Diablo Valley Post Acute

In the surveyor’s words

From the most serious findings on record at Diablo Valley Post Acute, in the surveyor’s own words.

• Actual harm, isolatedF600Mar 17, 2026

  Based 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. […]

• Actual harm, isolatedF610Mar 17, 2026

  Based 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. […]

• Actual harm, isolatedF684Dec 23, 2025

  Based 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].These failures resulted in actual harm to Resident 1, who experienced prolonged, untreated… […]

• No harm, potential for more than minimal, widespreadF812Aug 13, 2026

  Based on observation, staff interview, and record review, the facility failed to store and prepare food in accordance with professional standards for safety when: Dry food items were stored less than six inches from the floor.A resident's ice pack was stored in the resident refrigerator.A resident's drink was not labelled with use by or opened date in the Resident Refrigerator.Cook (CK) 1 did not wear a beard restraint when they prepared resident food.There was hair on the inside part of the ice machine. During an observation on 8/10/26, at 9:44 a.m., in the dry storage, food thickener, flour, oatmeal and rice were stored approximately 5.5 inches from the floor. […]

• No harm, potential for more than minimal, widespreadF812May 26, 2026

  Based 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. […]