Walnut Creek Nursing Center

In the surveyor’s words

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

• Actual harm, isolatedF686Mar 20, 2025

  Based 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… […]

• Actual harm, isolatedF689Jul 6, 2023

  THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, review of hospital records, review of facility investigation, staff interview, policy review, and review of facility corrective action, the facility failed to ensure staff used the appropriate number of staff and safely repositioned a resident when providing care in bed. This resulted in actual harm when Resident #83 was being provided care from one staff member instead of two, was holding onto the bedside chair for support when turned onto her side, and rolled out of the bed onto the floor obtaining fractures to her left ankle and toes. […]

• Actual harm, isolatedF689Mar 28, 2023

  Based on medical record review, review of the hospital record, review of the fall investigation, staff interview, and policy review, the facility failed to ensure incontinence care was provided in a manner to prevent an avoidable fall with injury. This resulted in Actual Harm when State tested Nursing Assistant (STNA) #200 provided incontinence care alone, rolled the resident and then turned away from the resident to obtain supplies. Subsequently, Resident #01 fell off the bed onto the floor and sustained a closed fracture of the right humeral head requiring an emergency room visit. This affected one resident (#01) of three residents reviewed for falls. The facility census was 87. Findings include: Review of the medical record for Resident #01 revealed an admitted [DATE]. […]

• No harm, potential for more than minimal, widespreadF880Jan 14, 2026

  Based 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.Findings include:Review of the Infection Control tracking Logs for June 2025, July 2025, and August 2025 revealed infections were monitored and there was no Coronavirus (COVID-19) or Tuberculosis (TB) in the facility. There were no Infection Control Logs for September 2025, October 2025, November 2025, December 2025 and January 2026.Review of the COVID-19 positive residents dated 11/26/25, revealed there were four residents who tested positive for COVID-19 in November 2025. […]

• No harm, potential for more than minimal, widespreadF812May 28, 2025

  Based 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. Findings include: Observations of the kitchen on 05/21/25 at 2:14 P.M. revealed Dietary Aide (DA) #150 preparing meals trays and DA #160 arranging drink cups and preparing drinks. Neither DA #150 or DA #160 had were wearing hairnets or had their hair contained. Interview with DA #150 on 05/21/25 at 2:19 P.M. confirmed she was not wearing a hairnet. […]