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 Delta View Post Acute during CMS and state inspections, most recent first.
The facility failed to prevent physical abuse when two residents were left unsupervised in an activity room and one resident, with a history of cerebral infarct, struck another resident with a cognitive communication deficit on the back of the head twice. The assigned activity assistant left the room for about ten minutes with no other staff present, during which the incident occurred. An LVN later assessed the injured resident and noted a visible swollen bump and redness on the head. The DON reported that video confirmed the hitting, and the facility’s investigation identified one resident as the perpetrator and the other as the victim, contrary to the facility’s abuse prevention policy that requires residents be free from physical abuse.
A resident with dementia and documented impaired vision had an active physician order for an eye health and vision consult and a care plan intervention to arrange an eye care practitioner consultation, but no optometry appointment or exam was ever documented during the entire stay. The resident’s responsible party reported the resident had not had an eye exam and could not see with their glasses, and the ADON confirmed there was no record of any eye exam. The resident’s prescription glasses were found in a bedside drawer, and the DON acknowledged the resident should have had an optometry appointment. This occurred despite facility policy requiring social services and nursing to arrange ordered medical referrals.
The facility failed to implement an effective infection prevention and control program during an RSV outbreak, including proper isolation, monitoring, and reporting. A resident with COPD and pneumonia who tested RSV-positive in the hospital was readmitted and placed in a shared room without transmission-based precautions because the admitting nurse did not fully review the hospital discharge summary and the RSV result was not recognized until later. Another resident with cerebral infarction and Alzheimer’s disease who tested RSV-positive had no documented assessments, monitoring, progress notes, or care plan interventions related to RSV, and there was no evidence of physician or responsible party notification. The facility’s RSV line list omitted at least one RSV-positive resident, and there was no documented communication with public health authorities despite multiple confirmed RSV cases, contrary to facility policies requiring surveillance, contact precautions, outbreak management, and reporting.
A resident's legal representative did not receive requested medical and billing records until 22 working days after submitting a written request. The facility's process involved legal review and subsequent release by the DMR, but the records were not provided within the expected timeframe.
A resident's representative requested daily nurse staffing data for an 18-month period, but the facility only released medical, billing, and therapy records. The request for staffing data was forwarded to the Administrator and legal team, but was not processed or fulfilled, as the Administrator was unaware of the requirement to release such information. This resulted in the representative not receiving the requested nurse staffing data.
A resident's legal representative submitted a written request for the facility's required Policies and Procedures, but the request was not fulfilled. The Director of Medical Records forwarded the request to the Administrator and legal team, but no action was taken to provide the documents, and the Administrator was unaware of the requirement to release them outside of a court order. This was not in accordance with the facility's own policy for handling such requests.
Surveyors identified that three residents had inaccurate MDS assessments, including errors in coding PASRR Level II status, functional limitations, discharge dates, and medication administration. These inaccuracies were confirmed through record review, staff interviews, and direct observation, with staff acknowledging mistakes and lack of proper auditing.
A resident with non-Alzheimer's dementia who was able to communicate reported ongoing gum pain and eating discomfort. Although an LVN was aware of the issue and a dentist had provided an order for oral gel, there was no care plan developed to address the resident's gum pain. The DON confirmed the absence of a care plan for this concern.
Two residents did not receive appropriate care: one was given an improperly sized hand roll for a contracture, causing frustration and difficulty, while another experienced swelling, discoloration, and pain in both feet that went unaddressed for at least two days, with no documentation or timely assessment by nursing staff.
A resident with hypertension did not receive prescribed lisinopril due to the medication being unavailable, with nursing staff unable to locate it or ensure timely re-ordering. Additionally, an IV drug emergency kit was found opened without accurate documentation of medication removal or timely replacement, contrary to facility policy.
Surveyors found that two residents experienced medication errors, including administration of the wrong multivitamin, crushing of an extended-release blood pressure medication, and a missed dose of lisinopril due to unavailability. These events resulted in a medication error rate above five percent, in violation of facility policy and physician orders.
Surveyors found that food waste trash was not disposed of in a sanitary manner when the outside trash container behind the kitchen was overflowing and its lid was left open. The DM confirmed the trash was food waste, and a cook acknowledged that the lid should be closed at all times, as required by facility policy.
Staff documented the administration of a lidocaine patch in the E-MAR before it was actually given to a resident, and a social services assistant created and backdated multiple discharge planning notes for another resident, resulting in medical records that did not accurately reflect the care provided.
Three residents experienced lapses in infection control, including urinary drainage bags placed on the floor and a tube feeding pole with dried formula residue. Staff interviews confirmed awareness of proper procedures, and facility policies required keeping catheter bags off the floor and cleaning equipment daily.
A resident with cellulitis received a lidocaine 5% patch that was not removed according to the physician's order, resulting in the patch remaining on for longer than the prescribed 12-hour period. A nurse confirmed the patch should have been removed the previous evening, but it was still in place the following morning, leading to excessive lidocaine exposure.
A resident with mild cognitive impairment and muscle weakness was served a meal while reclined in a wheelchair, despite requesting to be seated upright. An activity aide provided the meal tray without repositioning the resident, resulting in the resident eating in an improper position until nursing staff later intervened.
The facility did not provide at least 80 sq. ft. per resident in several shared rooms, as confirmed by room measurements and record review. Although staff and residents reported being able to manage within the available space and no complaints or negative outcomes were noted, the rooms did not meet regulatory size requirements.
Failure to Supervise Residents Resulting in Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse when two residents were left unsupervised in the activity room and one resident struck the other. Resident 1, admitted in 2025 with a diagnosis of cognitive communication deficit, was in the activity room with Resident 2, who was admitted in 2024 with a diagnosis of other cerebral infarct. Activity Assistant 1, who was assigned to the activity room on the day of the incident, left the residents alone in the room for about ten minutes with no other staff present. During this period without staff supervision, Resident 2 tapped Resident 1 on the back of the head two times because Resident 1 would not stop backing up into them. Following the altercation, LVN 1 assessed Resident 1 and observed swelling and redness on Resident 1’s head, documented as a visible swelling bump in the nurse’s note, which stated the resident had been involved in a verbal altercation and sustained a minor injury after bumping their head. Resident 2 confirmed that there were no staff in the activity room for about ten minutes and stated that staff could have intervened if they had been present. The DON reported that video of the incident showed Resident 2 hitting Resident 1 in the activity room and acknowledged that staff should have been present in the activity room during the altercation. The facility’s investigation summary concluded there was thorough evidence of Resident 2, identified as the perpetrator, hitting Resident 1, identified as the victim, in violation of the facility’s abuse prevention policy, which states residents have the right to be free from physical abuse.
Failure to Arrange Timely Optometry Services for Resident With Impaired Vision
Penalty
Summary
The facility failed to assist a resident with impaired vision in obtaining timely optometry care despite documented need and physician orders. The resident, admitted in 2020 with dementia and documented impaired vision on the MDS dated 3/15/20, had corrective lenses and an order dated 3/5/20 for an eye health and vision consult with follow-up treatment as indicated. The resident’s care plan dated 11/11/22 identified impaired visual function and included an intervention to arrange consultation with an eye care practitioner as required, with a goal for the resident to maintain optimal quality of life within the limitations of visual function. During interviews, the resident’s responsible party reported that the resident had not had an eye exam and could not see with their glasses. The ADON confirmed there was no documentation or proof that the resident had an eye exam during their entire stay. Observation showed the resident’s prescription glasses stored in the bedside drawer rather than in use. The DON stated the resident should have had an optometry appointment during their stay and that this was important for safety. The facility’s policy on social services referrals required that referrals for medical services be based on physician evaluation or resident need and that social services collaborate with nursing or other disciplines to arrange ordered services, but this process was not carried out for the resident’s ordered eye care consult.
Failure to Implement Effective RSV Infection Control, Monitoring, and Reporting
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain an effective infection prevention and control program, including surveillance, during an RSV outbreak affecting multiple residents. Resident 1, admitted with diagnoses including pneumonia and COPD, tested positive for RSV in the hospital on 1/19/26 and was readmitted to the facility on 1/22/26. Upon readmission, Resident 1 was not placed on isolation precautions and was cohorted in a shared bedroom with two other residents during the RSV isolation period. The Infection Preventionist (IP) and DON stated the facility was unaware of the RSV diagnosis at the time of readmission because the hospital discharge documents were not uploaded into the EHR until 2/2/26, and the admitting nurse did not identify the RSV result, relying mainly on the nurse-to-nurse report and physician orders rather than reviewing the full discharge summary. The facility also failed to assess and monitor RSV-positive residents during the isolation period. Resident 2, admitted with cerebral infarction and Alzheimer’s disease, tested positive for RSV on 1/29/26. Review of Resident 2’s EHR showed no documentation of change in condition assessments, monitoring, progress notes, or care plan interventions related to RSV management. The IP confirmed there was no documentation that the physician or responsible party were notified after Resident 2’s positive RSV test, and that Resident 2 was not assessed or monitored to evaluate progression of symptoms or response to infection. For Resident 1, the IP stated the resident was not monitored for RSV after readmission, and LVN 1 confirmed Resident 1 was not placed in isolation upon the last two readmissions. The facility’s infection surveillance and reporting processes were also deficient. A facility-provided RSV record showed five residents tested positive for RSV within a 30-day period, but Resident 1, who was RSV-positive on 1/19/26, was not included on the RSV line list. The IP stated that more than two confirmed RSV cases should have been reported to public health authorities and acknowledged there was no formal or verifiable documented communication with local or state health departments regarding the RSV outbreak, recommendations, or guidance. The DON confirmed miscommunication among staff regarding RSV cases and acknowledged that nursing staff did not document Resident 2’s RSV status in the medical record. These practices were inconsistent with the facility’s written policies on RSV prevention, outbreak of communicable diseases, and infection prevention and control, which required monitoring for signs and symptoms, initiation of transmission-based precautions, surveillance and reporting of infectious diseases, and communication with public health authorities.
Delayed Release of Medical Records to Legal Representative
Penalty
Summary
The facility failed to provide a copy of requested medical records to the legal representative of a resident within the required timeframe. The legal representative submitted a written request for the resident's medical records, billing records, photography, charts, writings, admission agreements, utilization review committee records, and x-rays. The facility's records indicated that the request was received, but the records were not released until 22 working days after the request was made. The resident in question had been admitted to the facility and was later discharged to an acute care hospital. During interviews, the Director of Medical Records (DMR) stated that she believed the facility had 30 days to release medical records based on her training, though she could not recall the specifics of the training. The facility Administrator explained that medical record requests were first sent to the legal department for review, which typically took up to 24 hours, and that records should be released within 48 hours after the request. The facility's policy indicated that records may be released upon legal approval in accordance with the minimum necessary standard.
Failure to Provide Requested Nurse Staffing Data to Resident's Representative
Penalty
Summary
The facility failed to process a record request for nurse staffing data when a resident's representative requested this information. The request, dated 5/28/25, specifically asked for daily posted nurse staff data for each day of the 18 months prior to the request. Although the facility's log showed that the request was received, only the resident's medical records, billing, and therapy notes were released on 6/26/25. The Director of Medical Records stated that the request for nurse staffing data was forwarded to the facility's Administrator and legal team, but she did not process the request herself, as she was not responsible for releasing nurse staffing data. During an interview, the Administrator stated he was unaware of any requirement to release nurse staffing data to the public unless requested by a court, and confirmed that no staffing or policy information had been released to the requester. The facility's policy indicated that all requests for medical records, whether verbal or written, should be immediately forwarded to the Medical Records department or designated staff, but did not specify procedures for nurse staffing data requests. As a result, the requested nurse staffing data was not provided to the resident's representative.
Failure to Provide Policies and Procedures to Resident's Legal Representative
Penalty
Summary
The facility failed to comply with state regulations by not providing copies of its Policies and Procedures (P&P), as required by Title 22 California Code of Regulations section 72523, to the legal representative of a resident upon written request. The resident had been admitted and later discharged to an acute care hospital. A review of the admission record and the release of record log confirmed that the legal representative submitted a written request for all required administrative, management, personnel, and patient care policies. The Director of Medical Records (DMR) acknowledged receipt of the request and stated it was forwarded to the facility's Administrator (ADM) and legal team, but did not process the request for policy information. During interviews, the ADM stated unawareness of any requirement to release the facility's P&P to the public unless the request came from a court. The facility's own Medical Record Request Policy indicated that all requests for medical records, whether verbal or written, must be immediately forwarded to the Medical Records department or designated staff, including requests from residents or their personal representatives. Despite this policy, the facility did not release the requested P&P to the resident's legal representative.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for three sampled residents, resulting in discrepancies between documented assessments and residents' actual clinical conditions. For one resident with diagnoses including bipolar disorder, schizophrenia, and a right foot contracture, the MDS was not coded accurately in Section A to reflect a positive Preadmission Screening and Resident Review (PASRR) Level II evaluation for mental illness. Additionally, Section GG of the same resident's MDS incorrectly indicated impairment in both lower extremities, despite observation and staff interview confirming limitation only in the right foot. Another resident, admitted with myeloid leukemia and discharged against medical advice after one day, had an inaccurately coded discharge assessment. The MDS discharge date did not match the actual date the resident left the facility, as confirmed by the MDS coordinator, who acknowledged the error in the assessment reference date. A third resident, with a history of stroke, atrial fibrillation, and major depressive disorder, had inaccuracies in MDS Section N regarding medication administration. The MDS assessment failed to accurately reflect the administration of anticoagulant, anticonvulsant, and antidepressant medications, and incorrectly indicated the use of antibiotics during the observation period. Staff interviews revealed that the MDS coordinator responsible for the assessment was new to the role and that no audit of the assessment was conducted by supervisory staff.
Failure to Develop Care Plan for Resident's Gum Pain
Penalty
Summary
A deficiency was identified when the facility failed to develop and implement a care plan addressing a resident's gum pain and discomfort, as required by its Care Planning - Interdisciplinary Team policy. The resident, who had a diagnosis of non-Alzheimer's dementia and was able to communicate her needs, reported ongoing gum pain and discomfort with eating, and stated she had not seen a dentist. Although a licensed vocational nurse confirmed awareness of the resident's painful gum and noted that the resident had been seen by a dentist with an order for oral gel as needed, there was no care plan in place to address the gum pain. The director of nursing also confirmed that no care plan existed for this issue after reviewing the resident's records.
Failure to Provide Proper Supportive Devices and Timely Assessment of Circulatory Issues
Penalty
Summary
Two deficiencies were identified involving the care of two residents. One resident with a history of stroke and right-sided hemiplegia had a right hand contracture and was provided with a hand roll that was too large and had a loose elastic band. The resident reported that the hand roll frequently fell out of place and was difficult to keep positioned correctly, leading to frustration and emotional distress. Staff interviews confirmed that the hand roll was not the correct size, and the rehabilitation department was aware of the issue but had not yet provided an appropriately sized device. Another resident with diagnoses including peripheral vascular disease, peripheral arterial disease, renal insufficiency, and end-stage renal disease experienced swelling, black/bluish discoloration, and pain in both feet. The resident reported these symptoms, and observations confirmed the presence of discoloration and pain. Nursing staff assigned to the resident had not assessed the feet until at least two days after the symptoms began, and there was no documentation of the skin issues in the resident's electronic health record during the relevant period. These deficiencies were based on direct observations, resident interviews, and record reviews, which showed that the facility failed to provide appropriate treatment and care according to physician orders, resident preferences, and goals. The lack of timely and suitable interventions for both residents resulted in unaddressed discomfort and risk of further complications.
Failure to Provide Ordered Medication and Maintain Emergency IV Kit Documentation
Penalty
Summary
The facility failed to provide routine medication as ordered and did not ensure pharmaceutical services were delivered in accordance with prescriber orders and facility policy. Specifically, a resident admitted with essential hypertension had a physician's order for daily lisinopril, but the medication was not available for administration on multiple occasions. Nursing staff were unable to locate the medication in the medication cart and confirmed that the resident had not received the prescribed doses. Documentation in the Medication Administration Record showed missed doses, and staff reported contacting the pharmacy to re-order the medication, but the medication remained unavailable for at least two consecutive days. Additionally, the facility did not maintain accurate records or timely replacement of intravenous (IV) drug emergency kits. One of two IV drug emergency kits was found opened, but the associated utilization log did not accurately reflect what medication was removed or the date of removal. Staff were uncertain about the accuracy of the log, and the required documentation on the IV Drug Emergency Kit Use Form was incomplete. The facility's policy required that any medication removed from the emergency kit be documented and replaced promptly, but this was not done, potentially affecting the availability of emergency IV medications for all residents.
Medication Error Rate Exceeds Five Percent Due to Administration and Availability Failures
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required, resulting in a calculated error rate of 10.71% during the observed medication administration. For one resident with chronic obstructive pulmonary disease (COPD), a nurse administered a multivitamin with minerals instead of the prescribed multivitamin, contrary to the physician's order and the facility's medication administration policy. This error was directly observed during a medication pass and confirmed through review of the resident's orders and medication administration record. For another resident admitted with essential hypertension, a registered nurse crushed and administered an extended-release (ER) blood pressure medication (toprol xl ER), despite manufacturer instructions and the medication label stating it should not be crushed. The nurse acknowledged during interview that crushing the ER medication was inappropriate and could have adverse effects. Review of the medication label and manufacturer's specifications confirmed the medication should not be crushed or chewed. Additionally, the same resident did not receive a scheduled dose of lisinopril, another blood pressure medication, because the medication was not available in the facility. Multiple staff confirmed the medication was missing and had not been delivered by the pharmacy, resulting in the resident missing at least one scheduled dose. Facility policy requires medications to be administered as prescribed and within a specified timeframe, which was not followed in this instance.
Improper Disposal of Food Waste Trash
Penalty
Summary
Surveyors observed that the facility failed to dispose of food waste trash and garbage in a sanitary manner. During an observation at the dumpster area behind the kitchen, the trash container was found overflowing with bags of trash, and the lid was not closed. The Dietary Manager confirmed that the trash consisted of food waste. In a subsequent interview, a cook stated that food waste is disposed of into the trash can after each shift and acknowledged that the trash container lid is expected to be closed at all times. Review of the facility's sanitation and infection control policy indicated that outside trash compactors require a protective cover to prevent pests, animals, or debris from entering, and that lids should remain closed.
Inaccurate Medical Record Documentation and Backdating of Progress Notes
Penalty
Summary
The facility failed to maintain accurate and timely medical records for two residents. For one resident with a diagnosis of cellulitis of the left lower limb, a registered nurse documented the administration of a lidocaine patch in the Electronic Medication Administration Record (E-MAR) before actually administering the medication. The nurse stated that she documented the administration early to prevent the E-MAR from indicating a late administration, even though the medication was given at a later time as requested by the resident. Facility policy required that medication administration be documented immediately after it is given. In a separate incident, a social services assistant created and backdated multiple discharge planning progress notes for another resident, entering them on a single day but assigning dates spanning several months prior. The assistant admitted to routinely backdating notes and stated that this practice had not previously been questioned. Facility policy specified that late entries should be dated at the time of entry and clearly noted as late entries. These actions resulted in medical records that did not accurately reflect the timing and content of care provided.
Failure to Maintain Infection Control for Catheter and Feeding Equipment
Penalty
Summary
The facility failed to maintain a safe and sanitary environment to prevent the transmission of infections for three residents. In one instance, a resident with an indwelling suprapubic catheter was observed with their urinary drainage bag lying on the floor. The resident reported placing the bag on the floor for ease of mobility, as staff response to call lights was delayed, and staff confirmed the resident preferred the bag on the floor. The care plan for this resident indicated the need to keep the catheter below the bladder, and facility policy required catheter tubing and drainage bags to be kept off the floor. Another resident, newly admitted with multiple serious diagnoses including acute kidney failure and urinary retention, was observed with their urinary catheter drainage bag touching the floor and lacking a privacy cover. The resident was in a multi-bed room, and staff interviews confirmed the bag should not be on the floor due to infection control concerns. Facility policy also specified that catheter tubing and drainage bags must be kept off the floor to prevent complications such as urinary tract infections. A third resident, who was nonverbal and severely cognitively impaired, was observed with a tube feeding pole that had dried brown matter, identified as feeding formula, stuck to it. The primary nurse acknowledged the residue and stated the pole should be cleaned as needed. The infection preventionist confirmed that a dirty pole could increase infection risk, especially for a resident with a surgical opening, and stated that feeding poles should be cleaned daily and as needed. Facility policy required daily and as-needed cleaning and disinfection of durable medical equipment.
Failure to Remove Lidocaine Patch as Ordered
Penalty
Summary
A resident with a diagnosis of cellulitis of the left lower limb was admitted to the facility and had a physician's order for a lidocaine 5% patch to be applied daily at 9:00 a.m. and removed at 9:00 p.m. During a medication administration observation, a registered nurse removed a lidocaine patch from the resident's back that had been applied the previous morning, as indicated by the nurse's initials and the date written on the patch. The nurse confirmed that the patch should have been removed the previous evening according to the physician's order and the facility's medication administration policy, which requires medications to be administered in accordance with orders and specified time frames. Review of the resident's medication administration record confirmed the patch was applied in the morning but not removed at the scheduled time. Manufacturer's guidelines for the lidocaine patch specify that it should be worn for no more than 12 hours within a 24-hour period, as excessive dosing can result in increased absorption and high blood concentrations. The failure to remove the patch as ordered resulted in the resident receiving an excessive dose of lidocaine in a 24-hour period.
Failure to Properly Position Resident Before Meal Service
Penalty
Summary
A deficiency occurred when a resident with mild cognitive impairment, muscle wasting, and a need for assistance with personal care and positioning was not properly positioned in the dining room prior to eating lunch. The resident was observed lying in a high-rise wheelchair with the head of the wheelchair at about a 45-degree angle. Despite the resident's request to be seated upright before receiving the meal tray, the activity aide served the lunch tray without adjusting the resident's position. As a result, the resident ate lunch while reclined, causing food to drop onto his chest area. The activity aide stated she did not reposition the resident because she was not a nurse and did not want to return the lunch tray, so she left the tray in front of the resident. The nurses later repositioned the resident, allowing him to finish his lunch. The Director of Nursing confirmed that the facility's expectation was for both activity and nursing staff to assist with resident positioning before serving meal trays.
Failure to Meet Minimum Square Footage Requirements in Multiple Resident Rooms
Penalty
Summary
The facility failed to provide the required minimum of 80 square feet per resident in multiple resident bedrooms, as mandated by regulations. During observations, interviews, and a review of the Client Accommodations Analysis, it was found that numerous rooms with two or three beds each did not meet the 80 square feet per resident requirement. Specific measurements taken by maintenance staff confirmed that several rooms had as little as 70.26 to 79.76 square feet per resident. Despite this, observations showed that there was sufficient space for care provision, no heavy equipment obstructed movement, and residents had adequate personal space and privacy. Interviews with residents and staff indicated that, while some staff found the rooms somewhat small, they were able to manage care tasks without significant difficulty. Residents did not report any complaints regarding insufficient space for their belongings or movement. No negative outcomes or safety concerns were attributed to the decreased space in the identified rooms during the survey period.
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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 Antioch
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lone Tree Post Acute | 3.1 mi | — | 2 | 0 |
| Diamond Ridge Healthcare Center | 3.3 mi | — | 3 | 0 |
| Pittsburg Skilled Nursing Center | 3.9 mi | — | 0 | 0 |
| Stonebrook Post Acute | 9.6 mi | — | 4 | 0 |
| Diablo Valley Post Acute | 11.2 mi | — | 11 | 0 |
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