Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Concord Post Acute during CMS and state inspections, most recent first.
The facility failed to prevent physical abuse in two separate incidents involving residents with dementia and agitation. In one case, two residents in a hallway began yelling, and while an LVN attempted redirection, one resident punched the other in the head and was scratched on the neck in return, causing minor injuries to both. In another case, a resident reported that his roommate hit him while he slept, and an LVN observed multiple skin tears and scratches on him and a facial scratch on the roommate, who was pacing angrily and refused assessment. The DON later acknowledged that one involved resident lacked a dementia care plan and stated that such a plan could have prevented the altercation, despite a facility policy stating residents have the right to be free from abuse and neglect.
A resident with Alzheimer’s disease, severe cognitive impairment (BIMS 0/15), and multiple fall risk factors, including unsteady gait with a front wheel walker, incontinence, wandering, and prior falls, had a care plan identifying high fall risk and directing staff to monitor and assist her while ambulating in the patio. Despite this, staff did not supervise the resident while she was on the patio, and she fell, sustaining a cut and bump to the back of the head and requiring transfer to an acute care hospital. The DON acknowledged that the fall could have been avoided if staff had followed the care plan intervention for patio supervision, contrary to the facility’s policy requiring implementation of comprehensive, person-centered care plans.
A resident with Alzheimer’s disease, severe cognitive impairment (BIMS 0/15), a documented history of wandering, and high fall risk was care planned to be monitored and assisted while ambulating in the patio. On the evening of the incident, the assigned CNA last saw the resident after providing incontinent care, and a hallway monitor CNA later observed the resident walking toward another station but did not follow because the resident became agitated when interrupted. The patio door from one station was kept open and its alarm had not been functioning for a long time, and the door lock was not activated until later in the evening, allowing the resident to access the patio unsupervised. The resident was subsequently found on the ground in the patio area with a bump and bleeding on the back of the head and a tipped front‑wheel walker nearby, and was transferred to the hospital for further evaluation.
A facility hired an individual as an RN who used another person's license and had a revoked LVN license. Discrepancies between the individual's identification and the RN license were missed during the background check, and required employment and reference checks were not completed or documented. The facility's policy for verifying licensure and references was not followed, resulting in the employment of an unlicensed nurse.
Failure to Prevent Resident-to-Resident Physical Abuse Involving Dementia and Agitation
Penalty
Summary
The deficiency involves the facility’s failure to protect four residents from physical abuse during two separate resident‑to‑resident altercations. In the first incident, a resident with dementia and behavioral disturbance (Resident 2), who was documented as able to make himself understood and understand others, and another resident with severe cognitive impairment (Resident 3, BIMS score 3/15) engaged in a physical altercation in the hallway between two nursing stations. Staff reported hearing screaming and, upon responding, observed Resident 3 in his wheelchair yelling at Resident 2. While one LVN attempted to redirect Resident 3 back to his room, Resident 2 struck Resident 3 in the head with his fist, and Resident 3 scratched Resident 2 on the left side of the neck with his fingernails, resulting in a one‑inch scratch with minimal bleeding for Resident 2 and a reddened area on the right forehead for Resident 3. In the second incident, two roommates with dementia and agitation (Residents 4 and 5) were involved in a physical altercation in their shared room. Resident 4, who usually understood others and could usually make himself understood, approached an LVN early in the morning visibly upset and reported that his roommate had hit him while he was sleeping. The LVN observed a superficial cut on the top of Resident 4’s head, a small scratch on the right cheek, and scratches on the right hand and left forearm, all with slight bleeding. When staff went to assess Resident 5, they found him out of bed, pacing angrily in the room, and noted a wound on the left side of his face; when the LVN attempted to approach using hand gestures, Resident 5 moved toward the doorway aggressively, gestured for the LVN to leave, and slammed the door, though the LVN was able to observe a scratch on his upper lip. The facility’s Director of Nursing stated that CNAs are updated on resident care plans during shift‑change huddles and that individualized, person‑centered care plans are supposed to be in place for all residents, particularly those with dementia who may experience agitation and aggression. During review of care plan reports for the involved residents, the DON acknowledged that Resident 2 did not have a care plan for dementia. The DON further stated that the altercation between Residents 2 and 3 could have been avoided if Resident 2 had a dementia care plan in effect. The facility’s written policy on resident rights states that residents have the right to be free from abuse, neglect, misappropriation of property, and exploitation, but the events described show that the facility did not prevent physical abuse between residents in these cases.
Failure to Implement Fall Prevention Care Plan for High-Risk Resident
Penalty
Summary
The facility failed to implement a comprehensive, person-centered care plan for one of five sampled residents by not providing the supervision specified in the resident’s fall care plan. The resident had a diagnosis of Alzheimer’s disease and a BIMS score of 0/15, indicating severe cognitive impairment. A fall risk assessment identified the resident as high risk for falls and injury due to unsteady gait with use of a front wheel walker, advanced age, incontinence, distraction, altered perception of surroundings, disorganized speech, restlessness, lethargy, varying mental function, wandering, abusive behavior, and resistance to care, with 1–2 falls in the prior 90 days. The resident’s fall care plan, reviewed on 2/7/25, documented that the resident was at high risk for falls related to confusion, gait/balance problems, incontinence, and unawareness of safety needs, and included an intervention that staff would monitor and assist the resident while ambulating in the patio. Despite this care plan intervention, the facility did not provide supervision to the resident while she was on the facility’s patio. As a result, the resident fell to the ground, sustaining a cut and bump to the back of the head and required transfer to an acute care hospital for further care and evaluation. During interview, the DON stated that the fall could have been avoided if a staff member had been on the patio with the resident as specified in the care plan. The facility’s policy on comprehensive, person-centered care plans required development and implementation of care plans with measurable objectives and timetables to meet residents’ physical, psychosocial, and functional needs, but this was not followed for this resident in relation to patio supervision.
Failure to Supervise High-Risk Wandering Resident in Patio Area
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and a hazard‑free environment for a resident with severe cognitive impairment and a known history of wandering and high fall risk. The resident had Alzheimer’s disease, a BIMS score of 0/15 indicating severe cognitive impairment, and was assessed as high risk for falls and injury due to unsteady gait with a front‑wheel walker, incontinence, confusion, wandering, and behavioral issues. A separate elopement and wandering risk assessment scored the resident at 18, above the threshold indicating risk for wandering or elopement. The resident’s fall care plan, reviewed on 2/7/25, specifically included an intervention that staff would monitor and assist the resident while ambulating in the patio. On the day of the incident, the resident was last seen by the assigned CNA around 6:25 p.m. when incontinent care was provided in the resident’s room; the CNA did not see the resident again until learning of the fall around 7:00 p.m. A hallway monitor CNA observed the resident walking toward another station and, after calling out and seeing the resident briefly look back and then continue walking, did not pursue the resident because the resident became agitated when her walking was interrupted. During this time, the door from Station 4 to the patio area was kept open to allow resident access, and the door lock was not activated until 8:00 p.m., allowing the resident to enter the patio area unsupervised. At approximately 7:00 p.m., another CNA found the resident alone on the ground in the Station 4 patio area, lying on the pavement and holding the back of her head. The responding LVN found the resident awake and alert, lying on the grass with slight bleeding at the back of the head and the front‑wheel walker tipped over nearby. Documentation in the change in condition progress note described a bump on the back of the head with slight bleeding and that the resident kept trying to get up unassisted during the nursing assessment before being assisted to a wheelchair and sent to the hospital. An LVN reported that the patio door was supposed to be alarmed but that the alarm had not worked for a long time and was not repaired until after the fall. The DON stated that primary safeguards for resident safety were hallway monitoring and coded/alarmed doors, and acknowledged that keeping the patio door open and not having staff present on the patio allowed the resident to go outside unsupervised, resulting in an unwitnessed fall.
Failure to Verify Nursing Licensure and Employment References
Penalty
Summary
The facility failed to comply with required employment and licensure verification procedures when it hired an individual who falsely represented themselves as a Registered Nurse (RN). The individual, whose Licensed Vocational Nurse (LVN) license had been revoked in 2020, used another person's RN license with a different spelling of the first name and a missing middle name. Despite discrepancies between the individual's identification and the RN license, the facility's Human Resources (HR) representative did not identify the inconsistency during the background check and verification process, resulting in the individual being hired as an RN. Record reviews revealed that the facility did not complete or document employment and personal reference checks for the individual prior to hiring. The Director of Staff Development (DSD) and HR were responsible for verifying nursing licenses and background checks, but neither confirmed that the license verification matched the applicant's identification. The Director of Nursing (DON) was unaware of the discrepancies until the survey and stated that the facility should have verified the license online and matched it to the applicant's identification. The facility's policy required verification of nursing licenses and contacting previous employers before hiring nursing personnel. However, these procedures were not followed, and the individual was employed without a valid nursing license. The failure to verify licensure and references allowed an unlicensed individual to work as an RN, contrary to facility policy and regulatory requirements.
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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 Concord
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Diablo Valley Post Acute | 1.4 mi | — | 11 | 0 |
| Bayberry Skilled Nursing & Healthcare Center | 1.5 mi | — | 16 | 0 |
| Willow Pass Healthcare Center | 1.8 mi | — | 6 | 0 |
| Shadelands Post Acute | 1.9 mi | — | 0 | 0 |
| Pleasant Hill Post Acute | 2.3 mi | — | 0 | 0 |
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