Walnut Creek Skilled Nursing & Rehabilitation Cent

In the surveyor’s words

From the most serious findings on record at Walnut Creek Skilled Nursing & Rehabilitation Cent, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF842May 20, 2026

  Based on observation, interview, and record review, facility failed to maintain complete and accurate medical records for three out of four (Residents 1, 2, and 3) reviewed residents. This failure had the potential to lead to incorrect monitoring for residents in the behavioral health unit, potentially leading to harm. During a review of facility's document titled, admission Record, for Resident 1, printed 5/19/26, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with multiple diagnoses, including schizoaffective disorder (a mental health condition that is marked by a mix of symptoms, including hallucinations and delusions and mood disorder symptoms). […]

• No harm, potential for more than minimal, patternF584Jun 13, 2025

  Based on observation, interview, and record review, the facility failed to ensure five of five sampled residents (Residents 148, 68, 109, 133, and 140) were provided a clean, sanitary and homelike environment when whitish grime, stains and dried matter were sticking on the surroundings of Residents 148, 68, 109, 133, and 140's mattresses. These failures had the potential to cause discomfort, emotional distress, and spread of disease-causing organisms to Residents 148, 68, 109, 133, and 140. […]

• No harm, potential for more than minimal, patternF757Jun 13, 2025

  Based on observation, interview, and record review, the facility failed to ensure for two out of 31 (Residents 138 and 49), were routinely given pain medications without clarification of physician's order and adequate indications. For Resident 138, he was regularly given Norco oral tablet (medication used to treat moderate to severe pain) 5-325 milligram (mg) tablet to be administered one tablet three times a day, and Tylenol Extra Strength oral tablet (medication used to treat minor pain and fever reducer) 500 mg tablet to be administered one tablet two times a day. […]

• No harm, potential for more than minimal, patternF812Jun 13, 2025

  Based on observation, interview and record review, the facility failed to prepare food in accordance with professional standards of food service safety when Facility [NAME] (FC) touched ready-to-eat food on multiple plates with the same gloved hand that was used to hold oven handles. This failure had the potential to result in cross-contamination and food-borne illness. Findings: During trayline observation and concurrent interview on 6/12/25 from 11:32 a.m. through 1:10 p.m. with Facility [NAME] (FC) and Kitchen Manager (KM), FC began to scoop food from the trays on the steam table, placed the food items on individual plates by pushing them off the ladle while wearing disposable gloves, at times gently pushing the food item towards the center of the plate. […]

• No harm, potential for more than minimal, patternF636Jan 26, 2024

  Based on interview and record review, the facility failed to complete and submit the quarterly and annual comprehensive Minimum Data Set (MDS, an assessment tool) assessments for 13 of 13 sampled residents. This failure placed residents at risk for not being assessed in a timely manner resulting in potential for inappropriate care planning and interventions. Findings: During a concurrent interview and record review on 1/25/24 at 9:41 a.m. with MDS coordinator (MDSC), Resident 97's quarterly MDS, with an assessment reference date (ARD, the last day of the observation or lookback period facilities use when filling out the MDS) of 11/21/23, was reviewed. The MDSC stated Resident 97's assessment was completed on 1/17/24 and transmitted on 1/22/24. […]