Walnut Creek Nursing and Rehab

In the surveyor’s words

From the most serious findings on record at Walnut Creek Nursing and Rehab, in the surveyor’s own words.

• Actual harm, isolatedF600Jun 23, 2026

  Based on review of facility policy, clinical records, and facility documentation; and staff interview, it was determined that the facility failed to provide services to create an environment free from neglect by transferring a resident improperly, resulting in actual harm when the resident suffered an unsurvivable subdural hematoma (type of brain bleed in which the blood pools between the skull and the brain and is usually caused by head trauma) that required medical treatment at a hospital for one of three residents reviewed (Closed Record Resident CR17). This deficiency is cited as past non-compliance. […]

• No harm, potential for more than minimal, patternF550May 14, 2026

  Based on review of facility policy, clinical records, observations, and interviews, it was determined that the facility failed to ensure that a resident's dignity was maintained for five of 26 residents reviewed (Residents R18, R62, R89, R110, and R122). Findings include: Review of the facility policy entitled, Dignity dated 1/12/26, revealed Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem .Residents are treated with dignity and respect at all times.Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents; for example: b. […]

• No harm, potential for more than minimal, patternF584May 14, 2026

  Based on observations, review of facility policies and documents, and staff interviews, it was determined that the facility failed to provide housekeeping services necessary to maintain a clean environment and maintain resident equipment in good repair in two of five resident Units (Unit 2 and Unit 4).Findings include: A facility policy entitled, Quality of Care-Homelike Environment dated 1/12/26, indicated that residents are provided with a safe, clean, comfortable and homelike environment: that facility staff and management shall maximize, to the extent possible, the characteristics of the facility to reflect a personalized, homelike setting and included clean, sanitary, and orderly environment. […]

• No harm, potential for more than minimal, patternF628May 14, 2026

  Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to provide the resident and/or resident representative with a written notice of the facility bed-hold policy (explanation of how long a bed can be held during a leave of absence and the cost per day), and failed to make certain that the necessary resident information was communicated to the receiving health care provider upon transfer to the hospital for four of seven residents reviewed (Residents R10, R18, R31, and R68).Findings include:Review of facility policy entitled Transfer or Discharge Documentation dated 1/12/26, indicated Should the resident be transferred or discharged for any reason, the following information will be communicated to the receiving facility or… […]

• No harm, potential for more than minimal, patternF655May 14, 2026

  Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to provide a written summary of the baseline care plan and order summary to the resident and/or representative for four of 26 residents reviewed (Residents R18, R31, R101, and R122).Findings include:Review of facility policy entitled Baseline Care Plan dated 1/12/26, revealed that a written summary of the baseline care plan shall be provided to the resident and representative in a language that the resident/representative can understand. The summary shall include, at a minimum, the following:The initial goals of the resident. […]