Health inspection·November 3, 2023

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accurately complete and/or update the Level I Preadmission Screening and Resident Review (PASARR, a federal requirement to ensure that residents are not inappropriately placed in nursing homes for long term care) assessment for one of one sampled resident (Resident 15) for a period of over four years. This failure resulted in an inaccurate reflection of Resident 15's medical status and had the potential to result in Resident 15 not receiving the care and services appropriate for her condition. Findings: During a review of Resident 15's admission Record, dated October 2023, the record indicated Resident 15 was originally admitted to the facility in December 2018. During a concurrent interview and record review on 11/3/23 at 11:58 a.m. with Director of Nursing (DON), Resident 15's PASARRs, dated 12/12/18 and 6/7/19 were reviewed. The DON stated the facility was expected to complete a PASARR screening prior to residents' admission to the facility. The DON stated the PASARR dated 12/12/18 was completed one week after Resident 15's admission to the facility and was inaccurately coded as No for Question 28 Has the resident been prescribed psychotropic medications (used to manage mental health conditions)? The DON stated Resident 15's clinical record showed that she received quetiapine (a psychotropic medication) 25 milligrams (mg) for hospital delirium (acute confusion) from 12/5/18 until 12/11/23. The DON stated the PASARR dated 6/7/19 was completed for Resident 15's readmission to the facility on 6/5/19. The PASARR dated 6/7/23 showed facility answered Yes to Question:17b Will the resident's stay at your facility likely to require less than 30 days of NF services? The DON stated Resident 15 did not leave and was a long-term resident at the facility. The DON stated the PASARR dated 6/7/23 did not reflect an accurate status of Resident 15. The DON stated the facility did not update and/or complete a new PASARR to reflect the actual status of Resident 15 since 6/7/19. During a concurrent interview and record review on 11/3/23 at 12:33 p.m. with Minimum Data Set Coordinator (MDSC), Resident 15's MDS assessment dated [DATE] was reviewed. The assessment showed Resident 15 had a diagnosis of Schizophrenia (a mental disorder characterized by disconnection from reality), Psychosis (condition that affects the brain processing of information) and had received psychotropic medication, but she was not eligible for Level II PASARR screening. The MDSC stated, Resident 15's mental illness diagnoses could have led her to have Level II PASARR screening, however she overlooked that need when she completed the MDS assessment. During a review of facility's Policy and Procedure (P&P), titled admission Criteria, dated March 2023, the P&P indicated. all new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre- admission Screening and Resident Review (PASARR) process .If the level 1 screen indicates that the individual may meet the criteria for a MD, ID, or RD, he or she is referred to the state PASRR representative for the Level II (evaluation and determination) screening process. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055085 If continuation sheet Page 2 of 13 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 11/03/2023 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)

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to provide assistance needed for fingernail care for one (Resident 30) of three sampled residents when Resident 30 had long fingernails with blackish material under the nail tips. Residents Affected - Few This failure had the potential for Resident 30 to be injured by long fingernails and develop an infection. Findings: Review of the Minimum Data Set (MDS Resident Assessment tool used to guide care), dated 8/25/23, indicated Resident 30's diagnoses included stroke (brain injury when blood flow to a part of the brain stops) and diabetes mellitus (a long-term (chronic) disease in which the body cannot regulate the amount of sugar in the blood). Resident 30 had clear speech, was able to understand others and be understood. Resident 30 required extensive physical assistance from one-person for personal hygiene, including combing hair, brushing teeth, shaving, washing, and drying face and hands. Review of Resident 30's Activities of Daily Living (ADLs) care plan, dated 8/25/23, indicated Resident 30 required extensive assistance with ADLs for shower, bathing, toilet, and hygiene. During an observation and concurrent interview on 10/30/23 at 10:23 a.m., with Resident 30, Resident 30 lay in bed. Resident 30 had long fingernails with blackish material under the nail tips. Resident 30 stated she would like to have her long fingernails trimmed. During an observation and concurrent interview on 10/30/23 at 10:25 a.m., with Licensed Vocational Nurse/Supervisor (LVN 1), and Resident 30, LVN 1 stated Resident 30's fingernails were long and had blackish material under the nail tips. LVN 1 stated he would ensure Resident 30's assigned licensed nurse trimmed the fingernails. During an interview on 10/30/23 at 10:36 a.m., with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated she was Resident 30's assigned nurse. LVN 2 stated she did not know why Resident 30's fingernails were not trimmed. Review of the facility's policy and procedure titled, Fingernails/Toenails, Care of, revised February 2022, indicated: The purpose of this procedure are to clean the nail bed, to keep nails trimmed and to prevent infections. Nail care includes daily cleaning and regular trimming. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055085 If continuation sheet Page 3 of 13 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 11/03/2023 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)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on interview and record review, the facility failed to ensure the pharmacist provided consultation services to ensure there was a record system for receipt and disposition and reconciliation of all controlled drugs maintained for three years. The failure to maintain records had the potential to result in drug diversion. Findings: During and concurrent interview and record review on 11/1/2,3 at 11:06 a.m., with Director of Nursing (DON), the controlled medication disposition binder was reviewed. The DON stated she had a huge stack of unorganized logs and medications packages for controlled medications which had been sent for disposal on 10/5/23. DON stated she had organized the logs and placed them in the disposition binder; the binder showed the last previous transfer for destruction date was 10/5/22, with no transfer for final disposal of controlled medication between 10/5/2022 to 10/5/2023. The DON stated she and the facility's Pharmacist (Pharm) were responsible to dispose of the controlled medications into the final incinerator container together. The DON stated Pharm had advised her the controlled medication disposal into the incinerator container should be completed on a quarterly basis, however she had not had the time to do so. The DON stated she was unable to find the controlled drug disposition records for the year of 2021. During a phone interview on 11/1/23, at 11:41 a.m., with Pharmacist (Pharm), Pharm stated the DON accumulated all the controlled drugs in need of disposal, then Pharm and the DON would reconcile the log and document any discrepancies. Pharm stated the controlled drugs in need of disposal would be placed in sealable plastic bags with a liquid in the bag, and then the entire plastic bag would be placed in an incinerator container. Pharm stated the incinerator container would go to a contractor for destruction. The Pharm stated controlled medication disposal should be done on a quarterly basis and the disposition documentation/log should be retained for 3 years. During a record review of the facility's policy and procedure titled, Discarding and Destroying Medications, dated 11/2022, completed medication disposition record are kept on file in the facility for at least two (2) years, or as mandated by state law governing the retention and storage of such records. Review of the California Codes for Pharmacy: 72371(c) (1) Patient's drugs supplied by prescription which have been discontinued and those which remain in the facility after discharge of the patient shall be destroyed by the facility in the following manner: (1) Drugs listed in Schedules II, III or IV of the Federal Comprehensive Drug Abuse Prevention and Control Act of 1970 shall be destroyed by the facility in the presence of a pharmacist and a registered nurse employed by the facility. The name of the patient, the name and strength of the drug, the prescription number, the amount destroyed, the date of destruction and the signatures of the witnesses required above shall be recorded in the patient's health record or in a separate log. Such log shall be retained for at least three years. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055085 If continuation sheet Page 4 of 13 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 11/03/2023 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)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure proper storage of medication when the following was noted: 1. Two bottles of expired 20 milliliters (ml) of lorazepam (a medication used to treat anxiety) for Resident 10 were stored in a dedicated refrigerator for ready to use medications. 2. The lid of black colored Medication Disposal Bin was kept very loosely open in medication storage room. The failure to dispose of expired lorazepam medication, posed a potential risk of utilizing the medication with decreased effectiveness for anxiety to Resident 10. The failure to ensure proper security of the Medication Disposal bin posed a potential authorized/unauthorized access to medications in the bin. Findings: 1. During an observation on [DATE] at 09:57 a.m. in Medication room [ROOM NUMBER], with Licensed Vocational Nurse (LVN) 1, two bottles of 20 ml of lorazepam with expiration date of [DATE] for Resident 10 were kept in a dedicated refrigerator for ready to use medications. LVN 1 stated medications were expired and should not be kept in the refrigerator. During a telephone interview on [DATE] at 11:32 a.m. with the facility's Pharmacist (Pharm), Pharm stated as soon as medications were expired or discontinued, they should be placed in the designated disposal area in medication room [ROOM NUMBER] to be disposed or destroyed. During a record review of Resident 10's Physician orders, dated [DATE], the order indicated Resident 10 had an order for lorazepam give 0.25 milliliters (mls) by mouth every 4 hours as needed for anxiety. A review of the medication administration record indicated, Resident 10 last received a dose of lorazepam on [DATE] at 07:46 p.m. During a review of the facility's policy and procedure titled, Storage of Medications, dated 11/2020, indicated Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. 2. During a concurrent observation and interview on [DATE] at 11:21 a.m. in Medication room [ROOM NUMBER], with the Director of Nursing (DON), a black colored Medication Disposal bin was kept next to the medication refrigerator. The lid to the medication disposal bin was easily removed. The disposal bin had pills, capsules, medication packages, nasal spray bottles, multiple use injection vials, and medication cups were easily accessible from the bin. The DON stated the lid to the medication disposal bin needed to be secured to the bin. The label on the disposal bin indicated, Hazardous Waste Pharmaceuticals: KEEP LID CLOSED, DO NOT REMOVE OR DISPENSE ITEMS FROM THIS CONTAINER . During a review of the facility's policy and procedure titled, Storage of Medications, dated 11/2020, the facility stores all drugs and biologicals in a safe, secure, and orderly manner. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055085 If continuation sheet Page 5 of 13 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 11/03/2023 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)

F 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on interviews and record review, the facility failed to ensure when it did not hire a full-time registered dietitian, the person designated to serve as the director of food and nutrition services met the federal and state educational qualifications for a dietary manager position. The lack of full-time, qualified oversight of food and nutrition staff placed residents who received food from the kitchen at risk for food borne illness (illness caused by food contaminated with bacteria, viruses, parasites, or toxins) and/or decreased nutrient intake which had the potential to result in malnutrition and/or death. Findings: During an interview on 10/30/23 9:35 a.m., with Dietary Supervisor (DS), DS stated he worked fulltime as the Dietary Supervisor. DS stated he had worked at the facility for one year. During an interview on 10/31/23 at 12:23 p.m., with Registered Dietitian (RD), RD stated he worked at the facility part time. RD stated he was usually at the facility two days a week. During an interview on 11/01/23 at 9:18 a.m., with DS, DS stated he had completed an online training course and had received a Food Manager certification. Review of the document titled, ServSafe Certification, with an examination date of 2/10/21, the document indicated DS had completed a standard training for the Food Protection Manager certification examination. The document indicated, Accredited by the American National Standards Institute-Conference for Food Protection (CFP), an accredited food safety exam that does not require classroom hours or necessarily involve a training program. During an interview and concurrent review on 11/01/23, at 10:29 a.m., with the Administrator (Admin), the DS ServSafe Certification, document was reviewed. The Admin stated the DS ServSafe certificate was not sufficient training to qualify DS for the dietary manager position. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055085 If continuation sheet Page 6 of 13 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 11/03/2023 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)

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, interviews and record review, the facility failed to ensure storage and preparation of food under sanitary conditions when: Residents Affected - Many 1. The facility failed to ensure two of two facility ovens were maintained in safe operating condition to provide cooked meals according to mealtime schedules: oven 1 was unable to cook chicken to the required food safety temperature; oven 2 was inoperable. 2. The facility failed to maintain the physical environment: the countertop toaster oven had brownish black debris both on the oven knobs and inside the oven; the kitchen floors had cracked tiles with blackish discoloration; a ceiling vent was covered with blackish, dusty material; the grease trap area was malodorous and not securely covered; a storage cabinet drawer did not fully close. These failures had the potential to result in food borne illnesses for residents who received food from the facility's kitchen. Findings: 1. During an observation on 10/30/23 at 1:15 p.m., with Dietary Supervisor (DS), in the kitchen, oven 2 had plates stored inside the oven. During a concurrent observation and interview on 10/31/23, at 11:23 p.m., with [NAME] (CK), in the kitchen, during lunch preparation, chicken breasts were cooked in oven 1. [NAME] (CK) measured the temperature of a chicken breast in the oven as 140 degrees Fahrenheit (F). The chicken remained in the oven for 15 more minutes, and CK rechecked the temperature of a chicken breast which still measured as 140 degrees F. CK removed the tray of chicken breasts from the oven onto to the top stove and continued cooking the chicken until the chicken breast temperature was measured as 170 degrees F. CK stated oven 1 was the only functioning oven in the facility. CK stated oven 1 delayed timely cooking and serving of residents' meals. CK stated oven 1 had a faulty fan that was not working properly so food trays had to be rotated in the oven for food to reach the necessary temperature to be safe for consumption. CK stated he had informed the Dietary Supervisor (DS) about the faulty ovens about three to six months ago. During an interview on 10/31/23 at 2:39 p.m., DS stated Maintenance Supervisor (MS) was aware of the faulty ovens. DS stated Administrator (Admin) had been informed of the faulty ovens and repairs needed in the kitchen about three to six months ago. During an interview on 10/31/23 at 2:03 p.m., MS stated he was aware of the need for oven replacement and repairs needed in the kitchen. During an interview on 11/01/23 at 9:38 a.m., with Admin and MS, Admin stated he was aware of the need to repair or replace the ovens. During a review of the 2022 Federal Food Code, the Food Code indicated equipment components such as doors and seals are to be kept intact and tight. 2. During an initial kitchen tour on 10/30/23, at 9:35 a.m., with the Dietary Supervisor (DS), the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055085 If continuation sheet Page 7 of 13 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 11/03/2023 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)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many following were observed: the countertop toaster oven had brownish black debris both on the oven knobs and inside the oven; the kitchen floors had cracked tiles with blackish discoloration, a ceiling vent was covered with blackish, dusty material; the grease trap area was malodorous and not securely covered. During an observation in the kitchen on 10/30/23, at 1:15 p.m., with DS, the following were observed: a cabinet drawer did not fully close. During an interview on 10/30/23, at 1:20 p.m., with DS, DS stated the Administrator (Admin) and the Maintenance Supervisor (MS) were aware of the need for repairs in the kitchen. During an interview on 10/31/23 at 2:03 p.m., MS stated the facility had plans to replace the kitchen cabinet, ovens, plumbing, floorings and grease trap. During an interview on 11/01/23, at 9:38 a.m., with Admin and MS, Admin stated he was aware of identified concerns in the kitchen. MS stated he was not sure who was responsible for the cleaning the vents. During a review of the facility's policy and procedure titled, Sanitation, revised November 2022, indicated, The food service area is maintained in a clean and sanitary manner . All kitchens, kitchen areas and dining areas are kept clean, free from garbage and debris, and protected from rodents and insects . All utensils, counters, shelves, and equipment are kept clean, maintained in good repair and are free from breaks, corrosions, open seams, cracks and chipped areas that may affect their use or proper cleaning. Seals, hinges and fasteners are kept in good repair . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055085 If continuation sheet Page 8 of 13 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 11/03/2023 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)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. 3. During a review of Resident 15's admission Record, undated, the record indicated Resident 15 was originally admitted to the facility in 2018 with a medical history of urinary tract infection (bladder infection) and Carrier of Carbapenem-Resistant Enterobacterales (CRE-an antibiotic resistant bacterial infection that can be transmitted by direct contact with an affected individual or indirect contact). During an observation on 10/30/23, at 10 a.m., outside Resident 15's room, the door to the room had signage which indicated, Stop, and Contact Precautions (measures that are intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or the resident's environment). During a review of Resident 15's Infection Control care plan initiated 12/17/20, revised on 7/31/23, the care plan indicated, due to the regulatory infection precautions, the resident is remaining in the room. During a concurrent interview and record review on 11/1/23, at 8:30 a.m., with Licensed Vocational Nurse 3 (LVN 3), Resident 15's Physician orders for the month of 11/2023 was reviewed. LVN 3 stated the order indicated Resident 15 was to be on Strict Contact Isolation with an order start date of 9/29/23. During a concurrent interview and record review on 11/02/23 at 5:14 p.m. with Restorative Nursing Assistant (RNA), RNA stated during exercise sessions, even though Resident 15 was on contact isolation, RNA provided physical assistance while Resident 15 walked in the hallways and on the outdoor patio. During a concurrent observation and interview on 11/3/23, at 9:19 a.m., with administrator (Admin), facility surveillance videos dated 10/23/23, and 10/25/23, were reviewed. Admin stated the surveillance video dated 10/23/23, showed Resident 15 in the lobby sitting on a wheelchair and chatting with the receptionist. Admin stated the surveillance video dated 10/25/23, showed Resident 15 seated on a wheelchair, wheeling herself in the dining area. 20 Based on observation, interview, and record review, the facility failed to maintain complete and accurate Medical Records for three (Residents 9, 30, and 15) of eleven sampled residents, when: 1. Licensed Vocational Nurse (LVN) 2 failed to immediately document in Resident 9's medical record, the administration of Resident 9's oxycodone (a controlled medication: medications which fall under US Drug Enforcement Agency (DEA) Schedules II-V, and have a potential for abuse, ranging from low to high, and may also lead to physical or psychological dependence). 2. LVN 2 and Licensed Vocational Nurse 5 (LVN 5) failed to document administration of multiple medications for Resident 30 on 10/6/23, 10/14/23, 10/18/23, 10/19/23. 3. Resident 15's care plan indicated Resident 15 was restricted to her room for infection control reasons since 12/17/20, while observations and interviews indicated Resident 15 had left her room for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055085 If continuation sheet Page 9 of 13 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 11/03/2023 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)

F 0842 ambulation therapy outside her room, as well as locomoting in a wheelchair in the lobby and dining areas. Level of Harm - Minimal harm or potential for actual harm The failure to maintain complete and accurate medical records for Resident 30, Resident 9, and Resident 15's had the potential to result in missed or duplicative medication administration, and inappropriate care provision from inaccurate care plans. Residents Affected - Some Findings: 1. During a concurrent observation and interview on 11/1/23, at 12:16 p.m., with LVN 2, at the medication cart, Resident 9's Medication Administration Record (MAR) and Controlled Drug Record (CDR) for oxycodone were reviewed. LVN 2 opened the medication cart and examined Resident 9's oxycodone supply. LVN 2 stated Resident 9 had 23 tablets of nine milligrams (mg) oxycodone myristate available in the medication cart supply. LVN 2 stated Resident 9's CDR indicated there should be 24 tablets available. LVN 2 stated she had administered one tablet of nine mg oxycodone to Resident 9 in the morning today but had not documented the administration on the CDR. LVN 2 stated Resident 9's MAR had no documentation of oxycodone administration for the 11/1/23, at 9 a.m., regularly scheduled nine mg dose of oxycodone. During an interview on 11/1/23, at 2:56 p.m., with the Director of Nursing (DON), the DON stated nurses were expected to document immediately after administration of medication. 2. During review of Resident 30's admission Record printed 10/31/23, the admission Record indicated Resident 30 was admitted to the facility in April 2023. During a concurrent interview and record review on 10/31/23, at 3:02 p.m., with the DON, Resident 30's MAR dated October 2023, and nursing progress notes dated 10/6/23 through 10/31/23, were reviewed. The DON stated she was unable to find any documentation in the MAR or the nursing progress notes to indicate nursing staff administered the following medications: 10/6/23 at 9 p.m.: Hydralazine (used for blood pressure) and Lantus Insulin (lowers blood sugar). 10/14/23 at 6:30 a.m.: Levothyroxine (a hormone), Pantoprazole (an antacid), routine Humalog Insulin (lowers blood sugar). 10/18/23 at 9:00 a.m.: Atorvastatin calcium (to lower cholesterol), Eliquis (a blood thinner), furosemide (promotes urination to decrease excess body fluids), Hydralazine, Lexapro (an anti-depressant), Isosorbide Mononitrate (lowers blood pressure), Metoprolol (lowers blood pressure), routine Humalog Insulin, and Ticagrelor (prevents blood clot formation). 10/18/23 at 11:30 a.m.: routine Humalog Insulin. 10/19/23 at 6:30 a.m.: routine Humalog Insulin. 10/19/23 at 11:30 a.m.: routine Humalog Insulin. During an interview on 10/31/23, at 3:18 p.m., with LVN 2, LVN 2 stated she had been Resident 30's charge nurse on 10/18/23 and 10/19/23 and was responsible for Resident 30's medication administration on those days. LVN 2 stated she had failed to document the medication administration on 10/18/23 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055085 If continuation sheet Page 10 of 13 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 11/03/2023 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)

F 0842 Level of Harm - Minimal harm or potential for actual harm because she had gotten sidetracked; LVN 2 was unable to provide an explanation for the lack of documentation on 10/19/23. During a phone interview on 11/03/23, at 2:17 p.m., LVN 5 stated she had been responsible for Resident 30's missed entries for 10/6/23 and 10/14/23. Residents Affected - Some During a review of the facility's policy and procedure titled, Documentation of Medication Administration, dated 11/2022, the policy and procedure indicated, administration of medication is documented immediately after it is given and .documentation of medication administration includes, as a minimum reason(s) why a medication was withheld, not administered, or refused (as applicable) . During a review of the facility's policy and procedure titled, Administering Medications, dated 4/2019, medications are administered in accordance with prescriber orders, including any required time frame .the individual administering the medication initials the Resident's MAR on the appropriate line after giving each medication and before administering the next ones . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055085 If continuation sheet Page 11 of 13 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 11/03/2023 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)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure proper infection prevention and control practices when Licensed Vocational Nurse (LVN) 3 did not perform hand hygiene during medication administration for Resident 2, Resident 5, and Resident 151. Residents Affected - Some This failure to ensure proper hand hygiene had the potential risk for transmission of infection to Residents 2, 5, 151, and throughout the facility. Findings: During an observation on 10/31/23 at 08:58 a.m., Licensed Vocational Nurse (LVN) 3 prepared Resident 2's morning medications outside his room and put them on a medication tray. Without performing hand hygiene, she put on an isolation gown and a pair of gloves. LVN 3 stated Resident 2 was on Contact Isolation (infection control measures used for a resident with infectious disease that may be spread by touching). LVN 3 went inside Resident 2's bathroom, turned the faucet on, grabbed water for medication administration, poured water in each medicine cup with the same gloved hands. LVN 3 then closed Resident 2's room door by touching the doorknob, picked up a disposable stethoscope (a medical instrument for listening to someone's heart or breathing) and a 30 milliliter (ml) syringe, checked Resident 2's Gastrointestinal feeding Tube (GT, device used to give direct access to the stomach for supplemental feeding, hydration, or medicine) for placement with same gloved hands. LVN 3 then, flushed GT with 30 ml water using the syringe, with same gloved hands. LVN 3 then administered one-by-one morning medications via GT to Resident 2. Without changing gloves and/or performing hand hygiene, LVN 3 then administered an injection of enoxaparin sodium (a medication which lowers risk of getting blood clots) to Resident 2 in the left upper abdomen. During an observation on 10/31/23 at 09:53 a.m., in Resident 151's room, LVN 3 placed morning medications on a medication tray on Resident 151's bedside table, pulled the privacy curtain and without performing hand hygiene, administered morning medications by mouth to Resident 151. LVN 3 then went out of Resident 151's room and wheeled a portable Vital Sign Machine (a medical instrument used to measure temperature, pulse, breathing, and blood pressure) into Resident 151's room. Without performing hand hygiene, she put on a new pair of gloves and checked Resident 151's vital signs. LVN 3 then administered eye drops medications to Resident 151's both eyes. During an interview on 10/31/23 at 09:54 a.m. LVN 3 stated that she should have changed her gloves and do hand hygiene with gel sanitizer or soap and water during medication administration for Resident 2 and Resident 151 to prevent cross contamination. During an observation on 11/01/23 at 11:59 a.m. LVN 3 administered a nebulizer (inhalation) medication treatment to Resident 5. LVN 3 entered Resident 5's room, with gloved hands touched door and side cart near bed. An observation was made of LVN 3 setting up the nebulizer with medication for Resident 5 with the same gloves throughout administration. During an interview on 10/31/23 at 2:44 p.m. with Director of Nursing (DON), the DON stated that hand hygiene was important to prevent infections which could lead to sepsis, rehospitalization, prolonged stay at nursing homes, hindrance in residents' progress and rehabilitation. The DON stated staff was expected to perform hand hygiene in between different routes of medications, before and after administration of medications, and after touching any items in residents' rooms. The DON stated she was working as a DON since 2/2023 in the facility but did not conduct any medication pass observation (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055085 If continuation sheet Page 12 of 13 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 11/03/2023 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)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete for licensed nurses. The DON stated facility utilized Nurse Consultant from their contracted pharmacy company for medication administration observations for Licensed Nurses on a quarterly basis. The DON stated Hand Washing was the common concern reported on most recent nurse consultant visits on 5/17/23 and 9/26/23. During a review of the facility's policy and procedure (P&P) titled, Handwashing/Hand Hygiene, dated 08/2019, the P&P indicated, all personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, visitors . use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: c) before preparing or handling medications . Event ID: Facility ID: 055085 If continuation sheet Page 13 of 13