Walnut Creek Nursing Center

Inspectors wroteBased on record review, staff interviews and policy review, the facility failed to provide skin assessments, wound treatments and wound measurements were completed in a timely manner. This affected two (#13 and #15) of three residents reviewed for pressure ulcer. The facility census was 110.

Inspectors wroteBased on record review, observation, staff interview and policy review, the facility failed to ensure medications were given as ordered. This affected one (#19) of four residents observed for medication administration. The facility census was 110.

Inspectors wroteBased on record review, staff interviews, and policy review, the facility failed to accurately monitor and track infections in the facility. This had the potential to affect all 107 residents in the facility. The facility census was 107.

Inspectors wroteBased on observation, staff interviews, and policy review, the facility failed to ensure the refrigerators were clean and free from expired foods. This had the potential to affect 106 residents with exception of Resident #42 who the facility identified as being nothing by mouth (NPO). The facility census was 107.

Inspectors wroteBased on record review, staff interviews, and policy review, the facility failed to ensure a thorough investigation was completed when a resident eloped from the facility. This affected one (Resident #89) out of one resident reviewed for elopement. The facility census was 107.

Inspectors wroteBased on record review, staff interviews, and policy review the facility failed to ensure comprehensive care plans were developed and accurate. This affected two (Residents #14 and #63) out of three residents reviewed for care plans. The facility census was 107.

Inspectors wroteBased on medical record review, staff interview, and review of facility policy, the facility failed to ensure neurological (neuro) assessments were completed for residents following unwitnessed falls. This affected one (Resident #110) out of four residents reviewed for assessments. The facility also failed to ensure a resident was properly assessed for a change in condition prior to a hospital transfer. This affected one (Resident #07) out of the four residents reviewed for change in condition. The facility census was 107.

Inspectors wroteBased on record review, staff interviews, review of video footage, review of personnel files, review of Self- Reported Incidents (SRI), and policy review, the facility failed to ensure timely required checks were completed on residents throughout the shift, failed to ensure residents were assessed following an unwitnessed fall and prior to moving the resident off of the floor and placing her back in the bed, failed to ensure the staff appropriately transferred residents following an unwitnessed fall and failed to ensure a post-fall assessment was completed following an unwitnessed fall. This affected one (Resident #01) out of three reviewed for falls. The facility census was 107.

Inspectors wroteBased on observations, resident and staff interviews, the facility failed to ensure the common dining environment was conducive for residents eating in the dining room. This affected two (Residents #24, and #63) out of the six reviewed for dining. This had the potential to affect all 16 residents who ate in the main dining room. The facility census was 107.

Inspectors wroteBased on observation, record review, staff interviews, and policy review, the facility failed to ensure medications were administered per physician orders and that medication errors were below five percent (%). This affected three (Residents #11, #47, and #112) out of four residents reviewed for medication administration. The facility census was 107.

Inspectors wroteBased on observation, staff interviews, and review of the facility policy, the facility failed to ensure residents were served food to meet their needs. This affected one (Resident #104) out of three residents reviewed for proper diets. The facility census was 107.

Inspectors wroteBased on record review, review of facility's Self-Reported Incidents (SRI) and investigation, resident interviews, review of personnel file, and staff interviews, the facility failed to ensure the residents were treated with respect and dignity. This affected two (#34 and #40) of five residents reviewed for abuse and dignity.

Inspectors wroteBased on medical record reviews, resident and staff interviews, review of facility Self-Reported Incidents (SRIs) and investigation, and policy review, the facility failed to ensure staff immediately reported allegations of abuse to administration and failed to complete a thorough investigations into allegations of abuse. This affected two (#34 and #105) of five residents reviewed for abuse. The facility census was 103.

Inspectors wroteBased on observations, staff interviews, and review of facility policy, the facility failed to ensure staff had there hair contained in food preparation areas and failed to ensure food was stored properly. This had the potential to 98 out of 98 residents who receive their meals/food from the kitchen, the facility identified one resident (#30) that did not receive food from the kitchen. The census was 99.

Inspectors wroteBased on medical record review, staff interview, physician interview, review of the National Pressure Injury Advisory Panel (NPIAP) website, the facility failed to adequately assess residents' skin, failed to identify a pressure ulcer (a pressure ulcer is a localized injury of the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction), and/or aid in the healing of existing pressure ulcers. This resulted in Actual Harm to one resident (#17) who was at risk for developing pressure ulcers, was readmitted to the facility without a pressure ulcer, and subsequently developed an avoidable, in-house acquired pressure ulcer on 01/31/25 which was first identified as a stage III (full-thickness skin loss in which adipose [fat] is visible) pressure ulcer to the sacrum. [...]

Inspectors wroteBased on medical record review, observation, staff interview, and review of facility policy, the facility failed to ensure fall interventions were in place for a resident who was at risk for falls and had recent falls. This affected one (#69) of the three residents reviewed for accidents. The census was 95.

Inspectors wroteBased on record review, staff interview, and facility policy review, the facility failed to ensure medications were administered per physician's order. This affected one (#71) resident out of the five residents reviewed for medications. The facility census was 95. Findings Include: Review of medical record for Resident #71 revealed an admission date 09/04/25. Diagnoses included acute respiratory failure, obstructive and reflux uropathy, acute and chronic respiratory failure, pleural effusion, chronic obstructive pulmonary disease, morbid obesity, and sleep apnea. [...]

Inspectors wroteBased on medical record review, staff interview, and review of facility policy, the facility failed to ensure abnormal involuntary movement scale (AIMS) assessments were completed as ordered. This affected two (#69 and #76) of the five residents reviewed for unnecessary medications. The facility also failed to ensure an ordered stop date for an as needed (PRN) antianxiety medication was implemented. This affected one (#69) of the five residents reviewed for unnecessary mediations. The census was 95.

Inspectors wroteBased on observations, interviews, and facility policy, the facility failed to ensure the proper storage of medications when outdated and expired medications were being stored in the medication carts. This affected two (#47 and #70) residents of the five residents reviewed for medications. The facility census was 95. Findings Include: Review of medical record for Resident #70 revealed an admission date 03/21/24. Diagnoses included depression, type two diabetes, anemia, and hypertension. Review of record for Resident #47, revealed an admission date 11/19/24. Diagnoses included heart failure, depression and atrial fibrillation. Observation of the 100-hall medication cart on 03/19/25 at 10:55 A.M. with Licensed Practical Nurse (LPN) #117, revealed an Insulin Aspart (fast acting insulin) 100 units per milliliter belonging to Resident #70 with an open date of 02/06/25. [...]

Inspectors wroteBased on medical record review, observation, staff interview, review of online resources from Centers for Disease Control and Prevention (CDC), and review of facility policy, the facility failed to timely implement Enhanced Barrier Precautions (EBP). This affected three (#14, #17, and #46) residents of five reviewed for Transmission-Based Precautions (TBP). The census was 95.

Inspectors wroteBased on medical records review, staff interview, observation, review of facility policy, and review of Centers of Disease Control and Prevention (CDC) guidance, the facility failed to ensure staff wore appropriate personal protective equipment (PPE) while caring for a resident who was positive with Coronavirus Disease 2019 (COVID-19). This affected one (#1) out of three residents reviewed for infection control. The census was 90.

Inspectors wroteBased on medical record review and staff interviews, the facility failed to ensure physician orders were followed and parameters were met prior to the administration of insulin resulting in significant medication errors. This affected one resident (#10) of three residents reviewed for medication administration. Facility census was 85.

Inspectors wroteBased on medical record review, observations and staff interview the facility failed to ensure residents were administered as ordered resulting in two medication errors out of 25 opportunities or an eight percent (%) medication error rate. This affected two (#18 and #19) out of of four residents observed for medication administration. The facility census was 88.

Inspectors wroteBased on medical record reviews, observations, staff interview and review of medication information from Medscape, the facility failed to ensure antipsychotic and/or blood pressure medications were administered as physician ordered resulting in significant medication errors. This affected three (#15, #13, #18) of four residents reviewed for medication administration. The facility census was 88.

Inspectors wroteBased on Quality Assessment and Assurance (QAA) record review, staff interview, and policy review, the facility failed to ensure QAA meetings were conducted at least quarterly and all required members were in attendance. This had the potential to affect all 85 residents of the facility. The facility census was 85.

Inspectors wroteBased on medical record reviews, staff interviews, and review of the Resident Assessment Instrument (RAI) Manual 3.0, the facility failed to compete quarterly Minimum Data Set (MDS) assessments within the required time frame. This affected four (#21, #39, #46 and #77) of the 19 residents reviewed for timely completion of MDS assessments. The facility census was 85.

Inspectors wroteBased on medical record review, staff interview, and review of the Resident Assessment Instrument (RAI) 3.0 manual, the facility failed to complete comprehensive Minimum Data Set (MDS) assessments within the required timeframe. This affected two (#40 and #57) of the 19 residents reviewed for timely completion of MDS assessments. The facility census was 85.

Inspectors wroteBased on medical record review, staff interview and review of the Resident Assessment Instrument (RAI) 3.0 manual, the facility failed to ensure resident interviews were conducted for cognition Brief Interview for Mental Status (BIMS) and for mood 9-Item Patient Health Questionnaire (PHQ-9) as required by RAI manual. This affected two (#57 and #77) of the 19 residents reviewed for Minimum Data Set (MDS) assessment accuracy. The facility census was 85.

Inspectors wroteBased on record review and staff interview, the facility failed to accurately fill out a Preadmission Screening and Resident Review (PASARR) for Residents. This affected one (#68) of the five residents reviewed for PASARR. The facility census was 85.

Inspectors wroteBased on medical record reviews, staff interviews, and review of the Resident Assessment Instrument (RAI) manual 3.0, the facility failed to develop and implement comprehensive person-centered care plans. This affected three (#31, #77, and #87) of the 19 residents reviewed for comprehensive person-centered care plans. The facility census was 85.

Inspectors wroteBased on observations, record review, staff and resident interviews, and review of facility policy, the facility failed to provide dependent residents with bathing needs. This affected two (#01 and #37) of the four residents reviewed for activities of daily living (ADLs). The facility census was 85.

Inspectors wroteBased on medical record review, staff interviews, and policy review, the facility failed to complete weekly skin assessments and the facility failed to complete wound treatments as ordered by the physician for a resident's surgical site. This affected one (#31) of the six residents reviewed for wound care. The facility census was 85.

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to complete weekly skin assessments and monitoring of pressure ulcer as per facility policy. This affected one (#77) of the two residents reviewed for pressure ulcers. The facility census was 85.

Inspectors wroteBased on medical record review, observation, and staff interview, the facility failed to ensure a resident's tube feeding was administered per physician orders. This affected one (#25) of two residents reviewed for tube feeding. The facility census was 85.

Inspectors wroteBased on record review, staff interviews, and review of facility policy, the facility failed to administer and document as needed (PRN) psychotropic medications for an appropriate indication, failed to implement non-pharmacological interventions prior to administration of PRN psychotropics and failed to timely evaluate and monitor the effectiveness of antipsychotic medications for residents. This affected three (#26, #37 and #46) of the six residents reviewed for unnecessary medication use. The facility census was 85. Finding Include: 1) Record review of Resident #26 revealed an original admission dated of 07/14/2023 with diagnosis's including but not limited to: metabolic encephalopathy, vascular dementia, bipolar disorder, adult failure to thrive, chronic atrial fibrillation, type two diabetes, sleep apnea, hallucination, and orthostatic hypotension. [...]

Inspectors wroteBased on medical record review, observation, and staff interview, the facility failed to ensure a Frazier Water Protocol (protocol to allow residents with dysphagia to freely consume thin liquid water with supervision) was followed per resident preference and as physician ordered. This affected one (#21) of one residents reviewed for hydration. The facility census was 85.

Inspectors wroteBased on medical record review, staff interviews, review of the facility's Self-Reported Incident (SRI), and policy review, the facility failed to protect the resident's right to be free from sexual abuse. This affected one (Resident #1) of three residents reviewed for sexual abuse. The facility census was 92.

Inspectors wroteBased on medical record review, observations and staff and resident interviews, the facility failed to provide wound care treatment as ordered by the physician. This affected two (#110 and #176) residents out of the three reviewed for wound care. The facility census was 92.

Inspectors wroteBased on observation and staff interview the facility failed to ensure call lights were answered in a timely manner by any staff available and trained to complete the task. This affected three resident rooms (#301, #308 and #310) of three resident rooms reviewed for call light response.

Inspectors wroteBased on medical record review, staff interview, family interview, observation, and review of the Centers for Disease Control (CDC) guidelines, the facility failed to ensure residents who were recently admitted to the facility were put on quarantine status. This affected three residents (#140, #258, and #292 ) of four reviewed for newly admissions. The facility Census was 99.

Inspectors wroteBased on medical record review, staff interview, and policy review the facility failed to notify the resident and the contact party of a room change. This affected two residents (#63 and #75) of 20 residents reviewed. The facility census was 99.

Inspectors wroteBased on medical record review, review of the Notice of Medicare Non Coverage forms, and staff interview the facility failed to ensure timely notification was made to the resident or residents representative of the discontinuation of skilled services. This affected two residents (#08 and #05) of three reviewed for beneficiary notice. The facility census was 99.

Inspectors wroteBased on record review, interview, and policy review the facility failed to report an allegation of resident to resident abuse. This affected two residents (#61 and #63) of 21 reviewed for abuse. The facility census was 99.

Inspectors wroteBased on medical record review, interview, and policy review the facility failed to thoroughly investigate an allegation of resident to resident abuse. This affected two residents (#61 and #63) of 21 reviewed for abuse. The facility census was 99.

Inspectors wroteBased on medical record review, staff and resident interview, and policy review, the facility failed to ensure residents were provided a written notice of reason for the transfer. This affected one resident (#257) of two residents reviewed for transfer. The facility census was 99.

Inspectors wroteBased on medical record review, staff interview and review of the Resident Assessment Instrument (RAI), the facility failed to timely complete resident minimum data set (MDS) assessments as required. This affected three (#49, #55 and #27) of three residents reviewed for timely completion and submission of the MDS to Centers of Medicare and Medicaid. Facility census was 88.

Inspectors wroteBased on medical record review, observation, and interview the facility failed to accurately code the Minimum Data Set (MDS) reflecting the current health care status. This affected one resident (#48) of three residents reviewed for MDS accuracy. The facility census was 99.

Inspectors wroteBased on medical record review, observation, staff interview, and policy review the facility failed to develop and implement a baseline plan of care and provide a summary to the resident within 48 hours after admission. This affected one resident (#247) of one resident reviewed for baseline plan of care. The facility census was 99.

Inspectors wroteBased on medical record review, staff interview, and policy review the facility failed to ensure the type and location of dialysis site access was addressed in the comprehensive care plan. This affected one resident (#38) of two residents who received dialysis. The census was 99. Findings Include: Review of the medical record for Resident #38 revealed an admission date of 04/28/15. Diagnoses included end stage renal disease on hemodialysis, diabetes mellitus type two, and vascular dementia. Review of the active physician orders revealed an order dated 02/23/21 for Resident #38 to receive hemodialysis on Tuesday and Thursday. Further review of the active physician orders revealed there were no orders indicating Resident #38's type and location of dialysis site access. [...]

Inspectors wroteBased on medical record review, observation, and interview the facility failed to ensure the comprehensive care was revised to include an accurate dialysis schedule, accurate medication usage, and constipation issues. This affected two residents (#38 and #48) of 29 residents reviewed for comprehensive care plans. The census was 99. Findings Include: 1. Review of the medical record for Resident #38 revealed an admission date of 04/28/15. Diagnoses included end stage renal disease on hemodialysis, diabetes mellitus type two, and vascular dementia. Review of the quarterly minimum data set assessment dated [DATE] revealed Resident #38 was cognitively intact and received dialysis. Review of the active physician orders revealed an order dated 02/23/21 for Resident #38 to receive hemodialysis on Tuesday and Thursday. [...]

Inspectors wroteBased on medical record review, staff interview, and policy review the facility failed to ensure a discharge summary was provided to residents upon discharge. This affected one resident (#89) of four residents reviewed for discharge/hospitalization. The facility census was 99. Findings Include: Review of the medical record for Resident #89 revealed an admission date of 03/29/21. Diagnoses included diabetes mellitus type two, hypertension, and cerebral infarction. Review of the admission minimum data set assessment dated [DATE] revealed Resident #89 had moderate cognitive impairment and required extensive assistance with activities of daily living. Review of the health status note dated 04/14/21 at 12:11 P.M. revealed Resident #89 discharged home and all belongings and medication went with the resident. [...]

Inspectors wroteBased on record review, interview, and policy review the facility failed to ensure residents were provided timely incontinence care. This affected two residents (#60 and #71) of two residents reviewed for incontinence care of 44 incontinent residents. The facility census was 99. Findings Include: 1. Review of the medical record for Resident #60 revealed an admission date of 04/10/18. Diagnoses included chronic kidney disease stage three, diabetes mellitus type two, and neuromuscular dysfunction of bladder. Review of the annual minimum data set assessment dated [DATE] revealed Resident #60 was cognitively intact, required limited assistance with activities of daily living, required total dependence assistance with bathing, and was always incontinent of bowel and bladder. Interview with Resident #60 on 05/11/21 at 11:18 A.M. [...]

Inspectors wroteBased on medical record review, interview, and policy review the facility staff failed to monitor a dialysis access site. This affected one resident (#38) of two residents who received dialysis. The census was 99. Findings Include: Review of the medical record for Resident #38 revealed an admission date of 04/28/15. Diagnoses included end stage renal disease on hemodialysis, diabetes mellitus type two, and vascular dementia. Review of the quarterly minimum data set assessment dated [DATE] revealed Resident #38 was cognitively intact and received dialysis. Review of the active physician orders revealed an order dated 02/23/21 for Resident #38 to receive hemodialysis on Tuesday and Thursday. Review of the active physician orders revealed they had no documentation of the type and location of the residents dialysis access site as well as any orders to monitor the dialysis access site. [...]

Inspectors wroteBased on observation, staff interview, and policy review the facility failed to ensure medication was stored in a secure manner away from resident access. This had the potential to affected seven residents (#31, #26, #28, #55, #74, #44 #255) who the facility identified as independently mobile and confused of 15 who resided on the memory care unit and six residents (#246, #251, #5, #8, #24, #34) of 47 residents residing on the 100 and 200 halls. The facility census was 99.