Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Rossmoor Post Acute during CMS and state inspections, most recent first.
Lack of Qualified Dietary Oversight: The facility did not maintain a qualified DM or full-time RD oversight of kitchen operations during two separate periods. Staff interviews showed the prior CDM had left, the replacement had not yet started, and the facility planned to split kitchen supervision among the ADM, Sous Chef, and other staff. In a later period, the RD coverage was part time or remote, with staff stating the RD did not oversee the kitchen and another RD was only present for a mock survey.
Incomplete and inaccurate controlled substance documentation was found for multiple residents. The facility could not locate some narcotic Shipping Manifests and one resident’s CDR was missing. In other cases, CDR entries were incomplete or did not match MAR documentation for oxycodone and hydrocodone/acetaminophen. The DON acknowledged the documentation gaps, and the consultant pharmacist reports reviewed did not identify these irregularities.
Infection Control Lapses During Food Handling and Tray Line Service: A dietary staff member handled ready-to-eat foods with contaminated gloves, a maintenance staff member entered the kitchen and took fruit without hand hygiene, and the same dietary staff member handled raw fish and then returned to the tray line without changing gloves or cleaning hands before touching ready-to-eat items used to garnish resident meals. The food cart was later sent to the Medbridge unit with trays already passed out to residents.
A resident with severe cognitive impairment, whose daughter was listed as the emergency contact and responsible party, was found with significant bleeding from injuries to the elbow and thumb, requiring EMS transfer to a hospital. Nursing documentation described the bleeding, wound care, and transfer, but there was no documentation that the resident’s representative was notified of the change in condition or the transfer. The DON confirmed the absence of notification and change-of-condition documentation, despite facility policy requiring prompt notification of the resident representative for injuries and hospital transfers.
A facility failed to accurately complete a PASARR for a resident with bipolar and anxiety disorders. The resident's Level I PASARR incorrectly indicated no serious mental disorder or psychotropic medication use, leading to a negative result and no Level II screening. The DON acknowledged the inaccuracy and stated that PASARRs should be reviewed for accuracy upon admission.
A facility failed to maintain infection control by not discarding a used IV catheter for a resident with dehydration risk. The catheter, dislodged during care, was left attached to IV tubing on an IV pole, posing a risk for bloodborne infections. Staff interviews revealed a lack of communication and adherence to proper disposal protocols.
The facility failed to secure resident-identifiable information when medication bubble packs with resident details were left on treatment carts in a hallway, accessible to staff, residents, and visitors. Interviews revealed non-compliance with facility policies on handling confidential information, with staff acknowledging the need for secure disposal and storage of such materials.
A resident, dependent on staff for most ADLs, fell out of bed during after-shower care due to inadequate supervision and staffing. The resident, who required substantial assistance, was being assisted by three staff members, including a registry CNA unfamiliar with her care needs. The bed moved slightly during repositioning, causing the resident to fall and sustain a head laceration and ankle contusion, necessitating emergency care.
A resident with acute respiratory failure and sleep apnea was inaccurately assessed on the MDS, as it failed to reflect the use of a BIPAP machine. The MDS Coordinator and DON confirmed the error, which did not accurately represent the resident's health status, potentially affecting care delivery.
A resident experienced discomfort and anxiety due to the facility's failure to provide a timely replacement for a missing BIPAP mask connector. The resident had to use an ill-fitting mask, leading to interrupted sleep and skin breakdown. Despite ordering the part, shipment delays were not communicated to the resident, exacerbating the situation.
A resident using an oxygen concentrator did not have the required oxygen safety signage posted on their room door, as observed during a survey. The facility's policy mandates such signage to ensure safety, given the flammable nature of oxygen. Staff interviews confirmed the oversight, highlighting a failure to adhere to safety protocols.
A facility failed to report a suspicion of sexual abuse involving a resident within the required regulatory timeframe. The incident was initially reported by a CNA during a care conference, but the MSW did not submit the necessary reporting form, believing the facility had done its part in the investigation. The resident had a history of Alzheimer's Disease and was dependent on others for toileting hygiene. The facility's policy requires immediate reporting of suspected abuse, but this was not followed.
Lack of Qualified Dietary Oversight
Penalty
Summary
The facility failed to ensure adequate kitchen oversight when it did not have a qualified Dietary Manager and the Registered Dietitian did not provide full-time oversight of the kitchen for two separate periods. During an interview with Human Resources, it was stated that the previous Certified Dietary Manager’s last day was 8/21/25 and that another dietary manager would not start until 9/4/25. Registered Dietitian 1 stated that the dietary manager was responsible for supervising day-to-day kitchen activities, while the dietitian’s role was limited to resident assessments, weight monitoring, tube feeding management, care conferences, and occasional random checks or walkthroughs of the kitchen. During an observation and interview in the kitchen, the surveyor entered without a hairnet and the Sous Chef stated that a hairnet was not required in the kitchen. The Sous Chef also stated they were not a certified dietary manager and that their primary duties were cooking and ordering supplies. Registered Dietitian 1 later stated that a dietary manager needed to be qualified to understand food safety and infection prevention. At an interview with the Administrator and Director of Nursing, the facility’s plan was reviewed showing that kitchen responsibilities would be split among the Administrator, the Sous Chef, and other staff, and the Administrator stated the facility did not plan or attempt to find a temporary certified dietary manager. In a separate period, staff interviews and record review showed there was again no full-time registered dietitian oversight of the kitchen. The Dietary Manager stated Registered Dietitian 1 was no longer working at the facility and had been gone for about a week, while Registered Dietitian 4 was starting that day. The Sous Chef stated Registered Dietitian 2 worked part time in the evening on clinical dietitian work and did not oversee the kitchen. Human Resources confirmed that Registered Dietitian 1 had been working part-time and remotely, and Registered Dietitian 2 was part time. Records showed Registered Dietitian 1 worked 5.75 hours over three days remotely, and Registered Dietitian 2 worked 25 evening hours over ten days. Registered Dietitian 4 stated they were starting full time that day and that Registered Dietitian 3 had been overseeing the kitchen, while the Dietary Manager and Administrator 2 stated Registered Dietitian 3 was only present for two days to conduct a mock survey and present results to staff.
Incomplete and Inaccurate Controlled Substance Documentation
Penalty
Summary
The facility failed to ensure that controlled medication records were complete and accurate for multiple residents. During record review and interviews, the Record Director stated that narcotic Shipping Manifests were stored onsite, but the facility could not locate the Shipping Manifests for the period reviewed. The Registered Nurse described the narcotic accountability process as including pharmacy delivery, nurse signature on the Shipping Manifest, placement of the narcotic and CDR in the medication cart, documentation of removal on the CDR, and completion of the MAR if the drug was administered. For one resident, the facility could not find the CDR for oxycodone 5 mg tablets. For another resident, the CDR showed two tablets removed, but the required fields for date, time, amount used, and administered by were left blank. The DON acknowledged that the required fields were not completed. The DON also acknowledged multiple instances in which CDR removals for several residents did not have corresponding MAR documentation on the dates and times listed in the record review, including oxycodone and hydrocodone/acetaminophen entries across several residents. The DON acknowledged the issues with the scheduled medication record system, including Shipping Manifests, CDRs, and MARs, and stated that it was the facility’s expectation that narcotic tracking documents be complete and accurate. The Consultant Pharmacist summary reports for February through August documented no irregularities observed and did not identify issues with incomplete or inaccurate scheduled medication records, despite the deficiencies found during survey review. The facility policy stated that controlled substance inventory is monitored and reconciled to identify loss or potential diversion and that the system includes records of personnel access and usage, MARs, declining inventory records, and destruction, waste, and return-to-pharmacy records.
Infection Control Lapses During Food Handling and Tray Line Service
Penalty
Summary
The facility failed to ensure infection control practices were followed during food service activities when [NAME] 1 handled ready-to-eat foods with contaminated gloves and did not perform hand hygiene between tasks. During observation on 8/27/25 at 4:21 p.m., [NAME] 1 was measuring temperatures of foods at the tray line while wearing gloves, adjusted their glasses with a gloved hand, removed an alcohol wipe from their pants pocket with the same gloved hand, and then continued taking temperatures of chicken patties and fish patties without performing hand hygiene or changing gloves. The facility also failed to prevent cross-contamination in the kitchen and on the dinner tray line. On 8/27/25 at 3:37 p.m., a maintenance staff member entered the kitchen and took a banana from the fruit container near the tray line without performing hand hygiene. On 8/27/25 at 4:25 p.m. and 4:50 p.m., [NAME] 1 handled a plate of raw fish, placed it into the oven, then returned to the tray line without hand hygiene or changing gloves and used the same gloved hand on chopped green onions that were used to garnish chicken entrees. The Sous Chef confirmed the fish in the oven was raw, and the food cart had been sent to the Medbridge unit where trays were already passed out to residents.
Failure to Notify Resident Representative of Change in Condition and Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s responsible party of a significant change in condition and transfer to an acute care hospital. The resident had severe cognitive impairment, with a BIMS score of 2/15, and was care planned as confused and exhibiting cognitive loss. The care plan included a goal to discuss concerns regarding overall status and health with the resident and family as needed. The admission record listed the resident’s daughter as the first emergency contact and responsible party. A progress note documented that in the early morning hours, the resident was found bleeding from injury sites on the left elbow and right thumb, with the gown and bedding soaked in blood. The RN documented that the wounds were cleaned, dressings applied, and emergency responders were called to transfer the resident to the hospital for further evaluation, and that the resident left the facility on a gurney with EMTs. During interviews and record review, the RN who wrote the note did not recall the specific incident or the transfer but stated that they usually notify family by phone and leave a voicemail if unable to reach them. The DON confirmed there was no documentation that the resident’s responsible party was notified of the change in condition or the transfer to the hospital, and also noted there was no separate change-of-condition documentation regarding the bleeding episode. The facility’s policy on “Change in a Resident’s Condition or Status” requires prompt notification of the resident, attending physician, and resident representative of changes in medical or mental condition or status, including when the resident is involved in an accident or incident resulting in injury or when it is necessary to transfer the resident to a hospital. Despite this policy and the resident’s documented cognitive impairment and identified responsible party, there was no evidence that the responsible party was informed of the bleeding incident or the hospital transfer.
Inaccurate PASARR Screening for Resident with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure an accurate preadmission screening and resident review (PASARR) for a resident with mental health diagnoses. The facility's policy requires all new admissions to be screened for mental disorders, intellectual disabilities, or related disorders through the PASARR process. The resident in question was admitted with a medical history of bipolar disorder and generalized anxiety disorder. However, the Level I PASARR screening inaccurately indicated that the resident did not have a serious mental disorder and was not prescribed psychotropic medications for such conditions. The Director of Nursing acknowledged that the Level I PASARR did not reflect the resident's mental illness diagnoses or the use of psychotropic medication, leading to a negative result and the absence of a Level II screening requirement. This discrepancy was identified during an interview, where the DON stated that all PASARRs should be reviewed for accuracy upon admission. The failure to accurately complete the PASARR screening resulted in the deficiency noted in the report.
Failure to Properly Dispose of IV Catheter
Penalty
Summary
The facility failed to maintain proper infection control practices, leading to a deficiency in the handling of an intravenous (IV) catheter for Resident #313. The resident, who was admitted with a medical history of encephalopathy and altered mental status, was at risk for dehydration and required IV fluids. On 02/09/2025, the resident's IV catheter became dislodged, and the used catheter was not immediately discarded as required. Instead, it was left attached to the IV tubing and hanging from an IV pole in the resident's room, posing a risk for bloodborne infections. Interviews with various staff members, including Licensed Vocational Nurses (LVNs), Registered Nurses (RNs), and the Director of Nursing (DON), revealed a lack of clarity and communication regarding the proper disposal of the used IV catheter. The staff members acknowledged that the catheter should have been discarded immediately in a sharps container to prevent potential infection transmission. The Director of Staff Development, who also served as the Infection Preventionist, confirmed that the failure to discard the catheter promptly posed a risk for bloodborne infection transmission to residents or staff who might come into contact with the items.
Confidentiality Breach of Resident Information
Penalty
Summary
The facility failed to ensure the confidentiality and security of resident-identifiable information when medication bubble packs labeled with resident information were found unsecured and accessible in public areas. During an observation, it was noted that empty medication bubble packs with resident information were placed on top of a treatment cart in a hallway, making them visible and accessible to staff, residents, and visitors. Additionally, a paper document with resident names and vital signs was visible through a plastic bag. This breach of confidentiality was further evidenced by the presence of a gray plastic wash basin on another treatment cart, which also contained an empty medication bubble pack with resident information. Interviews with facility staff revealed a lack of adherence to the facility's policies regarding the handling of confidential information. The Director of Staff Development acknowledged that medication bubble packs should not be placed in boxes for shredding and emphasized the importance of securing such information. The Medical Records staff admitted to not checking the contents of the boxes, assuming they were someone else's trash, and noted that boxes should have lids for privacy. The Administrator confirmed that the boxes should not be open and that it was the responsibility of the Medical Records staff to ensure proper handling of documents. The Director of Nursing highlighted the importance of HIPAA compliance and the responsibility of all staff to protect patient information.
Inadequate Supervision Leads to Resident Fall
Penalty
Summary
The facility failed to provide adequate safety measures and supervision, resulting in a resident falling out of bed during after-shower care. The resident, who was dependent on staff for most Activities of Daily Living (ADLs) due to conditions such as morbid obesity, cerebrovascular accident, and schizophrenia, required substantial assistance for repositioning. Despite this, only three staff members were present to assist the resident, who typically required a three to four-person assist. During the incident, the resident was being assisted by three staff members, including a registry CNA who was unfamiliar with the resident's care needs. As the resident was being turned to complete the application of an incontinent brief, the bed moved slightly, and the resident fell, hitting her head and sustaining a seven-centimeter laceration on her forehead, a brief loss of consciousness, and a contusion on her right ankle. The resident was subsequently transported to the emergency department for evaluation and treatment. Interviews with staff revealed that the registry CNA was not adequately oriented to the resident's specific care needs, and the facility's policy on fall prevention was not effectively implemented. The incident highlighted a lack of sufficient staffing and inadequate training for temporary staff, contributing to the resident's fall and subsequent injuries.
Inaccurate MDS Assessment for Resident with Sleep Apnea
Penalty
Summary
The facility failed to accurately assess a resident using the Minimum Data Set (MDS), which is a critical assessment tool used to direct care. This deficiency involved a resident who was admitted with multiple diagnoses, including acute respiratory failure with hypoxia and obesity. The resident's care plan indicated a risk for respiratory impairment related to sleep apnea, and active orders included the use of a BIPAP ventilator and oxygen therapy. However, the resident's Quarterly MDS Assessment did not reflect the use of a non-invasive mechanical ventilator, such as a BIPAP or CPAP machine, which was necessary for managing the resident's sleep apnea. Interviews with the MDS Coordinator and the Director of Nursing revealed that the MDS Assessment was incorrectly coded, failing to indicate the resident's use of a non-invasive mechanical ventilator. The MDS Coordinator acknowledged being unsure about the specific machine used by the resident, despite knowing that the resident had been using such a device since admission. The Director of Nursing confirmed the error in coding, which did not accurately reflect the resident's current health status. This oversight resulted in an inaccurate assessment of the resident's condition, potentially impacting the delivery of person-centered care.
Failure to Provide Timely Respiratory Care
Penalty
Summary
The facility failed to provide necessary respiratory care in a timely manner for a resident who required a BIPAP machine to manage sleep apnea and acute respiratory failure. The deficiency occurred when a connecting piece of the resident's BIPAP mask went missing after the facility replaced the machine's tubing. As a result, the resident had to use an ill-fitting, temporary mask that caused discomfort, interrupted sleep, and skin breakdown on the nose bridge. The resident, who was admitted with diagnoses including acute respiratory failure with hypoxia and obesity, experienced significant inconvenience and anxiety due to the delay in receiving the correct BIPAP mask connector. Despite the Central Supply Manager (CSM) ordering the missing piece from Vendor 1, shipment delays occurred, and the resident was not informed of these delays. The resident's condition was further exacerbated by the lack of timely communication and updates from the facility staff. The facility's inaction in promptly addressing the missing BIPAP mask piece and the subsequent shipment delays led to the resident's mental and physical exhaustion. The resident had to endure ten nights of discomfort and anxiety, which ultimately prompted her to order the missing piece herself. The facility's failure to address the skin breakdown until several days later further highlights the deficiency in providing adequate respiratory care in accordance with professional standards.
Failure to Post Oxygen Safety Signage
Penalty
Summary
The facility failed to post oxygen safety signage on the door of a resident's room who was using an oxygen concentrator. This deficiency was identified during a survey where it was observed that the resident, diagnosed with acute respiratory failure with hypoxia, had an oxygen concentrator at their bedside but lacked the required signage indicating oxygen use. The absence of this signage was confirmed during an interview with the Nurse Supervisor, who acknowledged the responsibility to ensure such signage was posted. Further interviews with facility staff, including a Registered Nurse and the Assistant Director of Nursing, reinforced the importance of oxygen signage for safety reasons, as oxygen is flammable and combustible. The facility's policy and procedure on oxygen administration, dated 2021, clearly stated the requirement to place 'Oxygen in Use' signs on the room entrance door and over the resident's bed. Despite these guidelines, the necessary signage was not in place, indicating a lapse in adherence to established safety protocols.
Failure to Report Suspected Abuse Timely
Penalty
Summary
The facility failed to report a suspicion of sexual abuse involving a resident within the required regulatory timeframe. The incident was initially brought to attention during a care conference by a CNA, who reported finding the resident with a bloody discharge on her brief and her blanket partially pulled down after a visit from her spouse. Despite this, the facility's MSW did not report the incident to the appropriate authorities and instead sought guidance from the Ombudsman, who provided the necessary reporting form. However, the MSW later decided not to submit the form, believing the facility had done its part in the investigation and found no need to report the incident. The resident involved had a history of Alzheimer's Disease and failure-to-thrive, and was dependent on others for toileting hygiene. The CNA reported the suspicious circumstances to an LVN, who denied receiving such a report. The Hospice Registered Nurse also noted the suspicious behavior of the resident's spouse but did not find any signs of pain or infection during her assessment. The facility's Administrator also believed there was no reportable incident and did not initiate an abuse investigation. The facility's policy requires immediate reporting of any suspected abuse, neglect, or injuries of unknown origin to various authorities, including the state licensing agency, local/state ombudsman, and law enforcement officials. However, in this case, the facility did not follow its own policy, resulting in a failure to ensure a timely and complete investigation and to protect the resident and other residents from potential abuse.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Walnut Creek
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Walnut Creek Skilled Nursing & Rehabilitation Cent | 0 mi | ★★★★★ | 4 | 0 |
| Tice Valley Post Acute | 0.1 mi | ★★★★★ | 14 | 0 |
| Tampico Healthcare Center | 2.5 mi | ★★★★★ | 3 | 0 |
| La Casa Via Transitional Care Center | 2.6 mi | ★★★★★ | 0 | 0 |
| Moraga Post Acute | 3.5 mi | ★★★★★ | 6 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.