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 Diablo Valley Post Acute during CMS and state inspections, most recent first.
A resident with morbid obesity, glaucoma, a history of falls, and heart failure experienced multiple falls and assisted-to-floor incidents during transfers with a standing lift, some occurring in the early morning and requiring several staff and a Hoyer lift to return the resident to bed or a wheelchair. An LVN acknowledged leaving after one such incident without documenting it, and progress notes showed a gap in documentation between the fall events and the time the resident was later found unresponsive and pronounced deceased. The ADON confirmed that required fall protocols, including immediate assessment, eInteract charting, 72-hour monitoring notes, and notification of the attending physician and family, were not completed, and that on the dates of the falls neither the physician nor the family was informed, contrary to facility policy on change in condition.
A resident with left-sided weakness and intact cognition repeatedly requested repair of a defective closet door that had visible gaps, overlapped an adjacent door, and interfered with drawer access; the door later detached and fell on the resident’s head and left foot, causing pain, bruising, and swelling of the left ankle. The Maintenance Director confirmed the wrong-size hinges had been used, leaving the door misaligned and requiring it to remain open for access. In addition, staff and residents reported rooms being cold, and spot checks showed several rooms with temperatures as low as 60–68°F, below the required 71–81°F range, despite expectations that thermostats be maintained within regulatory limits.
A resident with morbid obesity, heart failure, a history of falls, and high fall‑risk scores experienced multiple unwitnessed and assisted falls or floor‑level incidents over several days, including events involving a standing lift where the resident’s knees buckled and staff had to use a Hoyer lift to return the resident to bed or a wheelchair. Staff, including CNAs, LVNs, the IP, and nursing leadership, reported that these incidents were not consistently documented as falls, that required post‑fall assessments (vital signs, neuro checks, pain assessments), 72‑hour monitoring, and change‑of‑condition charting were not completed, and that the physician and family were not notified as required by facility fall protocol and care plans. The medical record showed a gap in progress notes before the resident was later found unresponsive and pronounced deceased, and there was no evidence of diagnostic testing or rehab reassessment of transfer methods, despite policy and care plan directives to follow fall protocol, evaluate causes, and ensure proper use of standing and Hoyer lifts.
A deficiency was cited when a CNA placed soiled linen directly on the floor without bagging it and then, while wearing the same gloves, repositioned a resident and touched room surfaces and personal care items before later bagging the linen and trash. The IP reported that facility policy requires all used laundry to be treated as contaminated and bagged at the point of collection, with bags kept at the foot of the bed, and that used linen is not to be placed on the floor because it may contain microorganisms that can be spread via staff shoes. Review of the written policy confirmed that all used laundry must be bagged at the collection point using standard precautions.
Two cognitively intact residents reported being sexually abused by a CNA during personal care. One resident, admitted with a leg fracture and muscle weakness, stated that during an evening brief change the CNA repeatedly wiped her perineal area, went deeper between her labia, and rubbed her clitoris with his finger despite her telling him to stop; she later told multiple staff that the CNA had penetrated her vagina during the diaper change. Another resident with hemiplegia and hemiparesis reported that during a scheduled shower the same CNA rubbed her breast while removing her sweater, attempted to wash her breasts again in the shower, inserted his finger into her anus while cleaning her buttocks, and later squeezed her nipples while drying her; she reported feeling nervous and later disclosed the incident to staff and the Ombudsman. These events occurred despite a written abuse-prevention policy stating residents’ right to be free from sexual abuse by staff.
Two cognitively intact residents alleged sexual abuse by the same CNA during incontinence care and a shower. One resident reported that the CNA repeatedly wiped and penetrated her vaginal area despite only urinary incontinence and told multiple licensed nurses she had been inappropriately touched and did not want him to care for her again. Supervisory staff treated the concern as a care complaint, and staffing records show the CNA continued to work regular shifts with resident contact. During this period, another resident with hemiplegia reported that the same CNA rubbed her breasts, inserted a finger into her anus while washing her buttocks in the shower, and later squeezed her nipples while drying her. The facility’s own abuse policy required immediate reporting, protection of residents, and removal of accused staff from resident contact pending investigation, but the CNA was not removed after the first allegation.
A resident with severe cognitive impairment was not protected from physical abuse by another cognitively impaired resident with documented physical behavioral symptoms toward others. Staff, including an LVN, the DON, and the administrator/abuse coordinator, described the aggressor as easily agitated, frequently upset by disturbances, and known to require redirection and separation from others. Despite this history, an altercation occurred in which the aggressive resident was observed by a CNA swinging a coffee cup toward the other resident’s head, causing a bump with discoloration on the forehead and a cut on the upper lip, contrary to the facility’s abuse-prevention policy.
A resident with a history of cardiac issues experienced prolonged chest and abdominal pain without timely assessment, monitoring, or administration of physician-ordered nitroglycerin by an unlicensed nurse using another individual's RN license. Despite clear orders and symptoms consistent with a heart attack, appropriate interventions and emergency services were delayed, and the resident was only transferred to the hospital after several hours, where they later expired.
The facility failed to maintain complete and accurate records for controlled medications, with multiple instances where CDRs did not match MARs, and required documentation such as shipping manifests and destruction logs were missing or incomplete. An unlicensed staff member, using another individual's RN license, was found to have administered and documented narcotics, leading to further discrepancies. Staff interviews confirmed that these failures resulted in unaccounted doses and incomplete reconciliation of controlled substances.
A resident with a history of osteomyelitis accidentally ingested Dakin's solution, a wound cleansing agent, after a nurse mistakenly provided it as water during medication administration. The error occurred when one nurse prepared the medication and another administered it, contrary to facility policy requiring safe and direct administration by the preparer.
A registered nurse did not use required PPE while providing high-contact care to a resident with a pressure ulcer in a room designated for Enhanced Barrier Precautions (EBP). The nurse performed tasks such as checking vital signs and changing a Lidocaine patch without donning gloves or a gown, despite facility policy requiring EBP to prevent the spread of multi-drug resistant organisms.
The facility did not resubmit required PASRR Level I screenings for two residents with mental health diagnoses, resulting in missing or incomplete evaluations. One resident with bipolar disorder and depression did not have a new Level I screening completed after 30 days as required, while another resident with schizophrenia did not receive a follow-up Level I or Level II evaluation after initial screening and case closure. Staff interviews revealed unclear assignment of responsibility and lack of timely action on PASRR requirements.
A nurse administered several scheduled medications to a resident with multiple chronic conditions but failed to document the administration on the eMAR at the time the medications were given, instead entering the information nearly three hours later. Staff interviews confirmed that facility policy requires immediate documentation after medication administration.
A resident with dementia and mood disorders received an incorrect dosage of Seroquel due to a transcription error, where a physician's order for 50 mg was entered and administered as 25 mg. The error persisted over multiple days and was only discovered after review by nursing leadership. Staff interviews confirmed the mistake and acknowledged expectations for accurate order entry and medication administration.
Two residents with cognitive impairments and complex medical histories were found with cups of pills left at their bedsides, despite facility policy requiring secure medication storage and no orders for self-administration. An LPN documented the medications as administered but left them at the bedside at the residents' requests, and facility leadership confirmed this practice was not permitted.
Surveyors found that the facility's medication error rate was 17.86%, significantly above the acceptable threshold. Two residents were affected: one received the wrong form of aspirin, and another did not receive four prescribed medications during a medication pass. Staff interviews confirmed that required verification steps were not consistently followed, despite facility policy and leadership expectations for thorough medication administration checks.
A resident with a history of fractures and chronic pain received PRN opioid pain medication, but staff failed to consistently document its administration on the MAR, resulting in a discrepancy between the narcotic record and the MAR. Nursing staff and leadership confirmed that this lack of documentation led to an inaccurate medical record regarding the resident's pain management.
A resident's personal belongings were improperly stored on the floor, violating infection control protocols. A housekeeper failed to perform hand hygiene after removing soiled gloves, and a CNA improperly handled soiled linens by wearing gloves in the hallway and not using a hamper, contrary to facility policy.
A facility failed to report an alleged abuse incident involving a resident with cognitive and mental health conditions within the required timeframe. The incident, where an LVN allegedly slapped the resident, was reported to the ADON, DON, and Administrator. However, the report to the state agency was incomplete, lacking necessary details, and the Administrator could not provide proof of reporting to law enforcement, violating the facility's policy on immediate reporting.
A resident's responsible party experienced a delay in accessing medical records, which were needed for treatment at another facility. The request was made to the Medical Records Director, who required a signed DPOA before releasing the records. Despite receiving the DPOA, the records were not sent until several days later due to a busy schedule, and not all requested records were provided.
Failure to Notify Physician and Family After Multiple Resident Falls
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s attending physician and representative after multiple falls and changes in condition. The resident had been admitted long-term with diagnoses including morbid obesity, open angle glaucoma, a history of falling, and heart failure. Review of the admission record and progress notes showed an eInteract SBAR summary when the resident was exposed to the flu virus and a nurse’s note documenting that the resident was later found unresponsive with no pulse or spontaneous breathing, with a code blue initiated and EMS pronouncing the resident deceased. However, there was no documentation in the progress notes between the dates of the reported falls and the date the resident was found unresponsive. Family reported learning from an anonymous caller that the resident had fallen twice before being found unresponsive, and stated that the resident was not taken to the hospital and the family was not informed of the falls. The family member also reported that the resident remained in bed all day on the day before being found unresponsive, which was unusual for the resident. Interviews with staff confirmed multiple fall events: a CNA described three separate incidents in which the resident either slipped or was lowered to the floor during transfers using a standing lift, requiring multiple staff and a Hoyer lift to assist the resident. One LVN stated that, on one early-morning incident when the resident was found sitting on the floor, the resident was moved to a wheelchair due to bed positioning and weight, and the LVN left for the day without documenting the incident, stating she was unaware documentation was required. Further review with the ADON showed that one of the falls was documented as a change of condition but lacked follow-through nursing progress notes, and that required fall protocol steps were not completed. The ADON stated that for any fall, whether witnessed or assisted, immediate assessment, physician and family notification, neurological checks for unwitnessed falls, fall risk assessment, eInteract charting, and 72-hour progress notes are required, along with an IDT conference on the next workday. The facility’s policy on change in condition/status requires licensed staff to notify the attending or on-call physician following any accident or incident involving the resident, including those resulting in injury or injuries of unknown origin. In this case, the ADON confirmed that on the dates of the falls, neither the physician nor the family was notified due to incomplete change-of-condition documentation, resulting in the failure to promptly inform the physician and resident representative of accidents that may have resulted in injury.
Unsafe Closet Door and Substandard Room Temperatures
Penalty
Summary
The facility failed to maintain a safe, comfortable, and homelike environment when it did not timely and properly repair a resident’s closet door despite staff awareness of the defect. A resident admitted with left hemiplegia and hemiparesis, and assessed as cognitively intact with a BIMS score of 13, reported repeatedly requesting repairs for a malfunctioning closet door. The door had a visible gap at the hinges, overlapped with the adjacent closet door, and was misaligned, making it impossible to open drawers correctly. According to the resident and the clinical record, the closet door subsequently fell on the resident’s head and left foot, impacting the left side of the head, arm, and ankle, and causing pain upon palpation, redness, bruising, and swelling of the left ankle that required ice packs. Later observation with the Maintenance Director confirmed the hinges used were the wrong size, resulting in a large gap on one side and overlap on the other, and the door had to be left open to access the adjacent door and bottom drawer. The facility also failed to maintain resident room temperatures within the required range of 71–81°F. Staff interviews indicated that when outside weather was cold, residents complained of feeling chilly, and resident council minutes documented issues raised about room temperatures, with management directing staff to perform daily temperature checks. The Maintenance Director stated that thermostats were set between 74–76°F and that room temperatures were expected to read between 71–81°F per regulation, with HVAC units checked weekly and as needed. However, concurrent temperature checks in multiple rooms showed readings of 60°F, 67°F, and 68°F, which were below the required range. A CNA reported that some residents complained their rooms were cold, and two residents stated their room was cold and that the heaters did not seem to be working.
Failure to Assess and Document Multiple Falls and Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to identify and assess a change in condition for a long‑term resident with a history of falls and multiple comorbidities, including morbid obesity, glaucoma, and heart failure. The resident’s MDS showed dependence on two or more helpers for transfers and maximum assistance for bed mobility, and a fall risk assessment score of 16 indicated high fall risk. Despite this, the facility did not complete timely post‑fall evaluations, including neurological checks, pain assessments, and monitoring for injury, after multiple fall or fall‑like events in the days immediately preceding the resident being found unresponsive and later pronounced deceased. Progress notes contained a gap in documentation for several days before the resident’s death, and there was no documentation of assessments or interventions following the reported incidents. Interviews with family and staff revealed multiple unwitnessed and assisted falls or “sliding” events that were not properly documented or assessed. A family member reported being informed anonymously that the resident had fallen twice in the days before being found unresponsive and stated the family was not notified of these falls. The family member also reported that the resident, who usually liked to get out of bed, stayed in bed all day on the day before death, which they perceived as unusual. Nursing staff, including an LVN, acknowledged that on one early morning, the resident was found on the floor next to the bed and was transferred to a wheelchair due to bed malfunction and the resident’s weight, but the LVN did not document the event and stated she was unaware documentation was required. The DON later confirmed that no fall, progress note, or IDT investigation was entered for that day and that no diagnostic tests or imaging were performed, with no record of any assessment or intervention. Additional staff interviews described several separate incidents in which the resident was found on the floor or was lowered to the floor during transfers, including use of a standing lift where the resident’s knees buckled and staff used a Hoyer lift to return the resident to bed or a wheelchair. Staff, including CNAs, LVNs, the Infection Preventionist, and the ADON, consistently described multiple falls or assisted falls, some unwitnessed, with involvement of several staff members to get the resident up. One nurse stated that all incidents should be documented in progress notes, that falls are considered a change of condition requiring vital signs, neuro checks, and 72‑hour monitoring, and that abnormal findings must be reported to the physician. The ADON confirmed that for the documented fall event, there were no follow‑through progress notes, no 72‑hour monitoring, and that neither the physician nor the family was notified due to incomplete change‑of‑condition documentation. Review of the facility’s fall care plans and fall policy showed expectations to follow fall protocol, notify physician and family, complete assessments, and evaluate causes within 24 hours, but these standards were not met for the resident’s multiple falls and floor‑level incidents. The facility’s records and interviews also showed gaps in ensuring appropriate transfer methods and staff training. A fall care plan included an intervention to educate staff on operating a standing lift, yet in‑service attendance records for Hoyer and standing lift use did not include the names of two CNAs assigned to the resident. The PT reported that Rehab had not received a nursing referral to reassess whether a standing lift remained appropriate for the resident, whose last rehab evaluation was when the resident was stronger. Staff accounts indicated that a standing lift was used despite concerns about its appropriateness for the resident’s weight and condition, and that improper use of the standing lift contributed to at least one incident where the resident was lowered to the floor. Collectively, the lack of timely assessment, incomplete or absent documentation, failure to perform neuro checks and 72‑hour monitoring, failure to notify the physician and family, and inconsistent adherence to fall protocols and equipment training led to the identified deficiency in providing treatment and care according to orders, resident preferences, goals, and professional standards. The facility’s own policy on falls required evaluation and documentation of falls, categorization of the type of fall, identification of possible causes within 24 hours, and ongoing evaluation by staff and physician, noting that complications such as fractures, bruising, or intracranial bleeding can appear hours to weeks after a fall. Despite this, there was no documentation of post‑fall assessments, neuro checks, or physician involvement after the resident’s multiple falls or floor‑level incidents. The absence of required documentation and monitoring, combined with the lack of timely clinical evaluation following these events, resulted in a delay in identifying the resident’s change in condition and in implementing necessary interventions, as stated in the report.
Failure to Follow Infection Control Practices for Soiled Linen Handling and Glove Use
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control when CNA 8 failed to follow facility policy and standard precautions while handling soiled linens and performing resident care. During an observation in a resident’s room, CNA 8 placed a soiled linen directly on the floor near a trash can without first bagging it, then, while still wearing the same gloves, repositioned the resident and adjusted the curtain and bed remote without changing gloves between these tasks. CNA 8 then picked up the linen and trash, bagged them, and exited the room, later acknowledging and apologizing for placing the linen on the floor without bagging it. In an interview, the IP stated that used linen must be bagged at the point of collection and not placed on the floor, and that unrolled bags are kept at the foot of the bed for this purpose because used linen is treated as contaminated. Review of the facility’s “Laundry and Bedding, Soiled” policy, last reviewed January 2026, confirmed that all used laundry is to be treated as contaminated and bagged at the collection point with standard precautions. These failures created a risk for the spread of infectious organisms, as noted by the surveyors and the IP, due to the potential for microorganisms on used linens to be spread by staff stepping on them and transferring bacteria via shoes throughout the facility.
Failure to Protect Cognitively Intact Residents From Sexual Abuse by CNA During Personal Care
Penalty
Summary
The facility failed to protect cognitively intact residents from sexual abuse during the provision of personal care by a CNA. Resident 1, admitted with a left lower leg fracture and generalized muscle weakness and with a BIMS score of 15, reported that during an evening diaper change her brief was only wet with urine. She stated that CNA 1 stood on the left side of her bed and used wet wipes to clean her vaginal area multiple times. When she flinched, CNA 1 asked if it hurt, then wiped again, going deeper between her labia and rubbing his finger within her clitoris. Resident 1 reported that she told CNA 1 to stop and that it was not okay, declined her usual barrier cream because she wanted the care to be finished, and later documented the incident in four pages of personal notes she kept at her bedside. Later that evening, Resident 1 told CNA 2 that she was uncomfortable with CNA 1 and did not want him to change her again. CNA 2 confirmed that he worked that afternoon, that Resident 1 appeared uncomfortable when discussing the diaper change, and that she stated she did not want CNA 1 to return to provide care. Resident 1 also spoke with RN 1 during medication administration and stated she did not like CNA 1 and did not want him to change her diaper again. On the following night shift, LVN 1 encountered Resident 1 during medication pass and observed that she was emotional. Resident 1 told LVN 1 that she had reported sexual abuse to two staff members and felt that nothing had happened. She clearly described that her diaper had only urine and that during the diaper change CNA 1 repeatedly wiped her and at one point touched and wiggled his finger in her vagina. RN 2 later interviewed Resident 1 and reported that she appeared distressed and tense and recounted that CNA 1 wiped her vaginal area excessively and penetrated her with his finger. Resident 2, admitted with hemiplegia and hemiparesis following intracranial bleeding and with a BIMS score of 14, reported a separate incident of sexual abuse by CNA 1 during a scheduled shower. Resident 2 stated that CNA 1 took her from the patio to her room to prepare for the shower and, when removing her sweater, rubbed her breast. She reported that she swiped his hand away and told him to stop. While seated on a shower chair in shower room A, Resident 2 stated that CNA 1 again attempted to wipe her breast area with a washcloth, prompting her to request the washcloth so she could clean her own breasts. Because she could not reach her buttocks, she allowed CNA 1 to clean that area; she demonstrated that while he was behind her cleaning her buttocks, he inserted his finger into her anus. She stated she was shocked and told him she was done and to take her back to her room. Resident 2 further reported that once back in her room, CNA 1 used a towel to dry her breast area and squeezed her nipples, and she felt nervous during and after the event. She stated she reported the incident to RNA 1 the next day. RNA 1 confirmed working that day, noted that Resident 2 appeared emotional and about to cry while recounting the shower experience from the previous afternoon, and verified from the staffing schedule that CNA 1 had assisted Resident 2 with her shower. Progress notes documented that Resident 2 informed staff that a male CNA who assisted with her shower had touched her inappropriately and that she was alert and oriented. An Ombudsman representative later interviewed Resident 2 privately and observed that Resident 2 became distraught and cried when recounting the events. The facility’s abuse, neglect, and exploitation prevention policy stated that residents have the right to be free from sexual abuse and that the program is intended to protect residents from abuse by anyone, including facility staff, underscoring that the described conduct by CNA 1 constituted a failure to protect residents from sexual abuse.
Failure to Remove Alleged Perpetrator After Sexual Abuse Allegation Resulting in Second Resident Abuse
Penalty
Summary
The deficiency involves the facility’s failure to identify and protect cognitively intact residents from alleged sexual abuse by a CNA, and to remove the alleged perpetrator from resident care after the first allegation. One resident, admitted with a left lower leg fracture and generalized muscle weakness and assessed with a BIMS score of 15 (cognitively intact), reported that during an evening incontinence care episode, a male CNA repeatedly wiped her vaginal area despite the brief being only wet with urine. She stated that the CNA wiped deeper between her labia and rubbed his finger within her clitoris, and that she told him to stop and that it was not okay. She usually required barrier cream but specifically declined it from this CNA and wanted the care to end. Later that evening, she told a familiar CNA that she had been inappropriately touched and asked who she could report it to; that CNA said he would inform the nurse. She then told an RN that she had been inappropriately touched by the CNA and that she never wanted him to change her again, but the RN did not ask further questions, focusing instead on ensuring the next shift knew she did not want that CNA assigned. The following early morning, the same resident, described as emotional, reported the incident again to an LVN, clearly stating that the brief contained only urine and that the CNA had repeatedly wiped her and wiggled his finger in her vagina. The LVN reported this to the nurse supervisor (an RN), who then visited the resident later that morning and heard a consistent account that the CNA had excessively wiped her vaginal area and penetrated her with his finger. The RN reported this to supervisory staff, including the Director of Staff Development and indicated that the Administrator would be notified. However, the Assistant DON later characterized the resident’s complaint as a “customer care complaint” and focused on the resident’s request not to have the CNA assigned to her, after confirming with the RN that the resident had reported rough incontinence care and requested not to be cared for by that CNA. Despite the resident’s clear allegations of sexual abuse and multiple reports to different licensed nurses, the CNA remained on the staffing schedule and continued to work resident care shifts. Staffing records show that the CNA worked the 2:45 p.m. to 11:15 p.m. shift on the date of the first alleged incident and then worked both the 6:30 a.m. to 3:00 p.m. and 2:45 p.m. to 11:15 p.m. shifts the following day, indicating he was not removed from resident contact after the initial allegation. During this time, a second cognitively intact resident, admitted with hemiplegia and hemiparesis following a non‑traumatic intracerebral bleed and with a BIMS score of 14, reported that the same CNA sexually abused her during a scheduled shower. She stated that when the CNA removed her sweater, he rubbed her breast, and she pushed his hand away and told him to stop. In the shower, she reported that he again attempted to wash her breast area with a washcloth, prompting her to request the washcloth so she could clean that area herself. She could not reach her buttocks, so the CNA washed that area from behind while she sat on a shower chair; she demonstrated that he inserted his finger into her anus. She further reported that after the shower, when drying her chest, he squeezed her nipples, leaving her feeling nervous during and after the event. She reported this to another staff member the next day. The facility’s abuse policy required immediate reporting to the administrator, protection of residents, and placing any employee accused of abuse on leave with no resident contact until the investigation was complete, but the CNA was not removed from duty after the first allegation, which allowed him to continue providing care and led to a second resident’s report of sexual abuse.
Failure to Protect a Cognitively Impaired Resident From Physical Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident, resulting in injury. Resident 1, who had a severely impaired cognition with a BIMS score of 3 out of 15 on the 11/14/25 MDS, was involved in a resident-to-resident altercation with Resident 2. Resident 2 had moderately impaired cognition with a BIMS score of 8 out of 15 on the 8/19/25 MDS, and the MDS Section E documented physical behavioral symptoms directed toward others occurring one to three days out of seven, including behaviors such as hitting, kicking, pushing, scratching, grabbing, or sexually abusing others. Staff interviews indicated that Resident 2 was easily agitated, sometimes irritated by other residents, and often required separation from others. The DON stated Resident 2 had good and bad days due to dementia, could be easily upset by various disturbances, and had prior behavior problems related to a need for medication adjustment. On 8/12/2025 at 10:15 a.m., an incident summary documented a resident-to-resident altercation between Resident 1 and Resident 2. A CNA observed Resident 2 swinging a coffee cup toward Resident 1's head, which resulted in Resident 1 sustaining a blue-purple bump with discoloration on the right frontal area of the head and a cut on the upper lip. Prior to this, on 1/28/26 at 11:24 a.m., Resident 1 had been observed sitting in a wheelchair outside the room with no discoloration or wounds noted on the face, indicating the injuries were associated with the altercation. The Administrator, who also served as the abuse coordinator, stated that Resident 2 was typically upset or agitated about anything and required communication or talking down to diffuse behavior, and that specific CNAs and Social Services staff were very familiar with Resident 2’s behavior and need for redirection. Despite the facility’s written Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy dated April 2021, which required protection of residents from abuse by anyone including other residents, Resident 1 was not protected from physical abuse by Resident 2.
Failure to Provide Timely Assessment and Intervention for Chest Pain by Unlicensed Nurse
Penalty
Summary
The facility failed to provide timely and appropriate nursing assessment, monitoring, and interventions for a resident who experienced ongoing chest and abdominal pain for approximately nine hours. The resident, who had a history of hypertension, gastric outlet obstruction, stroke, recent ventral hernia repair, and a recent non-ST elevated myocardial infarction (NSTEMI), was under the care of a staff member who was unlicensed and using another individual's RN license. Despite physician orders for nitroglycerin to be administered for chest pain and instructions to call 911 if pain persisted, the medication was not given, and emergency services were not initiated in a timely manner. Record reviews revealed that the unlicensed nurse did not document comprehensive pain assessments or nursing interventions beyond the administration of PRN pain medications, and there was no evidence that nitroglycerin was administered at any point during the resident's episode of chest pain. The resident's pain was not relieved by pain medication, and symptoms included increased respiration, moaning, groaning, facial grimacing, and physical signs of distress. Documentation also showed discrepancies in the administration and issuance of controlled substances, and there was no record of timely physician notification or appropriate escalation of care. Interviews with facility staff, including the DON, ADON, and nurse supervisor, confirmed a lack of awareness regarding the unlicensed status of the nurse and failures in following physician orders and facility policies for pain assessment, medication administration, and response to significant changes in condition. The resident was eventually transferred to the hospital, where nitroglycerin was administered by EMS, but the resident expired shortly after arrival due to an acute ST elevation myocardial infarction and cardiac arrest.
Deficient Controlled Substance Documentation and Unlicensed Medication Administration
Penalty
Summary
The facility failed to ensure that pharmaceutical services, specifically the management of controlled medications, were complete and accurate for multiple residents. Discrepancies were found between Controlled Drug Records (CDR) and Medication Administration Records (MAR) for several residents, including instances where medication removals did not correspond to documented administrations. In some cases, documentation was missing or illegible, and shipping manifests, CDRs, and destruction logs were incomplete or could not be located. These documentation failures were observed for at least six residents, with specific examples showing that doses of controlled substances were unaccounted for or not properly reconciled. One significant event involved an unlicensed individual who was employed as nursing staff and used another person's RN license to administer medications. This individual had a revoked LVN license due to prior drug diversion and was found to have signed out controlled substances under another nurse's initials. The facility's records showed that this unlicensed staff member was responsible for discrepancies in the administration and documentation of narcotics, including the removal of medication after a resident had already been transferred to the hospital. The facility's own policies required that only authorized, licensed personnel handle and document controlled substances, and that all removals and administrations be accurately recorded. Further review of the facility's medication management system revealed that for several residents, the required documentation for controlled substances was missing or incomplete. For example, one resident's shipping manifest indicated receipt of a controlled medication, but the corresponding CDR could not be found, and the MAR showed only a few doses administered with the remainder unaccounted for. In other cases, the CDR documented medication removals that did not match any MAR entries, and destruction or return records were not available. These failures were confirmed through interviews with facility staff, who acknowledged the discrepancies and the inability to account for all controlled substances as required by facility policy.
Improper Medication Administration Leads to Accidental Ingestion of Dakin's Solution
Penalty
Summary
A deficiency occurred when a licensed nurse prepared medication for a resident and handed it to another licensed nurse for administration, resulting in a breakdown of safe medication administration practices. Specifically, a resident with multiple diagnoses, including osteomyelitis, was admitted to the facility and required pain management with Morphine Sulfate ER. On the day of the incident, a nurse brought a cup containing a clear liquid, which was on top of the treatment cart, to the resident along with pain medication. The resident ingested the liquid and immediately reported that it tasted like bleach. Further review revealed that the clear liquid was Dakin's solution, a diluted bleach solution intended for wound cleansing, not for oral consumption. The progress notes indicated that the solution had been poured for wound treatment, but due to miscommunication and improper handoff, another nurse mistakenly gave it to the resident as water. The facility's policy required that medications be administered safely and by the individual who prepared them, with proper documentation, which was not followed in this instance.
Failure to Follow Enhanced Barrier Precautions During Resident Care
Penalty
Summary
A deficiency occurred when a registered nurse (RN) failed to follow Enhanced Barrier Precautions (EBP) during the care of a resident who was admitted with diagnoses including a pressure ulcer, chronic diastolic heart failure, atrial fibrillation, and hypertension. The resident's room was clearly marked as requiring EBP due to the presence of a pressure ulcer, which necessitates targeted use of personal protective equipment (PPE) such as gowns and gloves during high-contact care activities. Despite this, the RN entered the resident's room multiple times to perform direct care activities, including checking blood pressure and pulse, administering medications, and removing and applying a Lidocaine patch, all without donning the required PPE. The RN acknowledged during an interview that the room was designated for EBP because of the resident's pressure ulcer but admitted to not using PPE while performing these care tasks. Facility policy specifies that EBP is intended to prevent the spread of multi-drug resistant organisms (MDROs) during high-contact activities involving resident care, equipment, or skin. The failure to consistently implement EBP as outlined in facility policy was directly observed and confirmed through staff interview and record review.
Failure to Resubmit PASRR Screenings for Residents with Mental Health Diagnoses
Penalty
Summary
The facility failed to resubmit required Preadmission Screening and Resident Review (PASRR) Level I evaluations for two residents with mental health diagnoses. For one resident with a history of bipolar disorder and major depressive disorder, the initial PASRR Level I screening was negative and the resident was admitted as an Exempted Hospital Discharge. However, the facility did not resubmit a new Level I screening on the 31st day as required, and there was no current Level I screening in the resident's record. Interviews with staff revealed that no individual had been assigned responsibility for ensuring the timely resubmission of the PASRR, and the process was not clearly defined among staff members. For another resident with a diagnosis of schizophrenia, the initial PASRR Level I screening was positive for suspected mental illness, and a Level II evaluation was required. The state agency closed the case after determining that the resident was isolated for health or safety reasons, instructing the facility to submit a new Level I screening to reopen the case. The facility did not submit the required new Level I screening, and as a result, the Level II evaluation was never completed. Staff interviews confirmed that the process for submitting PASRR evaluations was unclear, and the individual previously responsible for submissions was no longer employed at the facility. Throughout the investigation, staff including the Admissions Assistant, MDS Coordinator, DON, and Administrator acknowledged the lack of clear assignment of responsibility and failure to act promptly on PASRR-related correspondence. The facility's policy required maintenance of PASRR documentation and timely action on positive screenings, but these procedures were not followed for the two residents reviewed.
Failure to Timely Document Medication Administration on eMAR
Penalty
Summary
The facility failed to ensure that staff documented medication administration on the electronic Medication Administration Record (eMAR) in a timely manner for one resident. According to facility policy, the individual administering medication must initial the resident's MAR immediately after giving each medication and before administering the next. During an observed medication pass, a nurse administered several scheduled medications to a resident but did not document the administration on the eMAR at the time the medications were given. The nurse later confirmed in an interview that she had not documented the administration because she was in a hurry to move to the next resident. Audit reports showed that the documentation was entered nearly three hours after the medications were actually administered. The resident involved had a history of essential primary hypertension, type 2 diabetes mellitus, bilateral primary osteoarthritis of the knee, and adult failure to thrive, and was assessed as having moderate cognitive impairment. The resident's care plan included interventions for medication administration and monitoring for side effects. Multiple staff interviews, including with the ADON, DON, and Administrator, confirmed that the expectation was for medication administration to be documented immediately after giving the medication, and that delayed documentation was not consistent with good practice or facility policy.
Failure to Accurately Transcribe and Administer Medication Orders
Penalty
Summary
The facility failed to ensure that medication orders were accurately transcribed and administered as prescribed for one resident. A physician's order directed that the resident receive Seroquel 50 mg, one tablet twice daily and two tablets at bedtime. However, the order was incorrectly transcribed as Seroquel 25 mg, with instructions to give one tablet twice daily and two tablets at bedtime. This error was reflected in both the Order Summary Report and the Medication Administration Record (MAR), and the resident received the incorrect dosage over a period of time. The error was not identified until it was brought to the attention of the Assistant Director of Nursing (ADON), who acknowledged the mistake and indicated that more frequent audits or reviews might be necessary to prevent such errors. The resident involved had a history of dementia, major depressive disorder, and unspecified mood affective disorder, with moderate cognitive impairment as indicated by a BIMS score of 10. The care plan specifically noted the use of antipsychotic medication and the need to administer medications as ordered. Interviews with facility staff, including the LVN who entered the order and the DON, confirmed that the order was not transcribed correctly and that staff are expected to enter medication orders accurately. The facility's policy required medications to be administered as prescribed, but this was not followed in this instance.
Medications Improperly Left at Bedside for Two Residents
Penalty
Summary
The facility failed to ensure that medications were properly stored and not left at the bedside for two residents, resulting in an accident hazard. Facility policy required that medications be administered safely and only allowed self-administration if the interdisciplinary team and physician determined it was appropriate, with medications stored securely. However, for both residents involved, there were no physician orders or care plan interventions permitting self-administration or bedside storage of medications. One resident, with a history of hypertension, COPD, cerebral aneurysm, and anemia, was observed on multiple occasions with a cup containing multiple pills at their bedside. The resident stated that staff gave them the pills but they were waiting to take them. The resident's care plan did not include self-administration, and the medication administration record showed that a nurse documented the medications as administered. The nurse later confirmed leaving the medications at the bedside at the resident's request, despite the resident not being assessed for self-administration. A second resident, with diagnoses including diabetes, chronic kidney disease, and cognitive decline, was also observed with a cup of pills at their bedside while they were in bed with their eyes closed. This resident's care plan and physician orders did not permit self-administration or bedside storage of medications. The nurse documented the medications as administered, but the medications were left at the bedside. Facility leadership confirmed that medications should not be left at the bedside and that the nurse was responsible for ensuring medications were taken as ordered.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in an observed error rate of 17.86%. During medication administration observations, five errors were identified out of 28 opportunities, affecting two residents. Facility policy required medications to be administered safely, timely, and as prescribed, with staff expected to verify the right resident, medication, dose, route, time, and method through multiple checks before administration. For one resident with a history of essential hypertension and intact cognition, the nurse administered enteric coated aspirin instead of the prescribed chewable aspirin for DVT prophylaxis. The nurse acknowledged the need to ensure the correct medication and perform multiple checks, as outlined in facility policy. Interviews with nursing leadership confirmed expectations for thorough verification and adherence to the six rights of medication administration, including comparing medication labels with the eMAR and ensuring residents receive the correct medications as ordered. Another resident, with a history of hypertension, asthma, and moderate cognitive impairment, did not receive four prescribed medications during the observed medication pass. The nurse omitted famotidine, fluticasone, lactobacillus, and loratadine, all of which were active orders. Nursing leadership reiterated the importance of line-by-line checks against the MAR and counting medications to ensure accuracy. The administrator stated an expectation for a 0% medication error rate and emphasized the need for nurses to be thorough in medication administration.
Failure to Accurately Document Pain Medication Administration
Penalty
Summary
The facility failed to maintain accurate medical records regarding the administration of pain medication for one resident with a history of a left lower leg fracture, bilateral primary osteoarthritis of the knees, and polyneuropathy. The resident, who was cognitively intact, had an active order for Percocet 10-325 mg to be given every four hours as needed for moderate to severe pain. Documentation review revealed a significant discrepancy: while the Medication Administration Record (MAR) showed that the medication was administered 37 times over a two-week period, the narcotic record indicated that 73 pills were signed out during the same timeframe. Interviews with nursing staff confirmed that medications were sometimes signed out on the narcotic record but not consistently documented on the MAR. Nurses acknowledged the importance of accurate documentation on both records, as the MAR is used by physicians to monitor medication administration and make necessary adjustments. Facility leadership, including the ADON and DON, also emphasized the need for proper documentation to ensure an accurate record of what medications residents receive. The failure to consistently document administration of pain medication on the MAR resulted in an inaccurate medical record for the resident.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility staff failed to implement their infection prevention and control program in several instances. Personal belongings of a resident were found improperly stored on the floor, which was against the facility's infection control protocols. The resident, who had a history of urinary tract infection, irritable bowel syndrome, and type 2 diabetes mellitus with diabetic polyneuropathy, expressed dissatisfaction with her belongings being on the floor. The Licensed Vocational Nurse and Director of Nursing acknowledged that belongings should not be stored on the floor for infection control reasons, and the Infection Preventionist confirmed that staff were trained to store items in closets. Additionally, a housekeeper did not perform hand hygiene after removing soiled gloves, and there were no hand sanitizers available near the soiled utility room. The housekeeper, who only spoke Spanish, was not able to communicate effectively in English. Furthermore, a Certified Nursing Assistant improperly handled soiled linens by wearing gloves in the hallway and not using a hamper to transport the linens, contrary to the facility's policy. The Assistant Director of Nursing confirmed that staff were required to use hampers and not wear gloves in the hallway.
Failure to Timely Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report an allegation of abuse within the required timeframe to the State Survey Agency and Adult Protective Services for a resident. The resident, who was admitted to the facility in 2024, had diagnoses including Cognitive Communication Deficit, Intermittent Explosive Disorder, and Senile Degeneration of Brain. An alleged incident occurred where a Licensed Vocational Nurse was reported to have slapped the resident on the face during care. The Assistant Director of Nursing received the report of the alleged abuse on the morning of November 19, 2024, and subsequently informed the Director of Nursing and the Administrator. The facility's Report of Suspected Dependent Adult-Elder Abuse was faxed to the California Department of Public Health on the same day, but the report was incomplete, lacking details such as the contact name, telephone number, and the time the incident was reported to law enforcement and the local ombudsman. The facility's policy requires that all reports of abuse be reported immediately, defined as within two hours for serious bodily injury or within 24 hours for other allegations. However, the Administrator could not provide proof of the fax to law enforcement or a case number, indicating a failure to adhere to the policy and ensure timely reporting of the incident.
Delayed Access to Medical Records for Resident's Responsible Party
Penalty
Summary
The facility's nursing staff failed to provide a resident's responsible party with access to medical records within 24 hours of a written request, resulting in delayed treatment at another facility. The resident, admitted in 2024, had a responsible party designated for emergency contact and financial decisions. On May 30, 2024, the responsible party requested the release of medical records via telephone to the facility's Medical Records Director (MRD). The MRD required a signed Durable Power of Attorney (DPOA) before releasing the records. The responsible party sent the DPOA via email on July 11, 2024, but the MRD delayed sending the requested documents until July 19, 2024, citing a busy schedule with numerous Additional Documentation Requests from Medicare. The facility's normal process is to release records two days after receiving a signed release form, but this timeline was not adhered to, and not all requested records were provided.
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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) |
|---|---|---|---|---|
| Willow Pass Healthcare Center | 1.1 mi | — | 6 | 0 |
| Concord Post Acute | 1.4 mi | — | 4 | 0 |
| Stonebrook Post Acute | 1.7 mi | — | 4 | 0 |
| Bayberry Skilled Nursing & Healthcare Center | 1.7 mi | — | 16 | 0 |
| Shadelands Post Acute | 2.7 mi | — | 0 | 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 August 2026) and official state health department websites.