Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
DIABLO VALLEY POST ACUTE
CONCORD, CA · 190 certified beds · Last Life Safety survey August 13, 2026
CMS Certification Number 055150 · first certified November 1980
Ownership
Operated by PACS GROUP · For profit - Limited Liability company
- Ownership changed March 1, 2023 (change of ownership)from WINDSOR CONVALESCENT AND REHAB CENTER OF CONCORD LLC
Position within CA
35 citations — more than 92% of the 1,165 certified nursing homes in CA. Compared within CA rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 8 citations; the earlier surveys on file averaged 13.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window opens August 2027 — about 9 months from now. This facility’s last Life Safety survey was August 2026. Facilities in CA are typically surveyed 12–16 months after the last one (median 14), measured over 1,814 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to about three years in Virginia. How the window is measured
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5 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities cited for sprinkler inspection and testing in CMS’s current file are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
4 of the 35 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
9 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 35 Life Safety citations above. The Physical Environment Index
- F-0880 Provide and implement an infection prevention and control program.
- F-0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
- F-0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F-0584 Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
How that compares
Compared with the median facility in CA, and nationally. Surveyors differ markedly between states, so the CA figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 35 |
| Median facility in CA | 19 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| September 14, 2023 | 18 |
| April 18, 2025 | 9 |
| August 13, 2026 | 8 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0363 | Install corridor and hallway doors that block smoke. | 3 | 2026-08-13 |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | 3 | 2026-08-13 |
| K-0920 | Ensure proper usage of power strips and extension cords. | 3 | 2026-08-13 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 3 | 2026-08-13 |
| K-0919 | Meet requirements for the use of electrical equipment. | 3 | 2026-08-13 |
| K-0712 | Have simulated fire drills held at unexpected times. | 2 | 2026-08-13 |
| K-0161 | Use approved construction type or materials. | 2 | 2025-04-18 |
| E-0031 | Provide emergency officials' contact information. | 2 | 2025-04-18 |
What the citations cover
- Smoke Deficiencies 13
- Gas, Vacuum, and Electrical Systems Deficiencies 9
- Emergency Preparedness Deficiencies 4
- Miscellaneous Deficiencies 3
- Other 6
| Category | Citations |
|---|---|
| Smoke Deficiencies | 13 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 9 |
| Emergency Preparedness Deficiencies | 4 |
| Miscellaneous Deficiencies | 3 |
| Egress Deficiencies | 3 |
| Construction Deficiencies | 2 |
| Services Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
August 13, 2026 — 8 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (August 24, 2026) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (August 24, 2026) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (August 24, 2026) |
| K-0711 | Provide a written emergency evacuation plan. | Deficient, Provider has date of correction (August 24, 2026) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (September 10, 2026) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (September 10, 2026) |
| K-0919 | Meet requirements for the use of electrical equipment. | Deficient, Provider has date of correction (August 24, 2026) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (September 10, 2026) |
April 18, 2025 — 9 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0031 | Provide emergency officials' contact information. | Deficient, Provider has date of correction (January 22, 2025) |
| K-0161 | Use approved construction type or materials. | Deficient, Provider has date of correction (April 23, 2025) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (May 6, 2025) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (May 2, 2025) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (April 28, 2025) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (April 28, 2025) |
| K-0919 | Meet requirements for the use of electrical equipment. | Deficient, Provider has date of correction (April 23, 2025) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (April 25, 2025) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (April 21, 2025) |
September 14, 2023 — 18 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (September 28, 2023) |
| E-0031 | Provide emergency officials' contact information. | Deficient, Provider has date of correction (September 28, 2023) |
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (September 28, 2023) |
| K-0161 | Use approved construction type or materials. | Deficient, Provider has date of correction (September 28, 2023) |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (September 28, 2023) |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (September 28, 2023) |
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (September 28, 2023) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (September 28, 2023) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (September 28, 2023) |
| K-0342 | Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Deficient, Provider has date of correction (September 28, 2023) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (September 28, 2023) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (September 28, 2023) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (September 28, 2023) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (September 28, 2023) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (September 28, 2023) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (September 28, 2023) |
| K-0919 | Meet requirements for the use of electrical equipment. | Deficient, Provider has date of correction (September 28, 2023) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (September 28, 2023) |
Reflects the CMS posting of October 1, 2026. Surveys conducted in the last few months may not appear yet.