Health inspection·August 1, 2023

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, for one of three sampled residents (Resident 1), the facility failed to provide Resident 1's Representative (RR) with a summary of the baseline care plan. This failure resulted in the lack of information about Resident 1's care. Findings: Review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included hypertension (high blood pressure), moderate protein calorie malnutrition, dysphagia (difficulty swallowing) need for assistance with personal care, malignant neoplasm (abnormal growth, cancer) of connective and soft tissue, presence of a cardiac pacemaker (small device implanted in the chest to help control the heartbeat), and atrial fibrillation (irregular and very rapid heart rhythm). The record indicated RR as Resident 1's responsible party/representative. During a telephone interview with RR on 2/1/23 at 11:32 a.m., RR stated not having received a summary of Resident 1's care plan or even a telephone call from any facility representative during Resident 1's stay from 2/1/22 through 2/6/22. RR stated of not being informed about the plan of care to be provided by the facility. Review of Resident 1's Patient Care Timeline notes from the hospital dated 2/6/22 indicated, RR stated .No one [at the facility] can tell me what is happening. During a telephone interview and concurrent review of Resident 1's clinical record with the Director of Nursing (DON) 2 ,on 1/31/23 at 4:11 p.m., DON 2 stated the baseline care plan was developed for Resident 1 on 2/122 but the clinical record did not indicate a summary of the care plan was provided to RR. Review of the facility's policy and procedure titled, Care Plans-Baseline, last revised March 2022, indicated the resident and/or representative are provided a written summary of the baseline care plan that includes stated goals and objectives of the resident, a summary of the resident's medications and dietary instructions and any services and treatments to be administered by the facility. The policy also indicated provision of the summary to the resident representative is documented in the clinical record. Review of Resident 1's Baseline Care Plan Person-Centered Care Planning dated 2/2/22 indicated, E. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 5 Event ID: 055085 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055085 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Moraga Post Acute 348 Rheem Boulevard Moraga, CA 94556 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)