Lone Tree Post Acute
LONE TREE POST ACUTE in ANTIOCH, CA — inspection on April 27, 2026.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
CDRs and corresponding MARs. ADON inspected the CDRs and MARs. ADON stated the CDRs and
Hydrocodone-Acetamin 5-325 mg #60 date 9/9/239/20/23 015710/6/23 44010/9/23 170010/11/23
085811/19/23 0200Resident 7, 4757090 Oxycodone (narcotic pain reliever) 5 mg tablet #30 date 10/12/2310/14/23 100010/16/23 83010/16/23 213010/22/23 211210/29/23 2000Resident 8, 4763608 Hydrocodone-Acetamin 10-325 mg #30 date 10/18/2311/4/23 183011/5/23 1002Continuing the concurrent interview and record review, on 4/10/26 at 10:35 a.m. ADON acknowledged the facility did not have the Shipping Manifests that match the CDRs as documented above.
She further acknowledged that information was inaccurate between CDRs and corresponding MARs as documented above.
She stated that it was the facility's expectation that all documents were to be available and accurate.
Continuing the concurrent interview and record review, on 4/10/26 at 10:35 a.m. ADON was requested to provide the Pharmacist inspection reports for 9/1/23 through 12/31/23.
ADON identified the Pharmacy QAPI (Quality Assurance and Performance Improvement, process to improve resident safety and compliance) Report, Q4 2023, October, November, December and Pharmacy QAPI Report, Q1 2024, January, February, March.
She inspected the reports and stated they did not document issues with incomplete or inaccurate scheduled medication records.
Durning a concurrent interview and record review, on 4/10/26 at 11:04 a.m. ADON identified the Consultant Pharmacist Policy for Pharmacy Services-Role of the Consultant Pharmacist.
She stated that it was the facility's expectation that issues with scheduled medications should have been identified.
Durning a concurrent interview and record review, on 4/10/26 at 11:07 a.m. ADON identified the policy for Controlled Substances.
She reviewed the policy and acknowledged it required the documentation (Shipping Manifests, CDRs and MARs) to be complete and accurate (monitored and reconciled). An administrative record review of the Facility's Policy for Controlled Substances (November 2022) showed, Dispensing and Reconciling Controlled Substances, 2.
The system of reconciling the receipt (Shipping Manifest) dispensing and disposition of controlled substances includes the following: a.
Records of personnel access and usage (CDR, destruction log): b.
Medication administration records (MAR): c.
Declining inventory records (CDR): and d.
Destruction, waste and return to pharmacy records. An administrative record review of the facility's Policy for Controlled Substances (November 2022) showed, Dispensing and Reconciling Controlled Substances, 1.
Controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow-up. An administrative record review, of the Policy for Pharmacy Services-Role of the Consultant Pharmacist (Revision Date April 2019) showed, Policy Interpretation and Implementation, 3.
The consultant pharmacist shall provide consultation on all aspects of pharmacy services in the facility, and collaborate with the facility and medical director to:, a. develop, implement, evaluate, and revise (as necessary) the procedures for the provision of all aspects of pharmacy services.
056021 04/27/2026
Lone Tree Post Acute 4001 Lone Tree Way Antioch, CA 94509
Based on observation, interview and record review, the facility failed to follow state Title 22
worker which affected all 98 residents.This failure resulted in all residents receiving social services care from unqualified staff.
During an interview on 4/9/26, at 1:24 p.m., with the Social Services Director (SSD), SSD stated they were the primary staff responsible for the social services department. SSD stated they had bachelor's degree in engineering.During a concurrent interview and record review on 4/10/26, at 9:40 a.m., with Human Resources (HR), SSD's two job descriptions both titled, Job Description: Social Services Director, dated 3/2017 and 2/2024 was reviewed. HR stated after review of the job descriptions, both job descriptions indicate a minimum education requirement of Bachelor's Degree in Social Work or Human Services. HR stated they did not have record of SSD's past education but stated SSD had a bachelor's degree in engineering.
During an interview on 4/10/26, at 3:50 p.m., with the administrator (ADM), the ADM stated they were aware SSD did not meet the qualifications based the facility job description and the facility did not have a qualified social worker to supervise or direct the department.
The ADM stated SSD possessed a bachelor's degree but the subject of study did not meet the job requirement.During a review of facility assessment titled, [Facility] Facility Assessment, dated 2/26, the facility assessment indicated the facility staffing plan included a full-time social worker.During a review of facility policy and procedure (P&P) titled, Social Services, dated 2001, the P&P indicated the facility provides medically related social services.the director of social services is a qualified social worker.During a review of California state regulation titled, Title 22 S72433, the state regulation indicated 'Social Work Service' means those services which assist.a patient and a patient's family to understand and cope with.personal, emotional and related health and environmental problems.During a review of California state regulation titled, Title 22 S72105, the state regulation indicated a Clinical Social Worker was person who is a licensed clinical social worker by the Board of Behavioral Sciences.During a review of California state regulation titled, Title 22 S72437, the state regulation indicated Social Work Service Unit-Staff.the social work service unit shall be organized, directed and supervised by a social worker, who is responsible for supervision of other social work staff, including social work assistants.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.