Penalty
Summary
The facility failed to ensure pain was controlled for one sampled resident who was admitted with HB-SS with acute chest syndrome and had intact cognition with a BIMS score of 14. The resident had physician orders for hydromorphone 2 mg tablets for severe pain, moderate pain, and pain, and the facility kept hydromorphone in an emergency medication kit (E-kit) on the medication carts. The facility’s process required the licensed nurse to call the pharmacy for a code before removing the medication from the E-kit when the resident’s ordered medication was not yet available from the pharmacy. On the evening of the resident’s admission, nursing documentation showed the resident complained of pain with a score of 10 at 9:19 p.m. The record also showed that staff had difficulty obtaining an order needed to get the pharmacy code to open the E-kit, and notes documented delays in obtaining the pain medication. The resident’s chart indicated the resident was in pain, that hospital and on-call providers were contacted without success, and that the resident stated oral medication would not help and requested IV pain medication. Before leaving, the resident took oral Dilaudid, and 911 was called to transport the resident to the emergency department. The MAR showed hydromorphone 2 mg was administered by mouth at 11:45 p.m., nearly 2 1/2 hours after the documented pain score of 10. RN 1 stated the notes showed a delay in giving pain medication, and the DON stated that a resident with serious pain needed to be treated right away and that it was not acceptable for a resident with a pain score of 10 to wait almost 2 1/2 hours for pain medication to become available. The facility’s pain management policy stated pain management is based on a facility-wide commitment to resident comfort and is the process of alleviating pain to a level acceptable to the resident.
Delay in Accessing Emergency Pain Medication
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident with HB-SS with acute chest syndrome when emergency pain medication was not obtained in a timely manner. The resident was admitted with orders for hydromorphone HCL 2 mg tablets for severe pain, moderate pain, and pain, and had a BIMS score of 14, indicating intact cognitive status. Facility staff described a process in which a licensed nurse had to call the pharmacy for a code before removing medication from the emergency kit when the resident’s ordered medication was not yet available from the pharmacy. On the evening of admission, nursing documentation showed the resident reported pain rated 10 out of 10 at 2119. Notes further documented that pain medication was delayed because of treatment/order issues, the hospital and NP were contacted without success, and there was a problem obtaining an order for controlled medication. Staff coordinated with the pharmacy to obtain a code for the emergency kit, but the resident stated oral medication would not help and requested transfer to the ED for IV pain medication. The resident received oral hydromorphone at 2345 and was transported by 911 to the hospital. Record review showed multiple hydromorphone orders entered the same day, including phone, verbal, prescriber written, and prescriber entered orders, which staff said reflected attempts to obtain an order needed to get the pharmacy code for the emergency kit. The RN stated the chart showed difficulty obtaining the order necessary to access the emergency medication, and the DON stated it was not acceptable for a resident with a pain score of 10 to wait almost 2 1/2 hours for pain medication to become available. The facility policy stated pain management is based on a facility-wide commitment to resident comfort and that residents will be admitted only if their medical and nursing needs can be met.
Failure to Reassess and Document Vital Signs
Penalty
Summary
The facility failed to provide necessary care and services to a resident, identified as Resident 1, in accordance with professional standards of practice. This deficiency occurred when a Licensed Vocational Nurse (LVN) did not reassess or document the resident's vital signs after a significant change in blood pressure and oxygen saturation was noted. These changes persisted for more than 12 hours without appropriate follow-up, placing the resident at risk for delayed medical intervention. Resident 1, who had medical diagnoses including multiple fractures of the pelvis, urinary tract infection, and atrial fibrillation, was admitted to the facility in November 2022. On November 22, 2022, the resident's blood pressure was recorded as 97/58 mm Hg, and oxygen saturation was at 90%, both lower than her baseline. Despite these abnormal readings, the LVN did not reassess the vital signs or document any further observations. The next set of vital signs was not recorded until the following morning, more than 15 hours later. The resident's condition deteriorated, leading to confusion and an eventual transfer to an acute care hospital on November 23, 2022, where she was diagnosed with altered mental status and hyponatremia. Interviews with facility staff, including a Registered Nurse (RN) and the Director of Nursing (DON), confirmed that the vital signs should have been rechecked and documented, and the physician notified if abnormalities persisted. The facility's policy on changes in a resident's condition also emphasized the need for detailed observations and documentation, which were not followed in this case.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near El Sobrante
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| San Pablo Healthcare & Wellness Center | 1.7 mi | ★★★★★ | 5 | 0 |
| Creekside Healthcare Center | 2.2 mi | ★★★★★ | 2 | 0 |
| Vale Healthcare Center | 2.2 mi | ★★★★★ | 6 | 0 |
| Richmond Post Acute Care | 2.9 mi | ★★★★★ | 0 | 0 |
| Shields Richmond Nursing Center | 3.7 mi | ★★★★★ | 3 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.