Diablo Valley Post Acute: Controlled Substance Failures - CA
The inspection, conducted as a complaint investigation and completed in early September, identified breakdowns in the facility's own written procedures for tracking narcotics and other controlled drugs. The violations occurred at 4:30 p.m. and 8:20 p.m. on August 30, at 3:30 a.m. on August 31, and at 9:00 a.m., 1:00 p.m., and 8:30 p.m. on September 2.
The facility's own policy, dated November 2022, lays out a clear chain of custody for controlled substances. When medications are delivered, a nurse and the person making the delivery are supposed to count the drugs together, then both sign the controlled substance record. That joint count is the first checkpoint in a system designed to catch discrepancies before they compound.
It wasn't happening.
The same policy requires that inventory be monitored and reconciled continuously, specifically to identify loss or potential diversion, and to minimize the time between when something goes missing and when staff notice. The longer that gap, the harder it becomes to determine what happened to a medication, or who had access to it.
Controlled substance diversion in nursing homes is not a theoretical concern. Opioids and other scheduled medications are among the most tightly regulated drugs in any clinical setting precisely because they are targets for theft, both by staff and by outsiders. When reconciliation systems break down, missing doses can go undetected for days or weeks. Residents prescribed those medications may receive less than what was documented, or nothing at all, while records show otherwise.
Diablo Valley Post Acute's policy required that reconciliation cover four categories of records: personnel access and usage logs, medication administration records, declining inventory records, and destruction and waste logs. Each category is a cross-check against the others. A dose recorded as administered should appear in the medication administration record and reduce the inventory count. A dose wasted should appear in the destruction log. When those records aren't kept in sync, the gaps become invisible.
The policy also required that accountability records for discontinued controlled substances stay with the unused supply until it is destroyed or returned to the pharmacy. That requirement exists so that drugs don't sit unaccounted for in a facility, separated from the paperwork that tracks them.
Inspectors classified the violation as causing minimal harm or potential for actual harm, and noted that some residents were affected. That classification reflects what inspectors could document, not necessarily the full scope of what the recordkeeping failures may have obscured. By definition, a system that isn't tracking medications properly cannot fully account for what it missed.
The inspection ran from late August through September 3, 2025, when the surveyor's findings were recorded at 6:13 p.m.
What the records could not show, and what the facility's own broken system made impossible to determine, was whether every dose prescribed to every resident during those shifts was actually received.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Diablo Valley Post Acute from 2025-12-23 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 25, 2026 · Our methodology
DIABLO VALLEY POST ACUTE in CONCORD, CA was cited for violations during a health inspection on December 23, 2025.
The violations occurred at 4:30 p.m.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.