Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
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 Shadelands Post Acute during CMS and state inspections, most recent first.
A resident with severe cognitive and mobility impairment, poor vision, and high fall risk had multiple unwitnessed falls while staff reported difficulty maintaining constant monitoring because they were caring for other residents and could not coordinate permanent observation. The resident was found after one fall sitting by the foot of the bed with gushing forehead bleeding and two open skin tears, and the DON could not provide documentation supporting the claimed hourly and frequent rounding.
Improper Handling of Soiled Resident Clothing: Staff failed to properly bag residents' dirty clothing before transporting it to the laundry. An ES Director observed three mesh bags of soiled clothing on the laundry room floor, and staff interviews confirmed that dirty clothing should be placed in a plastic bag before being put into a mesh laundry bag for transport. The IP also stated this was required to prevent spread of infection, and the facility policy directed soiled laundry to be handled and transported according to infection prevention best practices.
The facility failed to follow its antibiotic stewardship program for a resident who was started on Macrobid for urinary frequency after the family reported symptoms and the MD ordered urine testing. Lab results later showed urogenital flora, and the IP stated the antibiotic use did not meet McGeer’s Criteria and should have been discontinued. Review of the ATB log also showed multiple residents had antibiotic use that did not meet McGeer’s criteria, and staff stated nurses did not use criteria when communicating suspected infections or receiving antibiotic orders.
Failure to Offer Appropriate Pneumococcal Vaccination Series: Four residents were not ensured appropriate pneumococcal vaccine review and offering. One resident had a prior PPSV23 dose, while three residents had refused PPSV23 and had no other pneumococcal vaccine history. During record review, the IP stated she did not know the CDC recommendations or the timing for pneumococcal vaccination series, and the facility policy referenced following current CDC guidance.
A resident with stroke-related deficits, cognitive impairment, depression, and anxiety was given Trazodone for sleep/depression without the physician first informing the RP of the medication’s use, risks, and benefits. The resident had a severely impaired BIMS score, the MD stated he did not speak with the RP before prescribing the psychotropic medication, and the ADON completed the consent form based on an assumption that consent had already been obtained. The DON acknowledged informed consent had not been obtained before the medication was administered.
Inappropriate Pain Assessment Used for Cognitively Intact Resident: A resident who could communicate verbally and was cognitively intact requested pain medication for pain in both knees, but an LVN did not ask for a pain level and instead documented pain using the PAINAD scale, which is intended for residents who cannot reliably self-report. The resident received tramadol, and the record showed inconsistent pain documentation, including a pain level of zero on the MAR and a note of knee pain without a pain score.
Controlled Medication Not Reconciled With MAR Documentation: A resident admitted with osteomyelitis of the cervical vertebra, acute respiratory failure with hypoxia, and pneumonia had an order for oxycodone 10 mg PRN. The CDR showed one dose was signed out, but the MAR had no staff initials to show the dose was administered. The ADON confirmed the MAR did not document the medication as given, despite facility policy requiring MAR initials after administration and controlled substance reconciliation using the MAR.
Medication Administration Errors Exceeded Allowed Rate: Two medication errors were observed during med pass, resulting in a 7.69% error rate. An LPN gave tramadol to a resident whose pain level was documented as zero, and another LPN did not administer polyethylene glycol in accordance with the order requiring it to be dissolved in 4 to 8 oz of fluid. The residents involved had significant medical histories including heart failure, encephalopathy, a femur fracture, anemia, and HTN.
Unlabeled Nasal Spray and Unauthorized Inhaler Storage: An LPN administered afrin nasal spray to a resident even though the bottle and box were not labeled with the resident’s name, and an alvesco inhaler brought in by the family was stored in the med cart without an active order. The DON confirmed the inhaler had no current prescriber’s order, and the resident’s order summary showed no active order for the inhaler.
The facility failed to employ a full-time RD and had a DM who was not certified or qualified for the role. The DM stated he was in school and not certified, while the RD stated she worked only 24 hours per week. The Admin acknowledged the DM was not certified and was in a training program.
A resident admitted with major depressive disorder had a binding arbitration agreement signed by the family representative after all admission paperwork was presented together. The family representative said the agreement was not explained and they did not know it was optional. Staff interviews and facility policy confirmed the agreement should be clearly explained, including that it is optional and that signing waives the right to a trial.
Equipment Maintenance Failure: A resident's bed made a loud cranking noise when raised and lowered during care, and staff acknowledged the issue had been ongoing. A CNA said nursing staff and maintenance were aware, an RN said the bed was sometimes lubricated, and the MS said about half of the facility's beds made cranking noises and were oiled only when residents were discharged because of concern about lubricant smell. The Admin said the facility was in the process of buying new beds and planned to replace all residents' beds.
Unqualified Social Services Staffing and Supervision: The facility failed to ensure the social services department was staffed and supervised by qualified personnel, and all residents received social services from unqualified staff. HR reviewed the SSD job description and could not determine the minimum educational requirements, while also stating applicants were not checked for qualification. The SSD was the only social services staff member, and the ADM confirmed there was no qualified social worker overseeing the department.
Controlled medication records were not accurate for multiple residents. The DON and MRD described the controlled substance process as requiring pharmacy delivery records, CDR documentation, and MAR charting, but record review showed multiple Hydrocodone/APAP and Oxycodone removals on the CDRs that did not have corresponding MAR administrations. The pharmacist’s review also noted that PRN doses on the CDR should match nurse initials in the EMAR, and a pharmacy inspection found several controlled drug charting entries were not reconciled.
Inadequate Supervision for Resident With Repeated Falls
Penalty
Summary
The facility failed to ensure adequate supervision for a resident with a history of unwitnessed falls. Resident 74 was admitted with diagnoses including abnormalities of gait and mobility, hemiplegia and hemiparesis affecting the left side, lack of coordination, and cognitive communication deficit. The resident’s MDS showed severely impaired vision, dependence on two or more helpers to walk at least 10 feet, use of a walker and wheelchair, dependence with toileting hygiene, impairment on one side of the upper and lower extremities, and a BIMS score of 03 indicating severely impaired mental status. Record review showed the resident was assessed as high risk for falls, with fall risk scores of 20, 20, and 22. The progress notes documented multiple unwitnessed falls, including being found lying on the floor, on the floor mattress, and on top of the floor mattress. On 3/8/26 at 1:35 a.m., the resident was found sitting on top of the fall mattress by the foot of the bed with gushing blood from the forehead and two open skin tears, and was transferred to the ED for further evaluation. Staff interviews indicated the resident was placed opposite the nurses’ station and was difficult to monitor consistently because staff were attending to other residents, answering call lights, doing rounds, and providing wound care. The LVN stated the resident became agitated and got out of bed wanting to go home or look for her daughter, and that permanent one-on-one monitoring was hard to coordinate. The DON stated the resident was monitored with hourly and frequent rounding, but could not provide documentation to support that hourly and frequent rounding was provided. The fall care plan identified impaired safety judgment, impulsive behavior, decreased mobility, and failure to follow safety precautions, with frequent rounding added to fall rounds.
Improper Handling of Soiled Resident Clothing
Penalty
Summary
The facility failed to observe infection control practices when residents' dirty clothing was not bagged properly before being transported to the laundry. During a concurrent observation and interview on 5/13/26 at 3:19 p.m., three mesh bags of residents' dirty clothing were observed on the floor in the laundry room. The Environmental Services Director stated that residents' dirty clothing should be covered with a plastic bag when transported to the laundry room to prevent spread of infection. During interviews on 5/14/26, a CNA stated that residents' dirty clothing are placed in a plastic bag and then a hamper when transported to the laundry, and another CNA stated she had been trained to place dirty personal clothing in a plastic bag and then in a mesh laundry bag before transport. The second CNA stated she cared for the resident in room [ROOM NUMBER] and placed the dirty clothing in the laundry, and said it must have been an oversight that the clothing was not first placed in a plastic bag. The Infection Preventionist stated residents' dirty clothes need to be in a plastic bag and placed in mesh bags when transported to laundry. The facility policy titled, Laundry and Bedding, Soiled, dated January 2026, stated soiled laundry/bedding shall be handled, transported and processed according to best practices for infection prevention and control.
Failure to Follow Antibiotic Stewardship Criteria
Penalty
Summary
The facility failed to implement its antibiotic use protocols for one sampled resident who was prescribed Macrobid 100 mg twice daily for 5 days for a suspected UTI after the resident’s daughter reported frequent urination throughout the night and the physician was notified. The nurse’s note documented the report of urinary frequency, and urine testing was ordered. Lab results later showed that the urine culture collected on 4/11/26 and again on 4/17/26 final result indicated urogenital flora was isolated. During review of the facility’s monthly antibiotic stewardship/surveillance log, the Infection Preventionist stated the resident’s Macrobid use for UTI did not meet McGeer’s Criteria. She also stated nurses do not have or use criteria when receiving antibiotic orders, that McGeer criteria are used after residents are started on antibiotics, and that the resident’s antibiotic order should have been discontinued when the lab results showed urogenital flora. The review further found that multiple residents on the April 2026 antibiotic log had antibiotic use that did not meet McGeer’s criteria, and the facility’s policy stated antibiotics were to be prescribed and administered under the guidance of the antibiotic stewardship program.
Failure to Offer Appropriate Pneumococcal Vaccination Series
Penalty
Summary
The facility failed to ensure that four sampled residents were offered appropriate pneumococcal vaccination series. During review of Resident 3’s admission record and immunization record, the resident was noted to have received PPSV23 on 10/28/16. During the concurrent interview and record review, the LVN/Infection Preventionist stated she did not know the time interval for recommending a pneumococcal vaccine after the last dose and stated she was not aware of CDC recommendations for use of the pneumococcal vaccine series. Resident 9, Resident 24, and Resident 34 each had immunization records showing refusal of PPSV23 and no history of any other pneumococcal vaccine. During the concurrent interview and record review, the LVN/Infection Preventionist stated she did not know the CDC recommendations for use of the pneumococcal vaccine series. The facility policy titled Pneumococcal Vaccine, dated 2001, stated that administration of pneumococcal vaccines is made in accordance with current CDC recommendations at the time of vaccination.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that one sampled resident with hemiplegia and hemiparesis affecting the left-dominant side, cognitive communication deficit, depression, and anxiety was provided information necessary to obtain informed consent before Trazodone was administered. The resident’s admission MDS showed a BIMS score of 03, indicating severely impaired mental status, and the resident was unable to recall the correct year, month, and day of the week. The resident’s order summary showed Trazodone 50 mg at bedtime was prescribed for depression manifested by inability to sleep, and the MAR showed the medication was administered from 1/1/26 through 1/14/26. During the interdisciplinary team meeting, the resident’s responsible party was told about Trazodone and stated the resident would never consent to a psychotropic medication like Trazodone. The physician stated he did not obtain informed consent from the responsible party and did not speak with the responsible party before prescribing the medication. The assistant director of nursing completed the informed consent form but stated she assumed the physician had already obtained consent and did not remember whether she called the responsible party or the resident’s son. The director of nursing stated the facility was aware informed consent had not been obtained prior to administration and use of Trazodone. The facility policy stated the prescribing clinician will obtain informed consent from the resident or resident representative for use of a psychotropic medication.
Inappropriate Pain Assessment Used for Cognitively Intact Resident
Penalty
Summary
Provide safe, appropriate pain management for a resident who requires such services was not met when facility staff failed to perform an appropriate pain assessment for Resident 18. Resident 18 was admitted with metabolic encephalopathy, chronic diastolic heart failure, and pleural effusion. The MDS indicated he could make himself understood and understand others, and his BIMS score was 14 out of 15, indicating cognitively intact status. Nursing daily skilled charting also described him as able to communicate well verbally and responsive. On 5/12/26, Resident 18 requested pain medication from an LVN and stated he had pain in both knees. The LVN asked where the pain was, but did not ask for a pain level. The LVN then administered tramadol 50 mg and documented the resident's pain using the PAINAD scale, which is intended for residents who cannot reliably self-report pain. The medication administration note documented knee pain without a pain level, while the MAR later showed a pain level of zero for that administration. During interview, the LVN stated she did not ask Resident 18 for his pain level, and another staff member stated the pain assessment was based on the resident's reaction. The facility policy stated the Numeric Pain Scale should be used when the resident can reliably self-report and PAINAD should be used when the resident cannot reliably self-report.
Controlled Medication Not Reconciled With MAR Documentation
Penalty
Summary
Controlled medication accountability was not fully reconciled for one resident when a random controlled medication audit did not match the documentation. The resident was admitted with osteomyelitis of the cervical vertebra, acute respiratory failure with hypoxia, and pneumonia, and had an order for oxycodone 10 mg, one tablet by mouth every four hours as needed for pain. The controlled drug record showed one oxycodone 10 mg dose was signed out at 3:55 p.m., but the resident’s MAR for that day did not contain licensed staff initials in the box for the oxycodone dose to show it was administered. During a concurrent interview and record review, the ADON confirmed that the oxycodone was not documented as given on the MAR. The ADON stated the expectation was for staff to document in the MAR after the medication was taken out of the packaging and signed in the CDR so it would be known that the medication was given. The facility policy on controlled substances required reconciliation of controlled substances using medication administration records, and the medication administration policy stated the person administering the medication must initial the resident’s MAR after giving each medication.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility had a 7.69% medication error rate, with two medication errors identified out of 26 opportunities during medication administration for two sampled residents. The errors involved Resident 18 receiving tramadol when the documented pain level was zero, and Resident 59 not receiving polyethylene glycol as ordered. The report stated these failures resulted in the residents receiving medication not in accordance with the prescriber's orders. Resident 18 was admitted with metabolic encephalopathy, chronic diastolic heart failure, and pleural effusion. His MDS indicated he could make himself understood and understand others, and his BIMS score was 14 out of 15. During observation, he requested pain medication and said both knees hurt, but the LVN was not heard asking for a pain level. The LVN administered tramadol 50 mg, and the MAR later showed a pain level of zero at the time of administration. In interview, the LVN stated she did not ask Resident 18 for his pain level, and another staff member stated she based the pain assessment on his reaction. Resident 59 was admitted with a displaced midcervical fracture of the right femur, acute post hemorrhagic anemia, and essential hypertension. During medication administration, an LVN prepared polyethylene glycol by mixing 17 gm of powder into approximately 2.5 oz of water, although the order required dissolving it into 4 to 8 oz of water or juice. Resident 59 drank only about 1.5 oz of the mixture and said he did not want to drink all of the water, and the LVN removed the cup from the room. The facility policy stated medications must be administered in accordance with the orders.
Unlabeled Nasal Spray and Unauthorized Inhaler Storage
Penalty
Summary
Medication storage and labeling practices were not properly followed for Resident 60. During a medication administration observation, LVN 4 prepared and administered afrin nasal spray to Resident 60 even though the nasal spray bottle and box container were not labeled with the resident’s name. LVN 4 stated that the resident’s name should have been on both the bottle and the box. Resident 60 had been admitted with diagnoses including pulmonary embolism without acute cor pulmonale, bacteriuria, and hypothyroidism, and had an active order for afrin nasal spray for nasal congestion. The facility also stored Resident 60’s alvesco inhaler in the medication cart without an active prescriber’s order. During observation, the inhaler was found in a zip lock bag in the third left drawer of medication cart 2 with the resident’s name written on the bag. LVN 4 stated the medication had been brought in by the resident’s family member and that medications stored in the cart were for current resident use. The DON later stated the inhaler could not be used because there was no active order and that it should have been kept in the medication room until the family member picked it up. A review of the order summary confirmed there was no active order for the inhaler.
Unqualified dietary leadership and no full-time RD
Penalty
Summary
The facility failed to employ a full-time registered dietitian and also had a dietary manager who was not certified or qualified for the position. During interview, the Dietary Manager stated he was not a certified dietary manager and was currently in school. The Registered Dietitian stated she was hired part time and worked 24 hours per week. The Administrator acknowledged awareness that the Dietary Manager was in school and not certified. Record review of the Dietary Manager’s employee record showed he was hired on 10/3/22 as the Dietary Manager, and the Administrator stated he was currently in a training program.
Binding Arbitration Agreement Not Clearly Explained
Penalty
Summary
The facility failed to ensure that a binding arbitration agreement was explained in a manner understandable to the family representative of Resident 25. Resident 25 was admitted to the facility in March 2026 with a diagnosis of major depressive disorder. During an interview, the family representative stated they completed the admission paperwork and signed the binding arbitration agreement after being given all of the admission paperwork at one time and told to sign it. The family representative stated the agreement was not explained and that they did not understand it was optional. Facility staff interviews confirmed that the binding arbitration agreement was provided with the admission paperwork. The Resident Relations Liaison stated it was important to tell residents that the agreement was optional and not a condition of admission, but also stated that when the agreement was given to the family representative, it was not explained line by line. The Clinical Liaison stated residents and representatives needed to understand they were waiving the right to a trial when signing the agreement and that it was important to explain that it was optional and not required for admission. The facility policy stated residents or representatives are to be informed of the nature and implications of proposed binding arbitration agreements, that the optional nature of the agreement is to be clearly communicated, and that the terms are to be explained in a way that ensures understanding.
Equipment Maintenance Failure
Penalty
Summary
The facility failed to ensure essential equipment was properly maintained when Resident 34's bed made a loud cranking noise as it was moved up and down during care. During a concurrent observation and interview, Resident 34 was seen with a healed wound on the buttock while the bed was operated with the remote, and the bed produced the loud noise. Resident 34 stated he could live with the noise. Staff interviews showed the noise was known to nursing staff and maintenance. A CNA stated the bed made loud noise from time to time and that maintenance had been notified. An RN stated the bed was sometimes lubricated. The Maintenance Supervisor stated he was aware of the cranking noise, that about half of the resident beds in the facility made cranking noise, and that beds were oiled when residents were discharged because of concern about the smell of lubricant. He also stated the facility had a plan to replace beds that made loud noise when used. The Administrator stated the facility was in the process of buying new beds and planned to replace all residents' beds. The facility policy on Preventative Maintenance stated the facility shall maintain a preventative maintenance program designed to minimize equipment failure, maintain resident safety and comfort, reduce operational disruptions, and ensure compliance with regulatory requirements.
Unqualified Social Services Staffing and Supervision
Penalty
Summary
The facility failed to ensure the social services department was staffed and supervised by qualified staff for a census of 59 residents, resulting in all residents receiving social services from unqualified staff. During interview, the Social Services Director stated they had worked at the facility since 2022. Human Resources reviewed two versions of the Social Services Director job description and stated the revised version listed the qualifications section as preferred rather than required, leaving the minimum educational requirements unclear, although the ability to read and solve practical problems was identified as a requirement. Human Resources also reviewed the Social Services Director's employment application, which showed completion of high school and licensure as a vocational nurse. HR stated they did not check whether applicants were qualified for the position and that department managers were responsible for ensuring employees were qualified. HR further stated the Social Services Director was the only staff member in the social services department and did not have another supervisor. The Administrator stated they were the overall supervisor for all staff, including the Social Services Director, and confirmed there was no qualified social worker overseeing the social services department. Facility policy stated the director of social services is responsible for supervising social services personnel, and state regulations reviewed indicated the social work service unit shall be organized, directed, and supervised by a social worker.
Controlled Medication Records Were Not Reconciled
Penalty
Summary
The facility failed to ensure that the scheduled controlled medication system was accurate for Residents 1 through 5. During interviews, the DON and MRD described the process for controlled medications as pharmacy delivery with a Shipping Manifest and CDR, placement of the medication and CDR in the medication cart, nurse documentation of the date, time, and remaining amount on the CDR when medication was removed, and documentation of administration on the MAR. The facility was asked to provide all scheduled medication Shipping Manifests and CDRs from 9/1/23 through 3/31/24. During record review, the DON compared each resident’s CDR with the MAR and acknowledged multiple CDR removals that did not have corresponding MAR administrations. For Resident 1, two Hydrocodone/APAP removals were not matched on the MAR. For Resident 2, three Hydrocodone/APAP removals were not matched. For Resident 3, three Hydrocodone/APAP removals were not matched. For Resident 4, four Hydrocodone/APAP removals were not matched. For Resident 5, four Oxycodone removals were not matched. The DON also reviewed the pharmacist’s medication regimen review, which stated that each PRN dose documented on the CDR should have a corresponding nurse initialed entry in the EMAR, and a pharmacy inspection report noted that 10 of 14 controlled drug charting entries were not reconciled.
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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) |
|---|---|---|---|---|
| Concord Post Acute | 1.9 mi | ★★★★★ | 5 | 0 |
| La Casa Via Transitional Care Center | 2.1 mi | ★★★★★ | 0 | 0 |
| Tampico Healthcare Center | 2.1 mi | ★★★★★ | 3 | 0 |
| Pleasant Hill Post Acute | 2.2 mi | ★★★★★ | 22 | 0 |
| Diablo Valley Post Acute | 2.7 mi | ★★★★★ | 15 | 0 |
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