Health inspection·May 16, 2024

F 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a comprehensive admission Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan) assessment was completed within 14 calendar days of admission date for three of three sampled residents (Resident 45, Resident 313, Resident 317). This deficient practice resulted in delayed completion of admission assessment and had the potential to result in Resident 45, 313, and 317 not receiving the appropriate care and services needed based on their health status. Findings: During a review of Resident 45's admission Record (a document used to communicate basic information about a resident), dated 5/14/24, the admission Record indicated Resident 45 was admitted to the facility on [DATE]. During a review of Resident 313s admission Record, dated 5/16/24, the admission Record indicated Resident 313 was admitted to the facility 12/8/23. During a review of Resident 317's admission Record, dated 5/16/24, the admission Record indicated Resident 317 was admitted to the facility on [DATE]. During a concurrent interview and record review on 5/14/24 at 10:54 a.m. with the Minimum Data Set Coordinator 1 (MDSC 1), Resident 45's admission MDS assessment dated [DATE] was reviewed. The admission Record indicated the assessment was completed on 12/29/23. MDSC 1 stated Resident 45's admission MDS should have been completed by 12/23/23 (14 calendar days from date of admission). MDSC 1 stated admission MDS assessment completion was prioritized because admission assessments were used to plan resident's care, however timely completion for Resident 45's assessment was missed. MDSC 1 stated late completion of admission assessment could interfere with having a comprehensive care plan in place for residents. MDSC 1 stated facility's Director of Nursing (DON) was responsible for verifying the completion of MDS assessments. During a review of MDS 3.0 Final Validation Report dated 5/14/24 the MDS 3.0 Final Validation Report, indicated the MDS Assessment and care plan for Resident 45 was completed late. During a review of MDS 3.0 Final Validation Report dated 12/30/23, the MDS 3.0 Final Validation Report indicated the MDS Assessment and care plan for Residents 313 and 317 were completed late. Page 1 of 7 055049 055049 05/16/2024 Pleasant Hill Post Acute 1625 Oak Park Boulevard Pleasant Hill, CA 94523

F 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 05/14/24 at 11:50a.m. with DON, DON stated admission MDS assessments should be completed within 14 days from the assessment reference date (ARD- it is the end point for the observation/assessment period in the MDS assessment process). During an interview on 5/14/24 at 9:16 a.m. with Administrator (ADM), ADM stated he did not recall any issues with late MDS entries occurring for the month of December 2023. During a review of Centers of Medicare and Medicaid Services (CMS) 5.2, Long-Term Care Facility Resident Assessment Instrument, dated October 2023, the Long-Term Care Facility Resident Assessment Instrument indicated the admission Assessment must be completed no later than 14 days after admission to a facility. 055049 Page 2 of 7 055049 05/16/2024 Pleasant Hill Post Acute 1625 Oak Park Boulevard Pleasant Hill, CA 94523

F 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure three of three sampled residents' (Resident 45, 315 and 316)'s Minimum Data Set (MDS, an assessment tool used to guide resident care) discharge assessments were completed within 14 days from their discharge date from the facility. Residents Affected - Some This deficient practice has the potential to result in inaccurate census of the facility that may interfere with accurate planning for safe staffing. Findings: During an interview on 5/16/24 at 10:04 a.m. with Minimum Data Set Coordinator 1 (MDSC 1), MDSC 1 stated she was aware of the late MDS discharge entries. MDSC 1 stated there was no facility protocol on MDSC policies. During a concurrent interview and record review on 5/14/24, at 10:54 a.m., with MDSC 1, Resident 45's discharge MDS assessment was reviewed. MDSC 1 stated Resident 45 was discharged from facility on 1/9/24 and his MDS discharge was not completed until 2/14/24. MDSC 1 stated late completion of discharge MDS assessments resulted in an inaccurate reflection of resident census at the facility which could potentially interfere with census tracking and staffing ratios. During a record review of Resident 315's discharge MDS assessment, the assessment indicated Resident 315 was discharged from the facility on 1/10/24 and the assessment was completed on 2/7/24. During a record review of Resident 316's discharge MDS assessment indicated Resident 316 was discharged from the facility on 1/24/24 and the assessment was completed on 2/9/24. During a review of Centers of Medicare and Medicaid Services (CMS) 5.2, Long-Term Care Facility Resident Assessment Instrument, dated 10/2023, the instrument indicated, Discharge Assessment must be completed no later than 14 days after discharge from facility. 055049 Page 3 of 7 055049 05/16/2024 Pleasant Hill Post Acute 1625 Oak Park Boulevard Pleasant Hill, CA 94523

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility had a 13.79% medication error rate when four medication errors out of 29 opportunities were observed during medication administration for two of four sampled residents (Resident 165 and 264). Resident 165 did not receive an eye drop and an oral medication according to the physician's order. Resident 264's medication did not have a prescribed dosage for cholecalciferol (used to treat or prevent vitamin D deficiency). Residents Affected - Few These failures resulted in medication not given in accordance with the prescriber's orders, which may negatively affect the resident's health. Findings: 1. During medication administration observation on 5/14/24 at 9:05 a.m., Licensed Vocational Nurse (LVN) 1 was observed preparing and administering six medications to Resident 264. These medications included one tablet of Vitamin D3 (cholecalciferol) 10 micrograms (mcg), two tablets of stool softener 100 milligrams (mg), Fluticasone (medication that treats allergy symptoms like sneezing, itching and a runny or stuffy nose) 50 mcg nasal spray, one tablet of Metoprolol (medication to treat high blood pressure) 50 mg, one capsule of Triamterene-HCTZ (medication to treat high blood pressure and edema) 37.5-25 mg and one tablet of Losartan Potassium (medication to lower blood pressure) 100 mg. During a concurrent observation and interview on 5/15/24 at 10:08 a.m. with LVN 1, LVN 1 took two Vitamin D3 medication bottles from the first drawer of the medication cart, the first bottle was labeled Vitamin D3 10 mcg, and the other bottle was labeled Vitamin D3 25 mcg. LVN 1 stated she normally gave Vitamin D3 10 mcg for Cholecalciferol order unless specified by the doctor. During an interview on 5/15/24 at 1:50 p.m. with the Director of Nursing (DON), the DON stated the cholecalciferol dosage order should have been verified with the doctor. During a review of Resident 264's Physician's order dated 5/10/24, The Physician's order indicated to give 1 oral tablet of Cholecalciferol in the morning. During a review of the facility's policy and procedure (P&P) titled, Medication order, dated November 2023, the policy indicated When recording orders for medication, specify the . dosage, frequency, and strength of the medication ordered. 2. During medication administration observation on 5/14/24 at 9:35 a.m., LVN 1 was observed preparing and administering seven medications to Resident 165. These medications included one tablet of Acyclovir (medication to treat herpes virus infections) 400 mg, one tablet of Stool softener 100 mg, one tablet of Iron 325 mg, one tablet of Gabapentin (medication used to relieve nerve pain) 600 mg, one tablet of multivitamin with minerals, one single use container of Refresh (relieve dry eyes) eye drop and two tablets of Vitamin C 250 mg. During a review of Resident 165's Physician's order dated 5/3/24, the order indicated to instill 1 drop of Restasis multidose ophthalmic emulsion 0.05% in both eyes two times a day. During a review of Resident 165's Physician's order dated 5/4/24, the order indicated to give two tablets of vitamin c 500 mg in the morning. 055049 Page 4 of 7 055049 05/16/2024 Pleasant Hill Post Acute 1625 Oak Park Boulevard Pleasant Hill, CA 94523

F 0759 Level of Harm - Minimal harm or potential for actual harm During an interview on 5/15/24 at 10:11 a.m. with LVN 1, LVN 1 stated Refresh eye drops was the only eye drops supply in the medication cart for Resident 165. LVN 1 stated she should have given four tablets of vitamin c 250 mg for Resident 165. Residents Affected - Few 055049 Page 5 of 7 055049 05/16/2024 Pleasant Hill Post Acute 1625 Oak Park Boulevard Pleasant Hill, CA 94523

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to prepare and serve food under safe and sanitary conditions when: Residents Affected - Some - moldy and unusable foods were not discarded. - dented can was stored. - food items in dry storage room were not sealed. These failures placed the facility's 45 residents who received food from the kitchen at risk of foodborne illness. During initial observation of the kitchen on 5/13/24 at 9:43 a.m. accompanied by Registered Dietician (RD), showed the following: (a) opened bag with 16 moldy and unusable French bread were stored in the dry storage room labeled with received by 5/8/24 and used by 5/10/24 (b) dented can of six ounce of unsweetened applesauce was stored with remaining stock in dry storage room (c) opened box of hashbrown was not sealed (d) opened box of brown rice was not sealed. During a concurrent interview and observation on 5/13/24 at 9:53 a.m. with RD, RD acknowledged there were moldy French bread rolls stored that should have been discarded. RD stated the person who received supplies should have separated dented can from the stock. RD further added, there was potential risk of illness if residents consume moldy bread. RD also stated, the risk to residents could be illness if food from dented can was consumed. During a review of the facility's Policy and Procedure (P&P) titled, Food Storage Dented Cans, [undated], indicated, All dented cans (side seam or rim dent) and rusty cans are to be separated from remaining stock and placed in a specified labeled area for return to purveyor for refund . During a review of facility provided DRY STORAGE CHART, dated, 4/6/23, revealed, opened bread was to be stored for one (1) day .Rice: .Once opened, store in airtight container.Hashbrowns . Once opened, store in airtight container. 055049 Page 6 of 7 055049 05/16/2024 Pleasant Hill Post Acute 1625 Oak Park Boulevard Pleasant Hill, CA 94523

F 0912 Level of Harm - Potential for minimal harm Residents Affected - Some Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, the facility failed to provide at least 80 square (sq) feet (ft) of living space per resident for 24 residents who occupied the following multiple resident bedrooms: Rooms 12, 14, 15, 16, 17, 18, 19, 20, 21, and 22. This failure had the potential to result in a lack of sufficient space for the provision of care by facility staff and a lack of sufficient space for residents to have personal belongings at the bedside. Findings: During random interviews and observations of care and services from 5/13/24 to 5/16/24, there was sufficient space for the provision of care for the residents in all rooms. There was no heavy equipment kept in the rooms that might interfere with residents' care, and each resident had adequate personal space and privacy. There were no complaints from residents regarding insufficient space for their belongings. There were no negative consequences attributed to the decreased space and/or safety concerns in the identified rooms. During a record review of the Client Accommodations Analysis, dated 5/15/24, the following multiple resident rooms were identified having below the required 80 square feet requirement per resident: room [ROOM NUMBER] had 2 beds and 71.5 sq.ft./bed room [ROOM NUMBER] had 4 beds and 67.5 sq.ft./bed room [ROOM NUMBER] had 4 beds and 67.5 sq.ft./bed room [ROOM NUMBER] had 2 beds and 70 sq.ft./bed room [ROOM NUMBER] had 2 beds and 70 sq.ft./bed room [ROOM NUMBER] had 2 beds and 70 sq.ft./bed room [ROOM NUMBER] had 2 beds and 70 sq.ft./bed room [ROOM NUMBER] had 2 beds and 70 sq.ft./bed room [ROOM NUMBER] had 2 beds and 70 sq.ft./bed room [ROOM NUMBER] had 2 beds and 70 sq.ft./bed 055049 Page 7 of 7