Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
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 Tice Valley Post Acute during CMS and state inspections, most recent first.
Failure to Provide Scheduled Showers and Document Refusal: A resident with ESRD on dialysis and impaired cognition was dependent on staff for showers, but CNAs did not document or provide showers as scheduled. The resident reported not receiving a shower for two weeks, CNA said the resident refused due to back pain and difficulty sitting, and the DON could not produce documentation that the shower was offered, completed, or that the charge nurse was notified of the refusal.
Failure to maintain fingernail hygiene for a resident who required assistance with personal hygiene. Observations showed black debris under both hands' fingernails while the resident ate meals in bed, and a CNA stated he tried to clean the nails. The resident had muscle weakness, kidney failure, and DM, and the MDS indicated she needed supervision or touching assistance for personal hygiene.
Failure to follow a resident’s hemodialysis dressing care plan. A resident with kidney failure and dependence on dialysis had bandages on the left upper arm from dialysis that remained in place beyond the time described in the care plan. The resident stated she did not know when the bandages were to be removed, and the same bandages were still present the next day before the resident was scheduled to go to dialysis later that day.
A resident with dementia and other health issues fell from bed during incontinence care due to inadequate supervision and safety measures. The CNA assisting the resident was unable to prevent the fall, resulting in the resident sustaining a leg laceration and shoulder fracture. The facility's fall risk management policy was not effectively implemented.
Expired medical supplies, including Luer Lock Caps, Statlock Catheter Stabilization Devices, an IV Catheter, and a Kangaroo Feeding Bag Set, were found in the medication storage room. An LVN confirmed these items should be removed from use, and the DON stated they should have been discarded or returned to central supply. The facility's policy requires supervisors to remove expired supplies and replenish them immediately.
A facility failed to ensure a stock medication bottle of Senna had a legible expiration date, leading to its removal from use. An LVN found the expiration date on the bottle completely faded and unreadable, acknowledging it should not be used. Another LVN confirmed that medications with expired or illegible dates should be discarded immediately. The facility's policies require checking expiration dates and returning improperly labeled drugs to the pharmacy.
The facility failed to prevent cross-contamination and foodborne illness due to poor kitchen practices. Cutting boards were in poor condition, with deep scratches and stains, posing a contamination risk. Additionally, the freezer temperature log was incomplete for two days, as the PM shift cook did not record the necessary temperatures. These deficiencies could potentially affect the safety of food served to 117 residents.
The facility failed to ensure proper infection control practices for residents with C. diff, as staff did not wash hands with soap and water after care, used ineffective germicidal wipes, and lacked adequate training. Observations showed a CNA using hand sanitizer instead of washing hands, and a physical therapy aide using non-bleach wipes on equipment. Staff interviews revealed insufficient training on infection control protocols.
A resident with enterocolitis and mobility issues waited 45 minutes for hygiene assistance after activating the call light. Despite the call light being visible at the nurse's station, staff delayed responding, with CNA 2 initially informing the resident that CNA 3 would assist after a break. CNA 3 attended to another resident before assisting. Facility leadership confirmed that the delay was against policy, which requires prompt response to call lights.
A resident with multiple sclerosis and paraplegia fell out of bed during a linen change due to inadequate supervision and safety measures. The resident, who required substantial assistance, rolled off the bed and suffered a brief loss of consciousness and a headache. The facility's fall risk management policy was not effectively implemented.
Failure to Provide Scheduled Showers and Document Refusal
Penalty
Summary
The facility failed to provide services to maintain grooming and personal hygiene for one resident who was dependent on staff for showers. The resident was admitted with end stage renal disease and dependence on renal dialysis, and the MDS dated 2/18/26 indicated a BIMS score of 11 with impaired mental status, clear speech, and dependence on staff for showering, requiring the assistance of two or more helpers to complete the activity. The resident stated during interview that CNAs did not give her a shower for two weeks, and a nurse's note documented the resident saying, "I didn't get a shower." The shower schedule showed the resident was to receive showers twice weekly on Wednesday and Saturday, but the ADL documentation report for February and March 2026 showed no documentation that showers were provided as scheduled. During interview, CNA 1 stated the resident refused a shower due to back pain and difficulty sitting and that a bed bath was provided, but there was no documentation of the refusal and the charge nurse was not notified. The DON reviewed the shower schedule, progress notes, and ADL documentation and could not provide documentation that the resident was offered or received showers as scheduled or that the charge nurse was notified of the refusal.
Failure to Maintain Fingernail Hygiene
Penalty
Summary
The facility failed to provide activities of daily living assistance for Resident 50, who was unable to maintain nail hygiene. During an observation on 9/23/25 at 10:35 a.m., Resident 50 was sitting in bed eating yogurt and stated she could feed herself. Black debris was observed under the fingernails of both hands, and Resident 50 stated staff helped clean her fingernails. She also stated she is forgetful. A follow-up observation on 9/24/25 at 9:40 a.m. again showed Resident 50 eating breakfast with black debris under the fingernails of both hands. CNA 2 stated he tries to clean Resident 50's nails and later stated it was unhygienic to have unclean fingernails and that if Resident 50 scratched herself, skin could break down and lead to infection. Resident 50's record showed diagnoses of muscle weakness, kidney failure, and diabetes. Her quarterly MDS indicated a BIMS score of 13 and that she required supervision or touching assistance for personal hygiene. The facility policy for fingernail care stated nails should be cleaned daily and trimmed regularly, with dirt removed from around and under each nail.
Failure to Follow Hemodialysis Dressing Care Plan
Penalty
Summary
The facility failed to follow the hemodialysis care plan for Resident 50, who had kidney failure and dependence on dialysis and received dialysis treatments on Tuesdays, Thursdays, and Saturdays from 3:00 p.m. to 6:00 p.m. During an observation and interview, Resident 50 had bandages on the left upper arm from dialysis two days earlier and stated she did not know when they were to be removed. The next day, the same bandages were still on the left upper arm, and the resident stated she was going to dialysis after lunch. The care plan directed nursing staff to check the left upper arm fistula site dressing upon return from dialysis and to leave the dressing intact for 4 hours following dialysis treatments.
Resident Falls During Incontinence Care Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide appropriate safety measures and adequate supervision to prevent a resident from slipping out of bed and falling during incontinence care. The incident involved a resident with a history of dementia, diabetes, essential tremor, and morbid obesity, who was dependent on assistance for most activities of daily living. During the incident, the resident was being assisted by a CNA for incontinence care when she slipped out of bed, resulting in a fall that caused significant injuries. The resident was found on the floor in a prone position between the bed and wooden furniture, complaining of severe pain. The CNA, who was positioned on the left side of the bed, attempted to prevent the fall by holding the resident's waist while applying a brief, but the resident rolled out of bed. The CNA called for help, and with the assistance of an LVN and other staff, the resident was moved to a safer position on her back. The resident was subsequently transported to the emergency department, where she received treatment for a laceration on her leg and a fractured shoulder. Interviews with the CNA and LVN revealed that the resident had grabbed onto the headboard frame during the incident, and the CNA's attempt to reposition the resident was unsuccessful. The resident later recounted feeling pushed too hard by the CNA, which contributed to her fall. The facility's policy on falls and fall risk management was reviewed, indicating that staff should identify interventions to prevent falls and minimize complications, but these measures were not effectively implemented in this case.
Expired Medical Supplies Found in Medication Storage Room
Penalty
Summary
The facility failed to ensure that supplies stored in the Lexington medication storage room were appropriate for use, as several items were found to be expired. During an observation and interview with a Licensed Vocational Nurse (LVN), it was noted that ten Female Luer Lock Caps, two Statlock Catheter Stabilization Devices, one IV Catheter, and one Kangaroo Feeding Bag Set were all past their expiration dates. The LVN acknowledged that expired items should be removed from resident use. In an interview with the Director of Nursing (DON), it was confirmed that the facility regularly used intravenous medical supplies and feeding bags, and that expired supplies should have been discarded or returned to central supply. A review of the facility's policy and procedure on requisitioning daily supplies indicated that supervisors are responsible for removing expired supplies and ensuring that supplies are replenished immediately. The failure to adhere to these procedures had the potential to result in residents receiving expired, ineffective, and contaminated medications and treatments.
Medication Expiration Date Illegibility
Penalty
Summary
The facility failed to ensure that a stock medication bottle of Senna, a laxative used for short-term treatment of constipation, had a legible expiration date and was removed from resident use. During an observation and interview, a Licensed Vocational Nurse (LVN) discovered that the expiration date on the Senna bottle was completely faded and unreadable. The LVN acknowledged that the medication should not be used and removed it from the medication cart for disposal. Another LVN confirmed that medications with expired or illegible expiration dates should be discarded immediately, as they may lose effectiveness. The facility's policy and procedure for administering oral medications, dated 2001, requires checking the expiration date and returning expired medications to the pharmacy. Additionally, the policy for storage of medications mandates that drug containers with missing or incorrect labels be returned to the pharmacy for proper labeling before storage. The failure to adhere to these policies resulted in the potential for residents to receive expired and ineffective medication treatment.
Deficiencies in Kitchen Practices and Temperature Logging
Penalty
Summary
The facility failed to adhere to proper kitchen practices, which could lead to cross-contamination and foodborne illness. During an inspection, it was observed that four cutting boards in the kitchen were in poor condition, exhibiting black marks, smudges, faded colors, scratches, and deep cuts. The Dietary Manager acknowledged the need to replace these boards to prevent food contamination. The Registered Dietician confirmed that deep scratches on chopping boards pose a contamination risk, and the kitchen staff expressed concerns about the potential dangers of using such boards. The 2017 Federal Food Code specifies that food contact surfaces should be smooth and clean, and the current state of the cutting boards did not meet these standards. Additionally, the facility did not maintain accurate records of freezer temperatures, as the temperature log lacked entries for two consecutive days. The Dietary Manager admitted that the PM shift cook failed to complete the log, and the Dietary Aide acknowledged forgetting to document the temperatures. The Registered Dietician emphasized the importance of the freezer temperature log in ensuring food safety by preventing items from entering the temperature danger zone. The facility's policy requires daily recording of refrigerator and freezer temperatures, but this procedure was not followed, potentially compromising food safety for the 117 residents served by the kitchen.
Inadequate Infection Control Practices for C. diff in LTC Facility
Penalty
Summary
The facility failed to ensure staff followed infection control procedures for residents with Clostridioides difficile (C. diff) infections. Specifically, staff did not wash their hands with soap and water after caring for residents with C. diff, which is necessary to prevent the spread of the infection. Observations revealed that a Certified Nursing Assistant (CNA) used hand sanitizer instead of washing hands with soap and water after removing personal protective equipment (PPE) and exiting the rooms of residents on contact precautions for C. diff. This practice was contrary to the facility's policy and the Centers for Disease Control and Prevention (CDC) guidelines, which state that hand sanitizer is not effective against C. diff. Additionally, the facility did not use appropriate germicidal wipes to disinfect equipment used on residents with C. diff. A physical therapy aide was observed using a germicidal wipe that did not contain bleach to clean a heart rate device and a gait belt after use on a resident with C. diff. The Director of Nursing confirmed that the germicidal wipes used were not effective against C. diff, as they were not listed as an EPA-approved spore-killing disinfectant. Furthermore, the facility failed to ensure that staff were adequately trained on infection control and hand hygiene techniques. Interviews with staff revealed a lack of understanding regarding the necessity of washing hands with soap and water after caring for residents with C. diff. The Director of Staff Development could not verify that certain staff members, including a CNA contracted from an outside agency, had received proper orientation or training on the facility's hand hygiene standards. This lack of training contributed to the improper infection control practices observed.
Delayed Hygiene Care for Resident
Penalty
Summary
The facility failed to provide timely hygiene care for a resident, identified as Resident 43, who had to wait in stool and urine for 45 minutes before being assisted by staff. This incident was observed during a survey, where it was noted that the call light in Resident 43's room was activated and visible at the nurse's station. Despite this, there was a delay in response from the staff. Resident 43, who was admitted with enterocolitis due to Clostridium difficile, difficulty in walking, and muscle weakness, required moderate assistance with toileting hygiene. The resident reported that it often took staff an hour to respond to call lights, which was corroborated by the observations made during the survey. On the day of the incident, the call light was activated at 11:15 a.m., but it was not until 12:13 p.m. that the resident was finally being cleaned by CNA 3. During this period, CNA 2 initially responded to the call light but informed the resident that CNA 3 would assist after returning from break. CNA 3, upon returning, attended to another resident before assisting Resident 43. Interviews with RN 1, the Director of Staff Development, and the Director of Nursing confirmed that the facility's policy required staff to respond to call lights promptly and assist residents immediately. The delay in providing care was deemed unacceptable by the facility's leadership, as it left the resident feeling dejected and at risk for skin breakdown due to prolonged exposure to urine and stool.
Failure to Provide Adequate Supervision During Bed Linen Change
Penalty
Summary
The facility failed to provide appropriate safety measures and adequate supervision to prevent a resident from rolling out of bed and falling on the floor during a bed linen change. The incident involved a resident with multiple sclerosis and paraplegia, who required substantial assistance for all activities of daily living, including transfers and changing positions in bed. During the linen change, the resident was turned to a left side-lying position by a CNA, who then moved to the other side of the bed to secure the fitted sheet. The resident rolled off the bed and fell to the floor, resulting in a brief loss of consciousness and a headache that lasted over a week. The resident was transported to the emergency department for evaluation, where scans were negative for fractures or bleeding, and was subsequently returned to the facility for continued care with fall precautions in place. Interviews with the involved staff and the resident revealed that the CNA had turned the resident to the left side with the resident's right leg crossed over the left leg. The CNA was on the right upper side of the bed when the resident rolled off. The resident reported that the CNA had pushed against their back with enough force to cause the fall. The facility's policy on managing falls and fall risks was reviewed, indicating that staff should identify interventions to reduce falls and minimize complications. However, the policy was not effectively implemented in this case, leading to the resident's fall and subsequent injury.
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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 | 0.1 mi | ★★★★★ | 4 | 0 |
| Rossmoor Post Acute | 0.1 mi | ★★★★★ | 4 | 0 |
| Tampico Healthcare Center | 2.6 mi | ★★★★★ | 3 | 0 |
| La Casa Via Transitional Care Center | 2.7 mi | ★★★★★ | 0 | 0 |
| Moraga Post Acute | 3.4 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.