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 Lone Tree Post Acute during CMS and state inspections, most recent first.
The facility did not ensure that its social services department was directed and supervised by a qualified social worker, resulting in all residents receiving social services from unqualified staff. The Social Services Director reported having a bachelor's degree in engineering, while the facility’s job descriptions required a bachelor's degree in Social Work or Human Services. Human Resources confirmed the lack of appropriate educational qualifications, and the administrator acknowledged that there was no qualified social worker overseeing the department. This was inconsistent with the facility assessment, facility policy, and state Title 22 regulations, all of which required a qualified social worker to organize, direct, and supervise social work services.
Surveyors found that the facility’s controlled substance documentation system was incomplete and inaccurate, with missing shipping manifests, absent Controlled Drug Records (CDRs) for certain delivered narcotic prescriptions, and multiple discrepancies between CDRs and Medication Administration Records (MARs) for several residents’ oxycodone and hydrocodone-acetaminophen orders. Staff, including the MRD, an LVN, and the ADON, described a process requiring shipping manifests, CDRs, and MARs to track receipt, dispensing, and administration of controlled medications, but could not produce all required records or reconcile them. Review of facility policies showed that controlled substance inventories were supposed to be monitored and reconciled, and that the consultant pharmacist was expected to identify such issues, yet Pharmacy QAPI reports for the relevant quarters did not document these problems.
A resident admitted with pulmonary coccidioidomycosis did not have their baseline care plan updated to include necessary respiratory treatments such as suctioning, oxygen, and nebulizer use. Facility staff, including the MDS Nurse, ADON, and DON, acknowledged the omission, which was contrary to the facility's policy requiring such details in the care plan.
The facility reported a medication error rate of 7.41%, exceeding the acceptable threshold of 5%. Two residents did not receive their prescribed medications due to LVNs failing to perform necessary checks as per facility policy. The errors were identified through observations and interviews, highlighting a lapse in adherence to medication administration protocols.
Unqualified Staff Directing Social Services Department
Penalty
Summary
The facility failed to comply with Federal and California Title 22 requirements, as well as its own policies and facility assessment, by not ensuring that the social services department was staffed and supervised by a qualified social worker. The Social Services Director (SSD), identified as the primary staff responsible for the social services department, reported having a bachelor's degree in engineering. Human Resources confirmed that the SSD’s two job descriptions for Social Services Director, dated 3/2017 and 2/2024, required a minimum of a bachelor's degree in Social Work or Human Services, and that the facility had no record of the SSD having such qualifications. The administrator acknowledged awareness that the SSD did not meet the qualifications outlined in the facility job description and that the facility did not have a qualified social worker to supervise or direct the department. The facility assessment dated 2/26 documented that the facility’s staffing plan included a full-time social worker, and the facility’s policy and procedure titled “Social Services,” dated 2001, stated that the director of social services is a qualified social worker. State regulations reviewed by surveyors defined social work services and required that the social work service unit be organized, directed, and supervised by a social worker responsible for supervising other social work staff, including social work assistants. Despite these requirements, all 98 residents were receiving medically related social services from staff who did not meet the regulatory or facility-defined qualifications for a social worker or social services director.
Incomplete and Inaccurate Controlled Substance Documentation and Oversight
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate records for controlled (scheduled) medications, including shipping manifests, Controlled Drug Records (CDRs), Medication Administration Records (MARs), and destruction logs. The Medical Records Director (MRD) explained that scheduled medications were delivered by the pharmacy with a corresponding shipping manifest, which served as documentation that the medications were delivered and received, and that these manifests, along with CDRs, were to be retained by the facility. When surveyors requested shipping manifests and CDRs for a specified period, the MRD was unable to locate all of the requested shipping manifests, indicating gaps in the documentation of controlled substance receipt. Further review and interviews at the medication cart with an LVN showed that the facility’s described process required each controlled medication to arrive with a shipping manifest and a corresponding CDR, with the medication locked in the cart and the CDR kept at the cart to document each removal of medication. Administration was to be documented on the MAR, and completed CDRs, along with any remaining medications upon discontinuation, were to be sent to the Director of Nursing. However, when the Assistant Director of Nursing (ADON) later attempted to match shipping manifests with CDRs for several residents’ narcotic prescriptions, the facility could not locate the corresponding CDRs for specific oxycodone and hydrocodone-acetaminophen prescriptions, demonstrating that the record system for these controlled medications was incomplete. In addition, the ADON identified CDRs and corresponding MARs for multiple residents and found that the documentation on the CDRs did not match the MARs on several listed dates and times for hydrocodone-acetaminophen and oxycodone orders. The ADON acknowledged that the facility did not have shipping manifests that matched the CDRs for these medications and that the information between the CDRs and MARs was inaccurate. Review of the facility’s Controlled Substances policy, dated November 2022, showed that the system was required to reconcile receipt, dispensing, and disposition of controlled substances using shipping manifests, CDRs, MARs, and destruction/return records, and that controlled substance inventory was to be monitored and reconciled to identify loss or potential diversion. The ADON also reviewed Pharmacy QAPI reports and the consultant pharmacist policy and stated that the consultant pharmacist reports for the relevant quarters did not document issues with incomplete or inaccurate controlled medication records, despite the facility’s expectation that such issues should have been identified. The consultant pharmacist’s role, as outlined in the facility’s Policy for Pharmacy Services – Role of the Consultant Pharmacist (Revision Date April 2019), included providing consultation on all aspects of pharmacy services and collaborating with the facility and medical director to develop, implement, evaluate, and revise procedures for pharmacy services. Nonetheless, the Pharmacy QAPI reports for the specified quarters did not reflect the problems with incomplete or inaccurate controlled substance documentation that were identified during the survey. This combination of missing shipping manifests, absent CDRs for certain delivered narcotics, and discrepancies between CDRs and MARs for multiple residents’ controlled medications constituted the documented deficiency in the facility’s controlled substance record-keeping system.
Failure to Include Respiratory Treatments in Baseline Care Plan
Penalty
Summary
The facility failed to ensure that a baseline care plan was developed within 48 hours of admission for a resident with a primary diagnosis of pulmonary coccidioidomycosis. The baseline care plan did not include critical information such as the resident's respiratory diagnosis, the need for suctioning, or the orders for oxygen and nebulizer treatments. This omission was identified during a review of the resident's admission records and physician orders, which clearly outlined the necessary respiratory treatments and medications required for the resident's condition. Interviews with facility staff, including the MDS Nurse, Assistant Director of Nursing (ADON), and Director of Nursing (DON), revealed that the baseline care plan should have included the resident's primary diagnosis and related treatments. The staff acknowledged that the baseline care plan was incomplete and did not meet the facility's policy requirements. The Administrator also confirmed that the baseline care plan should reflect the resident's diagnosis and treatment orders, indicating a lapse in the facility's adherence to its own care planning procedures.
Medication Error Rate Exceeds 5% Due to Incomplete Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a rate of 7.41% during the observation period. This deficiency was identified through observations, interviews, and record reviews, where two medication errors were noted out of 27 opportunities. The errors involved two residents who did not receive their prescribed medications as ordered. Specifically, one resident did not receive their prescribed Aspirin 81 mg for stroke prevention, and another resident did not receive their fluticasone propionate nasal suspension for nasal allergy. The errors were attributed to the failure of the nursing staff to adhere to the facility's medication administration policy, which requires checking the medication label three times to verify the right resident, medication, dosage, time, and route. Interviews with the involved LVNs revealed that they did not perform the necessary checks to ensure all medications were administered as ordered. The Assistant Director of Nursing and the Director of Nursing both emphasized the importance of double and triple-checking the electronic medication administration record (eMAR) to ensure accuracy in medication administration.
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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) |
|---|---|---|---|---|
| Delta View Post Acute | 3.1 mi | — | 6 | 0 |
| Diamond Ridge Healthcare Center | 5.1 mi | — | 3 | 0 |
| Pittsburg Skilled Nursing Center | 6.1 mi | — | 0 | 0 |
| Stonebrook Post Acute | 10.4 mi | — | 4 | 0 |
| Diablo Valley Post Acute | 12 mi | — | 11 | 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.