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 Diamond Ridge Healthcare Center during CMS and state inspections, most recent first.
A resident who was cognitively intact and required substantial/maximal assistance with showering reported that a CNA did not wash the resident's buttocks during a shower, despite the resident's request and inability to reach that area. The CNA stated she avoided washing the buttocks because she was worried about hurting her back if she bent over and did not consider asking another CNA for help, leaving the resident feeling upset and angry until the area was cleaned later that day. The DSD and DON acknowledged the CNA should have completed the care to preserve the resident's dignity, consistent with the facility's Resident Rights policy requiring staff to be educated on residents' rights and proper care responsibilities.
A resident with unsteadiness on feet and a vertebral compression fracture, who was cognitively intact, fell from a Broda wheelchair and struck her face on the floor while being wheeled by a family member. The resident and the family member both reported that the facility had not provided instruction on the safe and proper use of the Broda wheelchair. Review of records and interviews with the PT, MDSC, and DON showed there was no care plan addressing safe use of the Broda wheelchair, no documentation of training for the family member on wheelchair safety, and no facility policy or procedure for Broda wheelchair use.
A resident with asthma experienced respiratory distress, and an LVN documented the event but did not notify the physician or responsible party as required by facility policy. The DON confirmed there was no documentation of notification, despite the policy mandating prompt communication for significant changes in condition.
The facility failed to maintain sanitary food storage and preparation practices, risking foodborne illness. Unlabeled sandwiches were found in the refrigerator, and expired food items were in dry storage. A resident had outdated sandwiches and moldy grapes on their bedside table, with staff acknowledging the risk of food poisoning. The facility's policy requires proper labeling and discarding of expired food.
The facility failed to develop baseline care plans within 48 hours for three residents, each with significant medical conditions, and did not provide written summaries to the residents or their representatives. Interviews with staff revealed that providing written summaries was not a standard practice, despite being required by the facility's policy.
The facility failed to maintain proper hygiene and grooming for four residents, including those with dementia and Parkinson's disease. Residents were found with long facial hair and dirty fingernails, despite being dependent on staff for personal care. The DON acknowledged the CNAs' responsibility in providing grooming services.
The facility failed to adhere to infection control practices, including a CNA not wearing a face shield in a COVID-19 isolation room, improper hand hygiene by staff, and inadequate cleaning of medical equipment. Personal care items were improperly stored, and an LVN did not perform hand hygiene during wound care, increasing the risk of infection spread.
A resident's discharge status was incorrectly coded on the MDS as being discharged to an acute care hospital, despite records and staff confirming the resident was discharged home. This resulted in incorrect data being sent to CMS.
A resident did not receive prescribed Cromolyn Sodium Ophthalmic Solution due to a failure in medication administration and follow-up. The LVN did not administer the eye drops, and the DON confirmed the medication was not delivered by the pharmacy. The resident experienced itchy eyes, and there was no documentation of follow-up with the pharmacy or notification to the MD, contrary to facility policy.
A resident with unspecified dementia was unnecessarily prescribed Risperidone, despite not having schizophrenia or exhibiting psychotic behaviors. The resident's MDS showed severely impaired cognition without indicators of psychosis, and staff confirmed the resident was non-violent. A pharmacy recommendation advised against Risperidone use due to increased risks, and the facility's policy required specific documentation for psychotropic drug use, which was not followed.
A facility failed to ensure proper medication storage and labeling, as observed during a survey. An inhalation medication was found undated, and an intravaginal medication was stored with oral medications, contrary to facility policies. The DON and a Consultant Pharmacist acknowledged the risks of these practices, including potential medication errors and infection.
A resident with dementia exhibited aggression towards others for most of May 2024, but the facility failed to revise the care plan until late in the month. Despite being on antipsychotic medication, the resident's aggressive behaviors persisted, and there was no documentation of an Interdisciplinary Team meeting to address the issue. The facility's policy required ongoing monitoring and revision of care plans, which was not followed.
A facility failed to protect a resident with Alzheimer's from physical abuse by a CNA who raised her arm as if to strike. The incident was witnessed by the resident's roommate, who reported previous aggressive behavior by the same CNA towards other residents. The facility's policy on abuse prevention was not effectively implemented.
Failure to Provide Dignified and Complete Personal Care During Shower
Penalty
Summary
The deficiency involves a failure to honor a resident's right to dignity and appropriate assistance with personal care during a shower. A cognitively intact resident, admitted with diagnoses that included a need for assistance with personal care, reported that on the morning of 12/27/25 a CNA did not wash her buttocks during a shower, despite the resident's request and her inability to reach that area herself. The resident stated the CNA told her she did not want to hurt her back by bending to wash the buttocks, which left the resident feeling upset and angry. The resident's MDS dated 11/7/25 documented a BIMS score of 15 and indicated the resident required substantial/maximal assistance for showering, meaning the helper provides more than half the effort and lifts or holds the resident's trunk and limbs. During an interview, the CNA confirmed she did not wash the resident's buttocks during the morning shower on 12/27/25 because she was worried about hurting her back if she bent over, and she acknowledged it did not occur to her to call another CNA for assistance. She stated she did not clean the resident's buttocks until later that afternoon, after the resident became upset about the incident. The DSD stated the CNA should not have refused to wash the resident's buttocks and should have asked another CNA for help, and the DON stated the CNA should have cleaned the resident's buttocks to preserve the resident's dignity and to prevent the risk of skin breakdown. The facility's Resident Rights policy, revised 12/19/22, indicated the facility will ensure all direct and indirect care staff are educated on residents' rights and the facility's responsibility to properly care for its residents.
Failure to Train Family Member on Safe Use of Broda Wheelchair Resulting in Resident Fall
Penalty
Summary
The facility failed to ensure a resident’s family member received proper training in the safe use of a Broda wheelchair, resulting in a fall. Resident 2, who had diagnoses including unsteadiness on feet and a vertebral compression fracture, had been using a Broda wheelchair in the facility. Her MDS showed a BIMS score of 13, indicating she was cognitively intact. On 12/16/25, while being wheeled by Family Member (FM) 1, Resident 2 fell from the Broda wheelchair and hit her face on the floor. In interviews, Resident 2 stated she fell hard, head first, and hurt all over, and further stated the fall could have been prevented if the facility had trained FM 1 on how to safely and properly wheel her in the Broda wheelchair. FM 1 also stated that the facility did not teach her how to properly use and wheel the Broda wheelchair. Record review and staff interviews showed there was no documented training for FM 1 on wheelchair safety prior to the fall, despite Resident 2’s use of the specialized Broda wheelchair. The SBAR note documented the witnessed fall while FM 1 was wheeling the resident. During review of Resident 2’s care plan and progress notes, the PT confirmed that Resident 2 had been using a Broda wheelchair and that there was no documentation that FM 1 was trained on its use, and also could not find a care plan addressing the resident’s safety while using the Broda wheelchair. The MDS Coordinator likewise confirmed there was no care plan on the safe use of the Broda wheelchair. The DON stated the facility did not have a policy and procedure on the use of the Broda wheelchair.
Failure to Notify Physician and Responsible Party of Resident's Respiratory Distress
Penalty
Summary
The facility failed to promptly notify both the physician and the responsible party when a resident experienced respiratory distress. According to the clinical record, the resident, who had a history of asthma, was noted by an LVN to have increasing difficulty breathing and shortness of breath. Despite this significant change in condition, the LVN did not contact the resident's physician or responsible party at the time of the event. During interviews and record reviews, it was confirmed that there was no documentation indicating that the physician or responsible party had been informed of the resident's respiratory episode. The Director of Nursing acknowledged the absence of notification and stated that facility policy requires informing the physician and responsible party of such changes in condition. The facility's policy specifically lists significant changes in physical condition, such as life-threatening events, as circumstances requiring immediate notification.
Food Storage and Preparation Deficiencies
Penalty
Summary
The facility failed to store and prepare foods in a sanitary manner, which could potentially expose residents to foodborne illness. During an observation in the kitchen, eleven unlabeled and undated sandwiches were found in the refrigerator, which the Dietary Supervisor acknowledged should have been discarded after their use-by date. The facility's policy requires that all food products be dated upon receipt, when opened, and when prepared, and that expired or outdated food products be discarded. Additionally, in the dry storage room, several food items, including pancake mix, dried cranberries, and hamburger buns, were found to be stored beyond their use-by dates, which the Dietary Supervisor agreed to discard. In Resident 54's room, two outdated sandwiches and a cup of grapes with mold were found on the bedside table. The Certified Nursing Assistant (CNA) confirmed the presence of these items and acknowledged the risk of food poisoning if consumed. The Director of Nursing stated that CNAs are responsible for removing old food items from residents' tables. Resident 54, who had a Brief Interview for Mental Status score indicating intact cognition, required partial assistance with eating. The facility's policy emphasizes that food items should be stored in accordance with good sanitary practices and that expired or outdated food products should be discarded.
Failure to Develop Timely Baseline Care Plans
Penalty
Summary
The facility failed to develop and provide baseline care plans within 48 hours of admission for three residents, identified as Resident 108, 109, and 363. Resident 108 was admitted with diagnoses of hemiplegia and hemiparesis, and the baseline care plan was not developed within the required timeframe. Additionally, neither Resident 108 nor their representatives received a written summary of the baseline care plan. Similar deficiencies were noted for Resident 109, who was also admitted with hemiplegia and hemiparesis, and Resident 363, who had a diagnosis of a right femur fracture. In each case, the baseline care plans were not completed within 48 hours, and the residents and their representatives were not provided with the necessary written summaries. Interviews with facility staff, including a Registered Nurse/Supervisor, a Licensed Vocational Nurse/Case Manager, the Assistant Director of Nursing, and the Director of Nursing, revealed that it was not the facility's practice to provide written summaries of baseline care plans to residents and their representatives. This practice was contrary to the facility's policy and procedure, which required the development of a baseline care plan within 48 hours of admission and the provision of a written summary to the resident and their representative. The failure to adhere to these procedures had the potential to reduce the continuity of care and communication between the residents, their representatives, and the facility staff.
Failure to Maintain Resident Hygiene and Grooming
Penalty
Summary
The facility failed to provide necessary care for four residents, resulting in poor grooming and personal hygiene. Resident 28, diagnosed with dementia and legal blindness, was observed with long facial hair and dirty fingernails. Despite being dependent on staff for personal hygiene, the resident's needs were not met, as confirmed by a CNA and LVN who acknowledged the resident's desire for grooming. Resident 21, with cerebrovascular disease and dementia, was also found with long, dirty fingernails. The resident was totally dependent on staff for personal hygiene, yet the care plan's goals for cleanliness and grooming were not achieved. A CNA noted the risk of infection due to the resident's habit of eating with her hands. Resident 63, diagnosed with Parkinson's disease, had long, thick facial hair and expressed a preference for trimming, which was not offered by the facility. Similarly, Resident 84, with dementia, had long facial hair on her chin and expressed discomfort, yet the facility did not provide grooming services. The DON acknowledged the responsibility of CNAs in maintaining residents' hygiene and the potential risks of neglecting these duties.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain proper infection control practices in several instances. A CNA entered a COVID-19 isolation room without wearing a face shield, despite the resident being on droplet and airborne precautions. The CNA acknowledged the requirement for face protection, and the Infection Preventionist confirmed the necessity of adhering to PPE guidelines. Additionally, another CNA did not perform hand hygiene after picking up an ice cube from the floor and before entering a resident's room, which was against the facility's hand hygiene policy. In another instance, a glucometer stored in a medication cart was found with dried blood stains, indicating a failure to clean and disinfect the device after use. The Director of Nursing and the Infection Preventionist both acknowledged this as an unacceptable practice that could lead to the spread of infection. Furthermore, a Licensed Vocational Nurse (LVN) placed a tray with multiple single-use lancets on a resident's bed and did not disinfect it afterward, potentially causing contamination. Additional deficiencies included an LVN dropping a medication bottle cap on the floor and placing it back without disinfection, and the improper storage of personal care items such as toothbrushes and razors in shared bathrooms. These items were not labeled or stored correctly, increasing the risk of cross-contamination. Moreover, an LVN failed to perform hand hygiene during a wound care procedure, which could lead to infection. These actions and inactions demonstrate a lack of adherence to infection control protocols, posing a risk of infection spread among residents.
Incorrect MDS Coding for Resident Discharge
Penalty
Summary
The facility failed to ensure accurate coding of a resident's discharge status on the Minimum Data Set (MDS), resulting in incorrect data being transmitted to the Centers for Medicare and Medicaid Services (CMS). Specifically, the MDS for a resident, who was discharged home, was incorrectly coded as being discharged to an acute care hospital. This error was identified during a review of the resident's records, which included an admission record, order summary, post-discharge plan of care, and physician's discharge summary, all indicating the resident was discharged home. The Minimum Data Set Coordinator (MDSC) confirmed the incorrect encoding during an interview and record review, acknowledging that the resident was indeed discharged home and not to a hospital.
Failure to Administer Prescribed Eye Medication
Penalty
Summary
The facility failed to ensure that a resident received Cromolyn Sodium Ophthalmic Solution as prescribed by the physician. The resident, who had a mildly impaired mental status, was supposed to receive the eye drops twice daily to manage allergic eye conditions. However, during a medication pass observation, the Licensed Vocational Nurse (LVN) only administered oral medications and did not provide the eye drops. The LVN admitted that the medication had been out of order for some time and did not inform the physician or seek advice regarding the missing medication. The Director of Nursing confirmed that the medication had been reordered but not delivered by the pharmacy. The resident reported experiencing very itchy eyes due to the lack of medication. The facility's Consultant Pharmacist indicated that the Cromolyn Sodium Ophthalmic Solution was necessary to prevent inflammation and worsening of allergy symptoms. There was no documentation showing that the pharmacy was followed up with or that the physician was notified about the missing medication, which was against the facility's policy and procedure for medication orders.
Unnecessary Administration of Risperidone to a Resident Without Schizophrenia
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary medication when the resident was prescribed and administered Risperidone, a medication used to treat symptoms of schizophrenia, despite not having a diagnosis of schizophrenia. The resident, who had unspecified dementia without behavioral or psychotic disturbances, was given Risperidone for screaming, which was not a violent or threatening behavior. The resident's Minimum Data Set (MDS) indicated severely impaired cognition and did not show indicators of psychosis or behavioral symptoms that would justify the use of Risperidone. Interviews with facility staff, including a CNA and an LVN, confirmed that the resident was blind, forgetful, and confused but not physically abusive or threatening. The Director of Nursing stated that the medication was prescribed due to the resident's screaming, despite the resident being non-violent. A pharmacy recommendation advised against the use of Risperidone for dementia-related psychosis due to increased morbidity and mortality risks. The facility's policy required documentation of a specific condition for psychotropic drug use, which was not adhered to in this case.
Improper Medication Storage and Labeling
Penalty
Summary
The facility failed to ensure proper medication storage and labeling practices, as observed during a survey. In one instance, a resident's inhalation medication, Symbicort, which has a limited shelf life after opening, was found undated in a medication cart. The Licensed Vocational Nurse (LVN) acknowledged that the medication should have been dated according to the facility's standard practice. The Director of Nursing (DON) confirmed that without an open date, it would be impossible for nurses to determine the expiration date of the medication, potentially leading to unsafe use. In another instance, a resident's intravaginal medication, Estradiol, was improperly stored with oral medications in a medication cart. The LVN recognized that the intravaginal medication should have been stored separately to prevent potential infection due to different administration routes. The DON stated that storing medications with different routes together was unacceptable due to the risk of infection. The facility's Consultant Pharmacist also noted that the improper storage of the Estradiol tablet posed a risk of it being administered orally, which could lead to medication errors. The facility's policies and procedures require medications to be labeled and stored according to state and federal regulations, with oral medications stored separately from other formulations.
Failure to Revise Care Plan for Aggressive Resident with Dementia
Penalty
Summary
The facility failed to develop new interventions to address behavioral care and treatment for a resident diagnosed with dementia who exhibited physical and verbal aggression towards others for 24 out of 31 days in May 2024. The resident, admitted with a diagnosis of dementia with behavioral disturbance, had a severely impaired cognition as indicated by a BIMS score of 5 out of 15. Despite being prescribed Quetiapine Fumarate for aggression, the resident continued to display aggressive behaviors, which were documented in the Medication Administration Record for 15 mornings and 24 evenings in May 2024. Interviews with the MDS Coordinator and the DON revealed that the resident's behavior care plan was not revised until late May 2024, despite multiple aggressive incidents. There was no documentation of the Interdisciplinary Team meeting to discuss the resident's dementia care since admission. The facility's policy required ongoing monitoring and revision of care plan goals and interventions, which was not adhered to in this case. Additionally, the Social Services Director conducted a psychosocial evaluation but could not find documentation of it.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse when a Certified Nursing Assistant (CNA) raised her arm at the resident as if to strike. The resident, who had a diagnosis of Alzheimer's disease and severely impaired mental status, required total care with activities of daily living. The incident was witnessed by the resident's roommate, who reported that the CNA had previously exhibited aggressive behavior towards other residents. The roommate, who had an intact mental status, stated that the CNA told her not to tell anyone about the incident, which she perceived as a threat. Further investigation revealed that the CNA had a history of being verbally and physically abusive to residents, including two other residents who reported rough handling and verbal aggression. The Director of Nursing and other staff members confirmed the CNA's history of aggressive behavior. The facility's policy on abuse, neglect, and exploitation was reviewed, indicating that the facility should have measures in place to prevent such incidents, but these measures were not effectively implemented in this case.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Pittsburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pittsburg Skilled Nursing Center | 1.1 mi | — | 0 | 0 |
| Delta View Post Acute | 3.3 mi | — | 6 | 0 |
| Lone Tree Post Acute | 5.1 mi | — | 2 | 0 |
| Stonebrook Post Acute | 6.4 mi | — | 4 | 0 |
| Diablo Valley Post Acute | 8 mi | — | 11 | 0 |
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