Double Tree Post Acute Care Center
Below-average Medicare ratings — review the inspection history and ask the administrator about recent corrections before visiting.
based on 73 Google reviews
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Quality Concerns Identified
Medicare inspection and quality data reveal areas that families should carefully evaluate before choosing this facility.
- Abuse citation on record
- Low overall rating (2/5 stars)
Below average in CA · Meets national RN staffing standard · Above recommended total nurse staffing · Worst in BVHC, LLC chain · $10,842 in fines · Abuse citation
What this means for your family
This facility offers excellent physical therapy and many nursing staff members are noted for being exceptionally kind. However, families should be extremely vigilant about communication with management and closely monitor the resident's nutrition and the security of their personal belongings.
Google Reviews
Google Reviews
73 reviews on Google“Families often praise the facility for its compassionate nursing staff and effective physical therapy team, particularly during rehabilitation. However, there are significant, recurring reports of poor communication from management, issues with lost personal property, and concerns regarding food quality and facility odors.”
Quality Themes
Tap a score for detailsStrengths
- Compassionate and hardworking nursing staff
- Effective physical and occupational therapy
- Clean and well-lit therapy areas
- Kind and professional social services team
Concerns
- Poor communication from management and doctors (mentioned by 4 reviewers)
- Loss of personal belongings and property (mentioned by 2 reviewers)
- Inconsistent food quality and nutrition (mentioned by 3 reviewers)
- Facility cleanliness and unpleasant odors (mentioned by 2 reviewers)
Rating Trends
Tap a year to see what changed
Distribution · 76 analyzed
How They Respond to Reviews
This facility rarely responds to reviews.
Questions for Your Tour
- 1We've heard wonderful things about the compassion of your nursing staff and the effectiveness of your therapy team; how do the nurses and therapists work together to coordinate a resident's care plan?
- 2Since we want to ensure our loved one stays well-nourished, could you tell us more about the daily meal service and how you ensure consistent food quality and nutrition?
- 3How does the management team ensure that families are kept informed and updated regarding any changes in a resident's medical status or care needs?
- 4What specific steps does the facility take to ensure that residents' personal belongings are kept safe and organized within their rooms?
- 5Can you describe the daily activity schedule and how the social services team helps residents engage with the community and participate in group events?
- 6In the event of a medical emergency after hours, what is the protocol for notifying the family and coordinating with doctors?
Personalized based on this facility's data
Key Review Excerpts
“The staff are amazing with him, ensuring he eats, is changed when necessary, and they treat him kindly with dignity & respect.”
“The CNAs, Nurses and other staff are amazing. Me Teresa is awesome. I love the way all staffing interacts with my brother Chaka.”
“The facility is clean, wide halls, and well lit. The therapy room is impressive, it is big and spacious - awesome therapy staff, and all staff at Double Tree Post Acute.”
Staffing
Staffing Hours
per resident/day · Medicare 2026This facility meets the national staffing benchmarks. Higher staffing is linked to fewer falls and better day-to-day care.
Quality Measures
Quality Measures
Resident outcomes compared with national, state, and local averages · 17 measures
14
measures
1
measures
2
measures
Residents on anti-anxiety or sleep medication
Residents whose bladder or bowel control got worse
Residents whose walking got worse
Residents with depression symptoms
Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.
Residents needing more daily help over time
Residents vaccinated for pneumonia
Short-stay residents vaccinated for the flu
Short-stay residents vaccinated for pneumonia
Short-stay residents newly given antipsychotics
US average from Medicare published data
Inspection History
Medicare Inspection History
3-year lookback · Medicare 2026
This facility has a concerning pattern of repeated deficiencies, with families filing at least 14 complaints that triggered federal investigations. Medication management problems persist across multiple surveys, with repeated issues around medication errors and pharmaceutical services appearing in 2021, 2023, and 2024. The facility also struggles with protection from abuse and neglect, with several complaint-driven violations, and food safety concerns that have recurred over time. While deficiencies appear to be corrected when cited, the repeated nature of problems in core care areas suggests ongoing challenges.
Jan 23, 2026Routine21
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Smoke Deficiencies
Have approved installation, maintenance and testing program for fire alarm systems.
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Nutrition and Dietary Deficiencies
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Gas, Vacuum, and Electrical Systems Deficiencies
Ensure proper usage of power strips and extension cords.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Resident Assessment and Care Planning Deficiencies
Ensure services provided by the nursing facility meet professional standards of quality.
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies
Provide enough food/fluids to maintain a resident's health.
Quality of Life and Care Deficiencies
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.
Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
Pharmacy Service Deficiencies
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.
Nutrition and Dietary Deficiencies
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Construction Deficiencies
Use approved construction type or materials.
Egress Deficiencies
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Egress Deficiencies
Install emergency lighting that can last at least 1 1/2 hours.
Smoke Deficiencies
Provide properly protected cooking facilities.
Smoke Deficiencies
Properly select, install, inspect, or maintain portable fire extinguishes.
Miscellaneous Deficiencies
Provide properly sized and located linen or trash receptacles.
Dec 22, 2025Complaint1
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Jul 9, 2025Complaint2
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Oct 24, 2024Complaint1
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Oct 3, 2024Routine18
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies
Ensure medication error rates are not 5 percent or greater.
Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
Pharmacy Service Deficiencies
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.
Environmental Deficiencies
Keep all essential equipment working safely.
Gas, Vacuum, and Electrical Systems Deficiencies
Ensure proper usage of power strips and extension cords.
Nutrition and Dietary Deficiencies
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Construction Deficiencies
Use approved construction type or materials.
Egress Deficiencies
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Smoke Deficiencies
Install corridor and hallway doors that block smoke.
Emergency Preparedness Deficiencies
Develop and maintain an Emergency Preparedness Program (EP).
Emergency Preparedness Deficiencies
Develop Emergency Preparedness policies and procedures.
Emergency Preparedness Deficiencies
Develop a communication plan.
Emergency Preparedness Deficiencies
List the names and contact information of those in the facility.
Emergency Preparedness Deficiencies
Establish emergency prep training and testing.
Emergency Preparedness Deficiencies
Conduct testing and exercise requirements.
Miscellaneous Deficiencies
Have simulated fire drills held at unexpected times.
Apr 17, 2024Complaint2
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Federal Penalties
Fine
Oct 3, 2024
$10,842
Ownership & Operations
Who Operates This Facility
Double Tree Post Acute Care Center
for profit
Chain Affiliation
Bvhc, LLC
12 facilities nationwide
Chain avg rating: 3.3/5 · Rank 11 of 12 (Worst)
Ownership & Management
Key personnel
Contact
Get in Touch
Contact this facility directly and verify the details that matter most to your family.
References & Resources
Medicare Care Compare
Official Medicare quality ratings, inspections & staffing data
Google Maps
Photos, directions & neighborhood info
Google Reviews
73 reviews from families & visitors
Official Website
Visit doubletreepa.com
Medicare data downloads
Original nursing home datasets
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