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Complaint Investigation

Stonebrook Post Acute

Inspection Date: December 22, 2025
Total Violations 1
Facility ID 555421
Location CONCORD, CA
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Inspection Findings

F-Tag F0584

Resident Rights Deficiencies
Harm Level: Potential for More Than Minimal Harm

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Based on observation, interview, and record review, the facility failed to maintain a homelike environment when three out of four sampled rooms (Room A, B, and C) were observed to have privacy curtains that were worn and frayed along the bottom and side edges, detracting from the homelike appearance of the resident rooms. This failure had the potential to negatively affect the residents' quality of life and homelike environment.During a concurrent observation and interview with Housekeeping Supervisor (HS) on 12/18/25 at 9:29 a.m., the bottom hems of the privacy curtains in room A and B were frayed with loose threads that were hanging down, and the fabric linings/nettings were exposed and detached near the lower edge. The side hem of the privacy curtain in room C appeared worn and frayed. The HS stated the curtains were torn and in need of replacement. HS stated there was no schedule for the facility staff to routinely check and inspect the curtains; instead, inspections were conducted on an as-needed basis. HS stated checking the condition of the privacy curtains was on his to-do list and he believed the facility had ordered new privacy curtains.During a record review of the facility's purchase order dated 11/6/25 with the Administrator (ADM) on 12/18/25 at 2:50 p.m., there were no privacy curtains ordered.During an interview

on 12/22/25 at 12:35 p.m., HS stated that 28 out of 69 resident rooms required replacement of privacy curtains.A review of facility policy and procedures (P&P) titled Homelike Environment, revision dated 2/2021, indicated, residents are provided with a safe, clean, comfortable, and homelike environment.

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:

📋 Inspection Summary

Stonebrook Post Acute in CONCORD, CA inspection on recent inspection.

Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.

What this means: Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. All deficiencies must be corrected within required timeframes and are subject to follow-up verification.

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 Stonebrook Post Acute or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.
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