Diablo Valley Post Acute
Inspection Findings
F-Tag F0600
F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and record review, the facility failed to ensure one of five sampled residents (Resident 1) was free from physical abuse from Resident 2.This failure resulted in Resident 1 sustaining a blue-purple bump to right frontal area of head and a cut on upper lip.During record review of admission record, printed on 1/28/26, Resident 1 was admitted on [DATE REDACTED].During record review of admission record, printed on 1/28/26, Resident 2 was admitted on [DATE REDACTED].During record review of Resident 1's Minimum Data Set (MDS, an assessment used to guide care) dated 11/14/25, indicated Resident 1's Brief Interview for Mental Status (BIMS, an assessment used to assess mental status) score was 3 out of 15, which indicated resident's cognition was severely impaired.During record review of Resident 2's Minimum Data Set (MDS,
an assessment used to guide care) dated 8/19/25, indicated Resident 2's Brief Interview for Mental Status (BIMS, an assessment used to assess mental status) score was 8 out of 15, which indicated resident's cognition was moderately impaired. Section E, assessed Resident 2's behavior symptoms indicated physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) occurred one to three days out of seven.During an observation on 1/28/26, at 11:24 a.m., Resident 1 was sitting up in wheelchair outside of room, no discoloration or wounds were noted
on face.During an interview on 1/28/26, at 11:27 a.m., Licensed Vocational Nurse (LVN) 1 stated Resident 2 was easily agitated and sometimes irritated by other residents. LVN 1 stated staff often have to separate Resident 2 from others. During an interview on 1/29/26, at 10:54 a.m., Director of Nursing (DON) stated Resident 2 often woke up on wrong side of bed if heard noises or disturbances in shared room. DON stated Resident 2 had good and bad days due to dementia and could be easily upset about various things. DON stated Resident 2 had behavior problems in the past due to a need for medication adjustment. During an
interview on 1/29/26, at 11:17 a.m., Administrator (Admin) stated he was also the abuse coordinator and participated in the investigation after the incident on 08/12/2025 and found Resident 2's behavior to typically be upset or agitated about anything and required communication or talking down to diffuse behavior. Admin stated specific Certified Nursing Assistants (CNA) and facility Social Service staff are very familiar with Resident 2's behavior and need for redirection. During record review of Incident Summary, dated 8/14/2025, indicated a Resident-to-Resident Altercation occurred on 8/12/2025, at 10:15 a.m., between Resident 1 and Resident 2. The incident description indicated Resident 2 was observed by CNA swinging a coffee cup toward Resident 1's head.Resident 1 sustained a bump/discoloration on the right frontal area and a cut on the upper lip.During a review of the facility's policy and procedure (P&P) titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, dated April 2021, the P&P indicated, Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to other residents.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
Facility ID:
If continuation sheet
Event ID:
DIABLO VALLEY POST ACUTE in CONCORD, CA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in CONCORD, CA, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from DIABLO VALLEY POST ACUTE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.