Health inspection·September 12, 2019

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a follow up interview with Resident 37 on 9/11/19 at 10:20 a.m., Resident 37 indicated the verbal abuse started two months ago and stated she wanted to move to a different room and did not want to be in the same room as Resident 38. During an interview with Licensed Vocational Nurse 1 (LVN 1) on 9/12/19 at 9:39 a.m., LVN 1 stated that on one occasion when she was taking Resident 37 to the bathroom, Resident 38 was behind the bathroom door. LVN 1 asked Resident 38 to move so Resident 37 could get into the bathroom. Resident 38 moved but started to say derogatory words to Resident 37, such as whore, monkey man, etc. LVN 1 stated she talked to Resident 38 and told her that was not a good thing to say to anyone. LVN 1 stated she reported the incident to the SW and thought the administrator was also informed. LVN 1 indicated that in the case of abuse, the facility protocol is: for the first time, talk to the abuser, for the second time, write an incident report, and for the third time, do interventions, such as moving the resident to a different room. A review of the facility's undated Abuse Reporting policy indicated, Verbal abuse is defined as any use of oral, written or gestured language that includes disparaging and derogatory terms to residents or their families . The policy further states, Any alleged violations involving mistreatment, neglect or abuse .must be reported to the Administrator .When an alleged or suspected case of mistreatment, neglect or abuse is report, the facility Administrator, the Director of Nursing, will notify the following persons or agencies of such incident: Ombudsman, State Licensing and Certification Agency, Resident Representative, Adult Protective Services, Law Enforcement Officials. The Abuse Reporting policy also states, The person(s) observing an incident of resident abuse or suspecting resident abuse must immediately report such incidents to the charge nurse .The charge nurse must complete a Resident Abuse Report From and written statements from witnesses, if any, will be provided to the Administrator within twenty-four (24) hours of the occurrence of such incident . During an interview with the facility's Social Worker (SW) on 9/11/19 at 10:35 a.m., SW stated the bullying started last month, as reported by Resident 37. SW stated that when she talked to Resident 38 about her behavior, she just blew me off and told me 'leave me alone, big girl'. SW stated she was looking for a different placement for Resident 38 but had not found one yet. SW stated there was no available bed to move Resident 37 into and when a bed opened, it was reserved for a new admission. SW stated she advised Resident 37, If you're not like that, and it is not true, then just leave the room and not feed into her [Resident 38] negativity. Don't give her the power over you. During a concurrent interview with SW on 9/11/19 at 10:45 a.m. and a review of Resident 37's medical record, SW was unable to show any documentation, care planning, or interventions addressing the impact of the verbal abuse on Resident 37. SW stated, I was focused more on Resident 38 and admitted she did not follow up with Resident 37. SW stated if she were Resident 37, she would feel angry, sad, and would not want to be in that room. During a subsequent interview with SW on 9/12/19 at 9:27 a.m., SW stated the incidents between Residents 37 and 38 were not reported to the State. SW stated the protocol is for the Interdisciplinary Team (IDT), which included the Director of Nursing (DON), to discuss abuse issues and then decide if the incident needed to be reported. SW stated Resident 37 was caused emotional harm by Resident 38. SW stated the intervention was for her to talk to Resident 38 about her behavior. SW indicated she had not called the behavioral provider to refer Resident 38's behavior for evaluation. SW stated that as a Mandatory Reporter (legally required to ensure a report is made when abuse is observed or suspected), she should have reported the incident. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055677 If continuation sheet Page 2 of 9 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 055677 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pittsburg Skilled Nursing Center 535 School Street Pittsburg, CA 94565 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 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview with DON on 9/12/19 at 10:18 a.m., DON stated the verbal abuse incident by Resident 38 towards Resident 37 was discussed among the IDT, including the administrator. The IDT concluded this was an isolated incident (happened only once) and therefore the IDT did not think it was reportable. DON indicated if a staff member did the same thing to a resident, the staff member would be suspended, investigated, and reported. DON also indicated she thought the issue between Resident 37 and Resident 38 was resolved. DON indicated if she were Resident 37, she would feel bad and angry. During an interview with the Nursing Home Administrator (NHA) on 9/12/19 at 1:34 p.m., NHA stated the incident was discussed by the IDT. NHA stated he did not feel that the issue was severe enough to be reported. NHA also stated the staff inform him of every incident that happens in the facility, even if he was out of the facility, and he determines when an incident is considered abuse and if it needed to be reported. NHA insisted the verbal abuse that happened between Resident 37 and Resident 38 was not severe enough. NHA stated he would feel bad if that incident happened to his mom. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055677 If continuation sheet Page 3 of 9 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 055677 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pittsburg Skilled Nursing Center 535 School Street Pittsburg, CA 94565 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 ensure one of 13 sampled residents (Resident 6) was able to carry out activities of daily living (ADLs) when staff repeatedly failed to assist the resident with inserting his dentures. Residents Affected - Few This failure resulted in Resident 6 feeling humiliated and neglected and had the potential to effect the resident's nutrition and oral hygiene. Findings: A review of Resident 6's dental exam dated 2/12/19 indicated Resident 6 had full upper dentures (FUD) and full lower dentures (FLD). During an observation and concurrent interview with Resident 6 on 9/9/19 at 8:33 a.m., the resident did not have his FUD and FLD in his mouth. Resident 6 stated, No one puts on my dentures. I don't know how to put them on. It has been at least two months since I have worn them. They are just sitting on my bedside table. During an observation and concurrent interview with Resident 6 on 9/9/19 at 2:30 p.m., the resident was observed in the activity room without his FUD and FLD in his mouth. Resident 6 stated, I always eat without my dentures, because no one puts it in. I'd rather have them on, but I have learned to eat without them. During an interview with Licensed Vocational Nurse 2 (LVN 2) on 9/9/19 at 3:02 p.m., LVN 2 stated the resident had dentures but refused to wear them. During an observation and concurrent interview with Resident 6 on 9/10/19 at 8:35 a.m., the resident was sitting in the patio, without his FUD and FLD inside his mouth. Resident 6 indicated all his dentures were still on his bedside table. Resident 6 also indicated staff have not offered to assist him with his dentures in two months, so he has not worn his dentures for two months. Resident 6 further stated, I don't know how to put them on. No one asked me today if I wanted to wear them or to even help me. No one here cares about me. I feel like a joke without my dentures. During an interview with LVN 2 on 9/10/19 at 8:38 a.m., LVN 2 stated the dentures were on Resident 6's bedside table, and LVN 2 assumed Resident 6 knew how to insert the dentures by himself. LVN 2 stated, I don't ask Resident 6 to put it on. It's his responsibility. LVN 2 further stated she does not document when Resident 6 refuses to wear his dentures. During a concurrent interview and record review with the Minimum Data Set Coordinator (MDSC) on 9/10/19 at 9:02 a.m., Resident 6's Minimum Data Set (MDS, an assessment tool used to guide care), dated 6/6/19, did not indicate in Section L that Resident 6 had dentures. MDSC indicated Resident 6 had dentures but never wore them so MDSC did not document Resident 6's dentures in the MDS. During a concurrent interview and record review with Registered Nurse (RN) on 9/11/19 at 10:12 a.m., Resident 6's care plan dated 7/18/17 showed, Resident 6 has potential for nutritional problem related to poor dentition .Refuse[s] to wear dentures. No interventions for Resident 6 refusing to wear his dentures were listed. RN indicated Resident 6's care plan should have interventions for refusing to wear dentures. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055677 If continuation sheet Page 4 of 9 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 055677 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pittsburg Skilled Nursing Center 535 School Street Pittsburg, CA 94565 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 Level of Harm - Minimal harm or potential for actual harm A review of the facility's Dentures, Cleaning and Storing policy, dated 4/07, indicated, The following information should be recorded in the resident's medical record: 1. The date and time the denture care was performed .2. The name and title of the individual(s) who performed the denture care .3. All assessment data obtained concerning the resident's mouth .6. If the resident refused the treatment, the reason(s) why and the interventions taken. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055677 If continuation sheet Page 5 of 9 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 055677 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pittsburg Skilled Nursing Center 535 School Street Pittsburg, CA 94565 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure two of 13 sampled residents (Residents 20 and 46) were provided with respiratory care per physicians' orders when: Residents Affected - Some 1. Resident 20 was given 4 Liters per minute (L/min) of oxygen instead of 2 L/min per doctor's orders. 2. Resident 46 was given 4.5 L/min of oxygen instead of 2 L/min per doctor's orders. These deficient practices had the potential for life-threatening complications related to oxygen toxicity. Findings: 1. A review of Resident 20's admission Record indicated Resident 20 was admitted with multiple diagnoses, including a malignant neoplasm (cancer) of the left bronchus (lung) and acute respiratory failure. During an observation on 9/9/19 at 9 a.m., Resident 20 was sitting on her bed, and oxygen was being administered to her at 4 L/min through a nasal cannula (NC, a tubing device that fits in the nose). Resident 20 was not able to answer questions at that time. A review of the Resident 20's Medication Review Report showed a physician's order dated 7/2/19 for Oxygen at 2 L/min via NC as needed for SOB [shortness of breath]. A review of Resident 20's Weights and Vital Summary covering 7/4/19 through 9/13/19 indicated oxygen saturation rates (the extent to which hemoglobin is saturated with oxygen) from 94% to 98% (normal is 95% or higher) and that oxygen was administered by NC on three days and by an oxygen mask on two days. During an interview with Licensed Vocational Nurse 3 (LVN 3) on 9/9/19 at 9:30 a.m., LVN 3 confirmed Resident 20's oxygen was at 4 L/min. LVN 3 stated if a resident receives more than the required oxygen, It affects the brain. During an interview with Hospice Nurse (HN) on 9/9/19 at 2:38 p.m., HN stated Resident 20 is on 2 L/min of oxygen as needed. HN further stated Maybe she (Resident 20), changed the oxygen setting herself to 4 L. The staff did not do it. HN further stated that if oxygen is increased and the resident cannot tolerate it, she gets a drowning feeling. A review of Resident 20's care plan, dated 7/3/19, and concurrent interview with the Minimum Data Set (MDS, an assessment tool used to guide care) Coordinator (MDSC) on 9/11/19 at 8:30 a.m., indicated Resident 20 receives oxygen therapy as needed related to lung cancer. MDSC stated she did not think the residents were able to adjust their own oxygen. A review of the facility's Oxygen Administration policy and procedure, revised 3/04 indicates the purpose of the P&P is to provide guidelines for safe oxygen administration. The P&P states, Verify that there is a physician's order for this procedure [oxygen administration]. Review the physician's orders or facility protocol for oxygen administration. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055677 If continuation sheet Page 6 of 9 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 055677 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pittsburg Skilled Nursing Center 535 School Street Pittsburg, CA 94565 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 2. A review of Resident 46's admission Record indicated Resident 46 was admitted to the facility with multiple diagnoses, including Chronic Obstructive Pulmonary Disease (COPD, a progressive, irreversible, life-threatening condition that affects the lungs and the person's ability to breathe) and acute respiratory failure. During an observation on 9/9/19 at 8:45 a.m., Resident 46 was in bed, and oxygen was being administered at 4.5 L/min via NC. During subsequent observations of Resident 46 on 9/9/19 at 1:30 p.m., on 9/10/19 at 10 a.m., and on 9/11/19 at 2 p.m., oxygen was being administered to the resident at 4.5 L/min. A review of Resident 46's care plan, dated 8/23/19, indicated Resident 46 has altered respiratory status and difficulty breathing related to acute respiratory failure and COPD and uses oxygen therapy. A review of the Resident 46's Medication Review Report showed a physician's order dated 8/28/19 for Oxygen at 2 L/min via NC every shift for SOB/Wheezing. Titrate [adjust] to 90% and above. A review of Resident 46's Weights and Vital Summary covering 8/23/19 through 9/12/19 indicated oxygen saturation rates from 95% to 97% and that oxygen was administered via NC on 21 days. A review of the clinical notes showed no reports to the physician regarding high oxygen saturation. During an interview with Licensed Vocational Nurse 3 (LVN 3) on 9/9/19 at 9:30 a.m., LVN 3 stated Resident 46 had an order for 2 L/min of oxygen via NC. During the interview, LVN 3 adjusted Resident 46's oxygen flow rate down to 2 L/min and stated Resident 46's oxygen saturation was 96%. During a telephone interview with the Medical Director (MD) on 9/12/19 at 10:37 a.m., MD 1 stated those with COPD should not be given high concentrations of oxygen. Upon learning of Resident 46's documented oxygen saturation rates of 95%-97%, MD 1 stated the oxygen saturation for Resident 46 should be maintained at 90%. During an interview with the Director of Nursing (DON) on 9/12/19 at 10:35 a.m., DON stated high oxygen for those with COPD could cause them to forget to breathe and lead to death. A review of the facility's Oxygen Administration policy and procedure, revised 3/04 indicates the purpose of the P&P is to provide guidelines for safe oxygen administration. The P&P states, Verify that there is a physician's order for this procedure [oxygen administration]. Review the physician's orders or facility protocol for oxygen administration. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055677 If continuation sheet Page 7 of 9 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 055677 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pittsburg Skilled Nursing Center 535 School Street Pittsburg, CA 94565 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 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 and interview, the facility failed to provide residents with at least 80 square feet (sq. ft.) per resident for rooms occupied by multiple residents for 12 of 20 rooms (Rooms 3, 4, 5, 7, 9, 10, 12, 15, 17, 18, 19, 20). This failure had the potential for reduced space for staff to deliver care and lack of sufficient space for storage of residents' belongings. Findings: During an observation on 09/10/19 at 10:10 a.m., with the Facility Director (FD), the following resident rooms and corresponding square footage (sq. ft.) were identified: room [ROOM NUMBER] was a total of 225.36 sq. ft. and had three beds making for 75.1 sq. feet of space per resident. room [ROOM NUMBER] was a total of 225.36 sq. ft. and had three beds making for 75.1 sq. feet of space per resident. room [ROOM NUMBER] was a total of 225.36 sq. ft. and had three beds making for 75.1 sq. feet of space per resident. room [ROOM NUMBER] was a total of 225.36 sq. ft. and had three beds making for 75.1 sq. feet of space per resident. room [ROOM NUMBER] was a total of 225.36 sq. ft. and had three beds making for 75.1 sq. feet of space per resident. room [ROOM NUMBER] was a total of 225.36 sq. ft. and had three beds making for 75.1 sq. feet of space per resident. room [ROOM NUMBER] was a total of 225.36 sq. ft. and had three beds making for 75.1 sq. feet of space per resident. room [ROOM NUMBER] was a total of 225.36 sq. ft. and had three beds making for 75.1 sq. feet of space per resident. room [ROOM NUMBER] was a total of 225.36 sq. ft. and had three beds making for 75.1 sq. feet of space per resident. room [ROOM NUMBER] was a total of 225.36 sq. ft. and had three beds making for 75.1 sq. feet of space per resident. room [ROOM NUMBER] was a total of 225.36 sq. ft. and had three beds making for 75.1 sq. feet of space per resident. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055677 If continuation sheet Page 8 of 9 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 055677 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pittsburg Skilled Nursing Center 535 School Street Pittsburg, CA 94565 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 0912 Level of Harm - Potential for minimal harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete room [ROOM NUMBER] was a total of 225.36 sq. ft. and had three beds making for 75.1 sq. feet of space per resident. During observations of care and services from 09/09/19 to 09/12/19, there was sufficient space for the provision of care for the residents in all rooms. There was no heavy equipment stored in the rooms that could 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 12 rooms. Event ID: Facility ID: 055677 If continuation sheet Page 9 of 9