Walnut Creek Nursing Center

Review of the medical record for Resident #105 revealed an admission date of 09/23/25 with diagnoses including anemia, heart failure, chronic kidney disease stage III, atrial fibrillation, and myelodysplastic syndrome. Resident #105 was discharged on 10/10/25.

The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #105 was cognitively intact and required partial/moderate staff assistance with bathing, toilet hygiene, bed mobility, and transfers.

Review of the facility's SRI number 265724 dated 09/26/25 at 4:34 P.M. stated on 09/25/25 at 9:00 P.M., Resident #105 was being assisted by CNA #211 and Licensed Practical Nurse (LPN) #220 and Resident #105 felt he was rushed with the mechanical lift transfer process and neither staff members were polite.

Review of the SRI investigation revealed an Employee Reporting form, that was not dated, did not indicate who obtained Resident #105's statement, was not signed, and did not have any questions on the form answered.

The form did contain documentation of a statement but did not indicate whose statement it was that said I was going to bed, I called and asked for help. I asked her to raise the bed, they tossed me in the bed and left me on the side of the bed, laying she didn't give me my call button, so I called out to see if anyone was in the hall.

She came in and yelled. (It was unspecified which staff member and what exactly was yelled at to Resident #105), The facility's investigation did not include CNA #211 and LPN #220's witness statements.

The investigation did not include any staff statements who worked the shift on 09/25/25.

The facility's investigation did not include Resident #105's roommate statement and/or other residents to see if they witnessed the incident and/or have concerns with CNA #211 and/or LPN #220.

Interview on 10/27/25 at 10:18 A.M. with the Director of Nursing (DON) confirmed SRI number 265724's investigation did not contain documentation to support witness statements were obtained.

The DON also confirmed the allegation of abuse was not reported immediately to Administrator or supervisor as per facility policy.

The DON also confirmed that the Employee Reporting form for SRI number 265724 did not contain the date/time, the name of the person who completed the form, the name of the person who provided the statement, or had any of the questions answered that were on the form.

Review of the facility policy titled Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property revealed the staff were to report all incidents/allegations of abuse immediately to the Administrator or designee.

Once the Administrator and State Agency are notified, an investigation of the allegation violation will be conducted and completed within five working days.

The investigation protocol included interviewing the resident, the accused, and all witnesses.

The witnesses generally, including anyone who witnessed or heard of the incident, came in close contact with the resident the day of the incident (including other residents, family members) and employees who worked closely with the accused employee(s) and/or alleged victim the day of the incident.

This deficiency represents non-compliance investigated under Complaint Number 2643951.

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