Health inspection·January 16, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report an allegation of abuse, within required expected timeframe, to the State Survey Agency and Adult Protective Services (APS), for one of two sampled residents (Resident 1). This failure had the potential to not ensure additional protection of Resident 1 and other residents from abuse. Findings: During record review of Resident 1 ' s Face Sheet (FS), the FS indicated Resident 1 is an [AGE] year old resident admitted to the facility in 2024. FS indicated Resident 1 had a responsible party (RP 1) for emergency contact and financial decisions. FS also indicated Resident 1 ' s diagnoses included Cognitive Communication Deficit (reduced awareness and ability to initiate and effectively communicate needs), Intermittent Explosive Disorder (a mental health condition that causes sudden and impulsive episodes of anger and aggression), and Senile Degeneration of Brain (mental deterioration [loss of intellectual ability] that is associated with the characteristics of old age). During an interview on 12/17/2024, at 12:59 p.m., with Assistant Director of Nursing (ADON) 1, ADON 1 stated she received an alleged abuse allegation report on 11/19/24 at around 6:30 a.m., from a Clinical Supervisor that involved a Licensed Vocational Nurse (LVN) slapping Resident 1 on the face, during care received on the night of 11/17/24. ADON 1 stated she reported the alleged abuse incident to the Director of Nursing (DON), in the morning of 11/19/24. ADON 1 also stated the alleged abuse incident was reported to the Administrator (ADM) the same morning, on 11/19/24. During a record review on 12/17/2024 at 1:55 p.m., the facility ' s SOC 341 (Report of Suspected Dependent Adult-Elder Abuse), faxed to California Department of Public Health (CDPH), involving the alleged abuse incident towards Resident 1, indicated transmittal on 11/19/24 at 10:38 a.m Further review of the SOC 341, indicated, 12/17/2024 as date completed. The SOC 341 report had no contact name, telephone number, date, and time, the alleged abuse incident was reported to Law Enforcement and the Local Ombudsman. During an interview on 11/19/2024 at 1:50 p.m., with ADM, ADM could not provide law enforcement badge number or case number when requested. ADM further stated that he does not have a proof of the fax. During a record review of facility ' s policy and procedure (P&P), titled, Abuse, Neglect, (continued on next page) 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 Page 1 of 4 Event ID: 055150 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055150 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Diablo Valley Post Acute 3806 Clayton Road Concord, CA 94521 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)