Diablo Valley Post Acute

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a safe, sanitary, and comfortable environment when:-Bugs, flies, and spiders were observed in/or near resident rooms.-Garbage leakage in the garbage compactor area was noted, creating odors.-Unused/out-of-service equipment were stored outdoors in an area where the ground was muddy. These failures potentially increase the risk of pest infestation and posed avoidable health and safety risks to residents.

Inspectors wroteBased on interview and record review, for two of two (Resident 2 and 3) sampled residents reviewed for Restorative Nursing Program (RNP, a structured nursing-driven program designed to maintain or improve a resident's functional abilities, prevent decline and support independence with daily mobility, self care, and other ADLs), the facility failed to provide Restorative Nursing Assistant services (RNA, also referred to as RNP) as required in the resident's comprehensive care plans nor did it maintain restorative program to prevent further functional decline when:-Resident 2's RNA program was not initiated timely after skilled therapy ended.-Resident 3's repeated refusals to RNA services for ambulation were not addressed for three months from May 2026 to July 2026. This failure had the potential to result in decreased range of motion and overall functional decline.

Inspectors wroteBased on observations and interviews, the facility failed to store food in accordance with professional standards for food safety when a can of [NAME] pears with a dented rim and a package of pasta was open to the air were found on the shelves in the dry storage area of the facility kitchen, and when ceiling tiles throughout the facility kitchen were found to be stained, separating, peeling and had significant gaps between tiles. This failure could have resulted in resident's being served contaminated food causing potentially serious illness. FindingsDuring a concurrent observation and interview on 5/26/26 at 12:10 p.m. with Dietary Supervisor 1(DS1) in the dry storage area of the facility kitchen , a can of [NAME] pears with a dented rim and a package of pasta open to the air, were found on the shelf in the dry storage area of the facility. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the California Department of Public Health(CDPH) of a cockroach infestation in the facility kitchen resulting in a 24-hour facility kitchen closure by local public health. This failure had the potential to put the facility at risk for providing meals which would have threatened the well-being of medically fragile residents. During an interview on 5/22/26 at 12:30 p.m. with Registered Dietician (RD1), RD1 stated the facility did not report the kitchen closure to the California Department of Public Health (CDPH), because RD1 thought local public health would notify CDPH.During a concurrent interview and record review on 5/26/26 at 4:00 p.m. with the Administrator (ADM) in the ADM's office, files of incidents reported to CDPH were reviewed. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to maintain an effective pest control program. This failure resulted in the presence of live cockroaches and cockroach remains in the facility kitchen. The presence of pests had the potential to contaminate food and cause disease. During an interview on 5/22/26 at 12:30 p.m. with Registered Dietician(RD1), RD1 stated on 5/20/26 the local health department found roach remains inside the panel located below the hot food service area. RD1 stated the kitchen was closed by local public health until pest control was completed and the kitchen was deep cleaned. During an interview on 5/22/26 at 3:30 p.m. with the Director of Maintenance(DM1), DM1 stated the facility kitchen had not been inspected for pests from 12/1/25 until 5/20/26. During an interview on 5/26/26 at 1:30 p.m. [...]

Inspectors wroteBased on interviews and a review of facility records, the facility failed to ensure a safe environment and adequate supervision for one of five sampled residents (Resident 1) when Resident 1 first eloped from the facility and later, while back in the facility, Resident 1 fell and sustained a fracture. This deficient practice resulted in serious and preventable harm to Resident 1, including injury and fracture. A review of Resident 1's admission RECORD indicated Resident 1 was admitted to the facility with multiple diagnosis including bipolar disorder (a chronic mental health condition characterized by extreme mood swings, alternating between high-energy mania (or milder hypomania) and low-energy depression) and Alcohol abuse. [...]

Inspectors wroteBased on interview and record review, for one of two sampled residents (Resident 1), the facility failed to notify Resident 1's Attending Physician and Resident 1's Representative (RR) 1 following Resident 1's multiple falls. This failure violated Resident 1's right to have the physician and RR 1 promptly informed of an accident that may result in injury and had the potential to delay necessary medical assessment and involvement in care decisions. During a review of Resident 1's admission Record (AR) dated [DATE], the AR indicated Resident was initially admitted to the facility in February 2005 with diagnoses that included morbid obesity, open angle glaucoma (an eye disease that causes slow, symptomless vision loss), history of falling, and heart failure. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a safe, comfortable and homelike environment for residents when:1. a. Resident 2's closet door was not repaired timely, despite staff awareness of the defect. The closet door subsequently detached and fell on Resident 2's ankle, causing pain, bruising and swelling. b. Staff repaired Resident 2's closet door using hinges that were not the correct size for the door. This resulted in a large gap on one side and the opposite side overlapping with another door. As a result, Resident 2's closet door must be left open so the other door can be accessed. Additionally, Resident 2's bottom drawer could not be accessed unless the top drawer was open. [...]

Inspectors wroteBased on interview and record review, for one of two sampled residents (Resident 1), the facility failed to identify and assess a change in condition for Resident 1 who experienced multiple falls when facility did not complete a timely evaluation of Resident 1's post-fall status, including neurological checks (neuro checks, relating to the brain, spinal cord and the nerves, checks for alertness, language, level of consciousness, muscle strength and coordination, sensation), pain assessment, and monitoring for injury according to professional standards of care. This failure resulted in a delay in identifying Resident 1's change of condition and in implementing necessary interventions. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow infection control practices to prevent cross-contamination during resident care when Certified Nursing Assistant (CNA) 8 was placed dirty linens directly on the floor without bagging them and touched multiple items at the bedside, including personal care supplies and environmental surfaces, without removing and changing gloves between tasks. These failures created a risk for the spread of infectious organisms. During a concurrent observation and interview on 4/21/26 at 6:19 a.m. with CNA 8, inside Resident 5's room, CNA 8 placed a soiled linen on the floor near the trash can without bagging it. CNA 8, wearing gloves, repositioned Resident 8, adjusted the curtain and bed remote without changing gloves. CNA 8 then picked up the linen and trash, bagged them and exited the room. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that two out of three sampled residents (Resident 1 and Resident 2), were protected from sexual abuse (non-consensual sexual contact of any type with a resident). Resident 1 and Resident 2 were sexually abused during care provided by Certified Nurse Assistant (CNA) 1. This failure resulted in Resident 1 and Resident 2 experiencing sexual abuse and emotional distress. Cross Reference to F610Findings:During a review of facility's admission Record (AR) printed on 03/10/2026, the AR indicated Resident 1 was admitted on [DATE], with diagnoses that included fracture of left lower leg and generalized muscle weakness. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to identify and ensure that two out of three sampled residents (Resident 1 and Resident 2), were protected from sexual abuse (non-consensual sexual contact of any type with a resident). Resident 1 reported to staff members being sexually abused during care provided by Certified Nurse Assistant (CNA) 1. CNA 1 was not removed from the staffing schedule and was allowed to continue to care for other residents in the facility. These failures in a delay in implementing protective and preventative action resulted in Resident 2 experiencing sexual abuse. Cross Reference to F600Findings: During a review of facility's admission Record (AR) printed on 03/10/2026, the AR indicated Resident 1 was admitted on [DATE], with diagnoses that included fracture of left lower leg and generalized muscle weakness. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of five sampled residents (Resident 1) was free from physical abuse from Resident 2. This failure resulted in Resident 1 sustaining a blue-purple bump to right frontal area of head and a cut on upper lip. During record review of admission record, printed on 1/28/26, Resident 1 was admitted on [DATE]. During record review of admission record, printed on 1/28/26, Resident 2 was admitted on [DATE]. During record review of Resident 1's Minimum Data Set (MDS, an assessment used to guide care) dated 11/14/25, indicated Resident 1's Brief Interview for Mental Status (BIMS, an assessment used to assess mental status) score was 3 out of 15, which indicated resident's cognition was severely impaired. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to provide timely and appropriate nursing assessment, monitoring, and interventions to one sampled resident (Resident 1) under the care of a previously employed nursing staff member who was unlicensed and was using another individual's Registered Nurse (RN) license, when Resident 1 did not receive a physician ordered medication, nitroglycerin (medication used to treat chest pain by relaxing and widening blood vessels, which helps more blood and oxygen reach the heart) and emergency services were not initiated in a timely manner despite Resident 1 experiencing ongoing chest and abdominal pain lasting for approximately nine hours on [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the scheduled (controlled medication, narcotic) medication system was complete (all documents available) and accurate (correct information) for six (Residents 1, 2, 3, 4, 5, and 11) of 14 sampled residents when:1. Resident 1 and Resident 2's Controlled Drug Records (CDR, accountability records, an inventory sheet that keeps records of the usage of controlled medications) contained discrepancies and did not reconcile with the Medication Administration Records (MAR) while Resident 1 and Resident 2 under the care of previously employed nursing staff member who was unlicensed and was using another individual's Registered Nurse (RN) license.2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure safe administration of medication for one out of six sampled residents (Resident 2) when the licensed nurse who prepared the medication handed it to another licensed nurse for administration. This resulted in the accidental ingestion of Dakin's solution (diluted solution of made of bleach and other ingredients usually used to cleanse wood to prevent infection) by Resident 2. This failure had the potential to cause harm to Resident 2's health due to the ingestion of a chemical not intended for oral consumption. During a review of the facility's admission Record, the admission record indicated Resident 2 was admitted to the facility in April 2025 with multiple diagnoses that included osteomyelitis (Inflammation of bone caused by infection, generally in the legs, arm, or spine). During an interview on 09/24/25 at 01:57 p.m. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure for one out six residents (Resident 1), Resident 1's was in a room with enhanced barrier precautions (EBP - an infection control intervention designed to reduce transmission of resistant organisms that employ targeted gown and glove use during high contact resident care activities), EBP was not followed during nursing care and treatment. This failure had potential to spread infection when prevention of was not consistently practiced.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to resubmit a Preadmission Screening and Resident Review (PASRR) Level I evaluation for 2 (Resident #120 and Resident #124) of 5 residents reviewed for PASRR.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure staff documented medication administration on the electronic Medication Administration Record (eMAR) in a timely manner for 1 (Resident #72) of 4 residents observed during medication administration.

Inspectors wroteBased on interview, record review, facility document review, and facility policy review, the facility failed to ensure medication orders were accurately transcribed for 1 (Resident #42) of 5 sampled residents reviewed for unnecessary medications.

Inspectors wroteBased on observation, interview, record review, facility document review, and facility policy review, the facility failed to ensure medications were properly stored and not left at the bedside for 2 (Resident #94 and Resident #34) of 2 residents reviewed for accident hazards.

Inspectors wroteBased on observation, record review, interview, and facility policy review, the facility failed to have a medication error rate of less than 5%, with an error rate of 17.86%, affecting 2 (Resident #113 and Resident #72) of 4 residents observed during medication administration. The facility had five errors out of 28 opportunities.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to maintain an accurate medical record related to the use of pain medications for 1 (Resident #46) of 3 residents reviewed for pain management.

Inspectors wroteBased on observation, interview and record review, the facility staff failed to implement their infection prevention and control program when: 1. Personal clothing and belongings were not stored in a clean and sanitary manner for one of three sampled residents (Resident 2). 2. Housekeeper (HK) 1 did not perform hand hygiene after removal of soiled gloves. 3. Certified Nursing Assistant (CNA) 1 did not properly handle and transport soiled linens. These failures have the potential to cause cross contamination and not prevent the development and spread of infections among residents, staff, and visitors.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of abuse, within required expected timeframe, to the State Survey Agency and Adult Protective Services (APS), for one of two sampled residents (Resident 1). This failure had the potential to not ensure additional protection of Resident 1 and other residents from abuse.

Inspectors wroteBased on observation, interview, and record review the facility nursing staff did not provide the resident ' s Responsible Party access to medical records within 24 hours of written request. For Resident 1, the failure to access readily available medical records resulted in delayed treatment at another facility, which had the potential for injury or harm.

Inspectors wroteBased on interview, and record review the facility failed to provide shower to one of three sampled residents (Resident 1) per shower schedule. This failure placed Resident 1 at risk for poor hygiene, compromised skin integrity and overall well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dignity for one of five sampled residents (Resident 165) was protected when Resident 165 was seen from the hallway, visible to other residents as well as visitors while using the bedside commode next to her bed. This failure resulted in Resident 165 feeling embarrassed.

Inspectors wroteBased on interview and record review the facility failed to ensure one (Resident 51) of six sampled residents received treatment services to address limitation in range of motion to left upper extremity when; Resident 51 had decreased functional use of left hand and resting splint was not applied to left hand as ordered by the physician. This failure had the potential to cause residents decline in range of motion and risk of decreased muscle strength.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide the necessary care and services related to intravenous (IV- device use to administer medications or solutions directly into the veins) therapy as ordered by the physician for one of two sampled residents Resident 92. This deficient practice had the potential for transmission of infections and bacteria to Resident 92.

Inspectors wroteBased on interview and record review, the facility failed to ensure two (Resident 47 and 118) of five sampled residents were free from unnecessary drug when; Resident 47 and 118 were administered antipsychotic drugs without adequate clinical indication for use: Resident 47 was administered Aripiprazole (Abilify) an antipsychotic drug for continuous purposeless yelling out. Resident 118 was administered Seroquel an antipsychotic drug for agitation and striking out at staff. Alzheimer's Dementia-is a progressive disease that destroys memory and other important mental functions. Antipsychotic medication are drugs used to treat schizophrenia and bipolar serious mental health conditions, capable of affecting the mind, emotions, and behavior. According to the manufacturer, elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. [...]

Inspectors wroteBased on interview and record review, the facility failed to collaborate with hospice representatives and coordinate facility staff participation in the hospice care planning process for one (Resident 118) of two sampled residents receiving hospice care. This failure had the potential to result in residents to not received person centered care.

Inspectors wroteBased on observation, interview and record review, for six of 23 sampled residents (Residents 55, 1, 103, 27, 46, and 94) the facility failed to provide personal hygiene assistance (combing hair, brushing teeth, clipping/cleaning fingernails, shaving, showering, washing/drying the face and hands) when: 1. Resident 55 had long, chipped fingernails and her facial hair was unshaved; 2. Resident 1 had long, dirty fingernails; 3. Resident 103 had long fingernails; 4. Resident 27 had long, dirty fingernails; 5. Resident 46 had long, dirty fingernails; and 6. Resident 94 was not showered as scheduled. This failure had the potential to cause infections, skin injuries, embarrassment, and low self-esteem.

Inspectors wroteBased on observation and record review, the facility failed to treat one of 23 sampled residents (Resident 94) with dignity when they left the resident, who was dependent on staff to dress him, in a hospital gown while he attended a group activity. This failure had the potential to humiliate Resident 94 and diminish his sense of self-worth.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of 23 sampled residents (Resident 207) was assessed accurately when information in two Minimum Data Sets (MDS - an assessment tool used to guide care) coded Resident 207's Hospice status inaccurately. This failure had the potential for Resident 207 to not receive appropriate interventions and treatments for end-of-life care.

Inspectors wroteBased on observation, interview, and record review, for one of 23 sampled residents (Resident 94) the facility failed to develop a care plan for the use of a hand mitt. There was no monitoring of the application or the skin condition for Resident 94's left hand. This failure had the potential cause Resident 94 to experience a decline in physical functioning of his left hand and in skin breakdown where the mitt was applied.

Inspectors wroteBased on observation, interview and record review, for three of three sampled residents (Residents 27, 46, and 35) the facility failed to provide the care and services to prevent an avoidable decline in range of motion and mobility when: 1. Resident 27 did not receive interventions necessary to prevent contractures (when normally stretchy tissues are replaced by non-stretchy, fiber-like tissues and prevent normal movement); 2. A physician's order to apply a splint to Resident 46's left hand was not followed; and 3. A physician's order to apply a splint to Resident 35's right lower leg was not followed. This failure had the potential for Residents 27 and 46's contractures to worsen and for Resident 35 to develop contractures.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication error rate was less than five percent (%). Medication pass observations on 8/27/19 and 8/28/19 revealed two errors out of 28 opportunities, resulting in an error rate of 7.14% when: 1. For Resident 78, Licensed Vocational Nurse 5 (LVN 5) administered insulin (medication that lowers blood sugar levels in those with diabetes) using an insulin pen without first priming (removing air from the needle and insulin cartrdge) it, then removed the needle from the skin prematurely; and 2. For Resident 153, Registered Nurse 2 (RN 2) administered one tablet of Vitamin D3 instead of two tablets, per physician's orders. These failures had the potential for Residents 78 and 153 not receiving the full therapeutic effect of their prescribed medications and could result in undesired health outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 23 sampled residents (Resident 148) were free from significant medication errors when Resident 148 was administered Renvela (a phosphate binder medication) after meals instead of with meals as per the manufacturer's instructions; This deficient practice had the potential for Resident 148 to develop hyperphosphatemia (too much phosphate), which is associated with an increased prevalence of heart and circulatory diseases and mortality rates in patients with End-Stage Renal (kidney) Disease (ESRD).

Inspectors wroteBased on observation, interview and record review, for one (Resident 94) of 23 sampled residents the facility failed to follow hand hygiene practices that prevent the spread of disease and infection when: Proper hand hygiene and glove changes were not performed during wound care treatment for Resident 94. This failure had the potential to spread infection.