Health inspection·June 24, 2022

F 0582 coverage. SSD further stated she did not know the purpose of issuing a NOMNC. Level of Harm - Minimal harm or potential for actual harm During a concurrent record review and interview with Business Office Consultant (BOC) and SSD, on 6/22/22, at 10:46 a.m., Resident 26, 31 and 34's SNF ABN all dated for 3/14/22 were reviewed. The section titled, signature of patient or authorized representative was blank on SNF ABN for Resident 26, 31 and 34. BOC stated she called the family representatives of Resident 26, 31 and 34. BOC stated she was unable to find the documentation of her communication in their clinical records or on the residents' SNF ABN's. BOC also stated she knew very little about SNF ABN and was unable to explain what was discussed during her phone conversation with Resident 26, 31, and 34's family representatives. Residents Affected - Some During an interview with Director of Nursing (DON) on 6/22/22, at 10:55 a.m., DON stated she was not sure when and why SNF ABN and NOMNC notices were issued to the residents. During a concurrent interview and record review with the Administrator (ADM) on 6/22/22, at 10:58 a.m., NOMNC and SNF ABN for Residents 26, 31 and 34 were reviewed. The ADM stated the notices were not acceptable since there were no documentation if residents or their representatives were made aware of the change in Medicare coverage or their appeal rights. The ADM stated the SSD was responsible for handling SNF ABN and NOMNC's. The ADM further stated he did not follow up or oversee the SSD to ensure if the facility was compliance in issuing the beneficiary protection notices. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055677 If continuation sheet Page 2 of 25 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 06/24/2022 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 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to attempt to use the least restrictive alternatives and to reevaluate the use of a Posey bed (a hospital bed, canopy, and mattress system where all walls are zipped up from outside and the resident cannot exit out of it without assistance) for one of 14 sampled residents (Resident 29) when Resident 29 used a Posey bed and was not reevaluated. Residents Affected - Few This failure placed Resident 29 at risk of impaired psychosocial well-being. Findings: During a record review of Resident 29's admission Record, dated 6/20/22, the record indicated Resident 29 was admitted to the facility on [DATE]. During a record review Resident 29's Minimum Data Set (MDS, an assessment tool used to guide care), dated 5/5/22, the MDS indicated Resident 29's cognitive skills for daily decision making was severely impaired. The MDS further indicated Resident 29 required total dependence on staff for activities of daily living (activities related to personal care including walking, dressing, eating). During concurrent observation and interview with Certified Nursing Assistant (CNA) 5 on 6/20/22, at 9:37 a.m., Resident 29 observed sleeping in a Posey bed restraint with walls zipped up. CNA 5 stated she had taken care of Resident 29 for more than five years. CNA 5 stated Resident 29 was in a Posey bed for more than five years because Resident 29 had jerky movements which increased her risk of falls and injury. During an observation on 6/21/22, at 9:53 a.m., Resident 29 was lying in a Posey bed with walls zipped up. During another observation on 6/22/22, at 1:50 p.m., Resident 29 was lying in a Posey bed with walls zipped up. During a record review of Resident 29's Interdisciplinary Progress Notes, dated 9/28/14, the note indicated Resident 29's bed was replaced by a Posey bed for a safety precaution related to the diagnosis of Huntington's Disease (a hereditary disease of brain cells degeneration which causes progressive loss of memory and loss of motor coordination and control). During an interview with CNA 5, on 6/22/22, at 1:51 p.m., CNA 5 stated she kept Resident 29's Posey bed canopy closed all the time. CNA 5 stated it was safer if the canopy was closed. CNA 5 stated Resident 29 was unsafe in a wheelchair. CNA 5 further stated the facility did not have any plans to reduce the Posey bed use. During an interview with Director of Nursing (DON) on 06/23/22, at 12:05 p.m., DON stated it was the interdisciplinary team (IDT)'s responsibility to reevaluate the long-term restraints usage. DON stated she expected staff to assist Resident 29 to get out of bed daily and to document attempts to reduce restraint usage. DON stated it was not okay for the facility to assist Resident 29 to only get her out of bed for deep cleaning of her room and for showers. DON stated the Posey bed was a restraint and it placed Resident 29 at risk of depression, isolation, unhappiness, and boredom. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055677 If continuation sheet Page 3 of 25 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 06/24/2022 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 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete During an interview with DON on 6/24/22, at 9:31 a.m., the DON stated she was unable to find any documentation in Resident 29's clinical record which indicated if the facility reevaluated the need of the Posey bed or attempted to use the least restrictive alternatives since Resident 29 was placed in the Posey bed. Review of facility's policy and procedures (P&P) titled, Use of Restraints, revised December 2008, the P&P indicated, restrained individuals shall be reviewed regularly (at least quarterly) to determine whether they are candidates for restraint reduction, less restrictive methods of restraints, or total restraint elimination. Event ID: Facility ID: 055677 If continuation sheet Page 4 of 25 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 06/24/2022 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to accurately complete the Minimum Data Set (MDS- an assessment tool used to guide care) for two of 14 sampled residents (Resident 27 and 29) when: Residents Affected - Some 1. Resident 27's MDS assessment inaccurately reflected significant weight loss; and 2. Resident 29's MDS assessment inaccurately reflected Resident 29 walking with one-staff total assistance and not receiving any physical restraints. This deficient practice resulted in an inaccurate reflection of Resident 27 and Resident 29's comprehensive assessment and had the potential for inadequate weight management for Resident 27 and inadequate care to meet Resident 29's needs. Findings: 1. During a review of Resident 27's admission Record, dated 6/23/22, the record indicated Resident 27 was admitted to the facility on [DATE]. During a phone interview on 6/23/22, at 11:00 a.m., with Minimum Data Set Coordinator (MDSC) 1, Resident 27's section K for MDS assessment, dated 4/24/22 was reviewed. The MDSC 1 stated Resident 27's MDS assessment indicated Yes to Loss of 5% or more in the last month or loss of 10% or more in last 6 months. During a phone interview with MDSC 1, on 6/23/22, at 11:05 p.m., Resident 27's Weights and Vitals Summary from 10/2021 through 06/2022 was reviewed. MDSC 1 stated Resident 27 weighed 108.2 pounds (lbs.) on 4/6/22 and 106.2 lbs. on 3/7/22. MDSC 1 stated the weight change between 03/2022 and 04/2022 (in one month) was not five percent. MDSC 1 then stated Resident 27 weighed 112.4 lbs. on 11/8/21, and the weight change between 04/2022 and 11/2021 (in six months) was not ten percent. The MDSC 1 stated the weight loss calculation was not done correctly. MDSC 1 further stated the MDS assessment dated [DATE] was inaccurate based on Resident 27's documented weight from 11/2021 through 04/2022. 2. During a record review of Resident 29's admission Record, dated 6/20/22, the record indicated Resident 29 was admitted to the facility on [DATE]. During a record review of Interdisciplinary Progress Notes, dated 9/28/14, the notes indicated Resident 29's bed was replaced by a Posey bed (a hospital bed, canopy, and mattress system where all walls are zipped up from outside and the resident cannot exit out of it without assistance) for a safety precaution related to the diagnosis of Huntington's Disease (a hereditary disease of brain cells degeneration which causes progressive loss of memory and loss of motor coordination/control). During a concurrent observation and interview with Certified Nursing Assistant (CNA) 5, on 6/20/22, at 9:37 a.m., Resident 29 was observed sleeping in a Posey bed with the walls zipped up. CNA 5 stated Resident 29 has been in the Posey bed for at least five years and did not get out of the bed except for showers and monthly deep cleaning of the room. During a concurrent record review and interview with MDSC 2, on 6/20/22, at 2:50 p.m., Resident 29's MDS Section P assessment, dated 5/5/22 was reviewed. MDSC 2 stated Section P indicated restraints (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055677 If continuation sheet Page 5 of 25 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 06/24/2022 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some were not used. MDSC 2 stated the Posey bed should be documented on P0100 Physical Restraints, D. Other in the MDS. MDSC 2 further stated Resident 29's MDS assessment was coded inaccurately and required a correction. During a concurrent record review and phone interview with MDSC 2, on 6/24/22, at 2:50 p.m., Resident 29's MDS Section G assessment, dated 2/4/22 and 5/5/22 were reviewed. The MDS assessments indicated Resident 29's ability to walk in the room was coded as total dependence with help of one staff. MDSC 2 stated Resident 29 was unable to walk and section G was coded inaccurately. MDSC 2 stated MDS nurses reviewed activities of daily living (activities related to personal care including walking, dressing, eating) notes and spoke to direct care staff to complete an accurate MDS assessment. During a record review of Resident 29's Nursing Assistant Charting, dated [DATE] and May 2022, the record indicated direct care staff documented activity Walk in Room was 8 [activity did not occur] for all shifts during [DATE] and May 2022. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055677 If continuation sheet Page 6 of 25 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 06/24/2022 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 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 the Pre-admission Screening and Resident Review (PASRR) assessment for one of two sampled residents (Resident 3) when Resident 3's PASRR did not reflect the diagnosis of Parkinson's Disease (a gradual and progressive movement disorder that initially causes tremor [vibration] in one hand, stiffness or slowing of movement). This failure placed Resident 3 at risk to not receive an in-depth mental illness evaluation and care appropriate to his needs. Findings: A review of Resident 3's admission Record, dated 6/20/22, indicated Resident 3 was originally admitted to the facility on [DATE] with Parkinson's Disease. During a concurrent interview and record review on 6/20/22, at 12:00 p.m., with Medical Records Director (MRD), Resident 3's clinical paper chart was reviewed. MRD 1 stated Resident 3's most recent PASRR Level I assessment was completed on 8/28/18. Resident 3's PASRR Level I screening Document indicated facility answered No to Question 21.a., The resident has a severe physical illness such as coma .Parkinson's disease .which results in a level of impairment so severe that the resident could not be expected to benefit from specialized services? During a concurrent interview and record review with Interim Director of Nursing (DON) and Registered Nurse (RN), on 6/22/22, at 1:40 p.m., Resident 3's admission Record printed 6/20/22 was reviewed. The admission record indicated Resident 3 had a diagnosis of Parkinson's Disease on admission to the facility. The DON and RN stated facility was expected to code Yes to Question 21.a on the PASRR Level I assessment dated [DATE]. During an interview on 6/22/22, at 1:45 p.m., the DON stated completing the PASRR assessment was a federal regulation. The DON stated completing the PASRR Level I assessment accurately was important to identify if residents with specific neurologic conditions require a PASRR Level II evaluation (in-depth mental illness evaluation) or not. The DON stated due to inaccurate coding, there is a risk of Resident 3 not receiving detailed assessment for appropriate services. The DON further stated since facility did not complete Resident 3's PASRR assessment accurately, Resident 3 did not receive a Level II evaluation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055677 If continuation sheet Page 7 of 25 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 06/24/2022 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to review and revise the care plan for one of 14 sampled residents (Resident 29) when Resident 29's care plan for a Posey bed restraint (a hospital bed, canopy and mattress system where all walls are zipped up from outside and the resident cannot exit out of it without assistance) was not reviewed and revised for two years and ten months. This failure placed Resident 29 at risk for impaired psychosocial well-being and had the potential to not meet Resident 29's care needs. Findings: During a record review of Resident 29's admission Record, dated 6/20/22, the record indicated Resident 29 was admitted to the facility on [DATE]. During a concurrent observation and interview with Certified Nursing Assistant (CNA) 5, on 6/20/22, at 9:37 a.m., Resident 29 was observed sleeping in a Posey bed with the walls zipped up. CNA 5 stated Resident 29 has been in the Posey bed for at least 5 years due to risk of falls. CNA 5 further stated Resident 29 did not get out of the bed except during showers and monthly room deep cleaning. During an interview with CNA 5, on 6/22/22, at 1:51 p.m., CNA 5 stated Resident 29 did not get out of bed because of Resident 29's jerky movements. CNA 5 stated she kept the Posey bed canopy closed all the time because it is safer for Resident 29 if it is closed. CNA 5 stated she is unaware of plans to reduce the usage of Posey bed for Resident 29. During a concurrent record review and interview on 6/23/22, at 12:05 p.m., with Director of Nursing (DON), Resident 29's Care Plan for the use of Posey Bed, dated 1/25/17 was reviewed. The care plan indicated Resident 29 uses a Posey bed for jerky movements from Huntington's Disease and to Ensure [Resident 29] is positioned correctly with proper body alignment while restrained. Resident 29's care plan also indicated, Provide a meaning full program of activities that accommodates restraint use without drawing unwanted attention. Provide restraint-free time during activities when possible to supervise closely. The DON confirmed the facility did not review or revise the care plan since 08/2019. The DON further stated if care plans were not reassessed as required, there was an increased risk of depression, isolation, unhappiness, and boredom. During a phone interview with Minimum Data Set Coordinator (MDSC) 1, on 6/20/22, at 2:50 p.m., MDSC 1 stated she met with Social Services Director (SSD) and Activities Director (AD 1) on 5/3/22 to reassess the Posey bed usage for Resident 29, however, MDSC 1 did not document it in Resident 29's record until she was asked about it on 6/20/22. During a concurrent record review and interview with SSD, on 6/20/22, at 2:50 p.m., Resident 29's Inter-Disciplinary Care Conference note, dated 5/3/22 was reviewed. Inter-Disciplinary Care Conference note did not indicate assessment of Posey bed use or changes to Posey bed care plan. SSD stated Resident 29's last care conference was on 5/3/22 but SSD and Resident 29's family representative did not participate in the care conference. During a review of facility's Policy and Procedures (P&P) titled Care Planning - Interdisciplinary (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055677 If continuation sheet Page 8 of 25 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 06/24/2022 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Team, dated 12/2008, the P&P indicated Interdisciplinary Team is responsible for the periodic review and updating of care plans; .b. When the desired outcome is not met; .d. At least quarterly. During a review of facility's P&P titled, Use of Restraints, dated 12/2008, the P&P indicated, restrained individuals shall be reviewed regularly (at least quarterly) to determine whether they are candidates for restraint reduction, less restrictive methods of restraints or total restraint elimination. Event ID: Facility ID: 055677 If continuation sheet Page 9 of 25 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 06/24/2022 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, for three of 34 sampled residents (Resident 31, 9, 21), the facility failed to provide the necessary care to maintain good grooming and personal hygiene when Resident 31, 9, and 21 had long, dirty, and/or jagged fingernails. Residents Affected - Some This failure resulted to Resident 31, 9, and 21 not receiving adequate nail care and had the potential for the spread of infection. Findings: During an initial observation on 6/20/22, at 11:45 a.m., Resident 31 had long, dirty and jagged fingernails. A review of Resident 31's admission Record, dated 6/21/22, indicated Resident 31 was admitted to the facility on [DATE], with hemiplegia (paralysis of one side of the body), hemiparesis following cerebral infarction (disrupted blood flow to the brain due to problems with the blood vessels that supply it) affecting right dominant side, muscle weakness, and other abnormalities of gait (walking) and mobility. A review of Resident 31's Minimum Data Set (MDS, an assessment tool used to guide care), dated 5/14/22, indicated Resident 31 had impaired cognition (trouble remembering, learning new things, concentrating, or making decisions that affect everyday life), and was dependent on staff for activities of daily living (activities related to personal care including walking, dressing, eating). During an observation and concurrent interview with Certified Nursing Assistant (CNA) 4, on 6/22/22, at 9:40 a.m., CNA 4 agreed Resident 31's fingernails were long, dirty and jagged. During an interview with the Registered Nurse (RN), on 6/22/22, at 10:10 a.m., RN said the CNAs were supposed to inspect the fingernails and toenails of the residents during shower days, and trim their nails as needed. RN stated diabetic (with high blood sugar) residents were to have their fingernails trimmed by the licensed nurses. RN further stated the podiatrist (foot doctor) was supposed to trim the toenails of residents who were diabetic. During a review of Resident 21's admission Record, dated 6/13/22, it indicated Resident 21 was admitted to the facility on [DATE] and had hemiplegia (weakness of one side of body) and hemiparesis (loss of strength on one side of the body) following cerebral infarction (stroke) affecting dominant side. During a record review of Resident 21's MDS, dated [DATE], the MDS Section G indicated, Resident 21 was totally dependent on staff for showers and to maintain personal hygiene and grooming. The MDS indicated Resident 21's BIMS score was three out of 15, indicating severe mental impairment. During a concurrent observation and interview on 6/21/22, at 1:30 p.m., with CNA 4, Resident 21 had long fingernails and black matter underneath fingernails on both hands. CNA 4 stated Resident 21 can dig long nails into his own hands and cause skin injury and infection. During a concurrent interview and record review with Director of Staff Development (DSD), on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055677 If continuation sheet Page 10 of 25 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 06/24/2022 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 Residents Affected - Some 06/21/22, at 2:03 p.m., Residents 21's Weekly shower and Body check sheet, dated June 2022 was reviewed. DSD stated the weekly shower sheet indicated Resident 21 received showers on 6/6/22 and 6/16/22 and received bed bath on all other days. DSD stated CNAs and Nurses were responsible for residents' nail care and hygiene. During a review of Resident 21's Care Plan-ADL [activities of daily living] self -care performance, revised on 11/2/21, the care plan indicated to check Resident 21's nail length and trim and clean on bath day and as necessary. During an interview on 6/22/22, at 9:19 a.m., the Director of Nursing (DON) stated staff were expected to anticipate Resident 21's needs, perform head to toe assessment during ADL care and provide nail care. The DON also stated the risk of not providing nail care could result in skin injury from scratching, nail deformity and possible infection and affect quality of life of residents. During a review of the facility's undated Policy and Procedure (P&P) titled, Care of Fingernails/Toenails, revised on 4/2007, the P&P indicated, Nail care includes daily cleaning and regular trimming .Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin. A review of Resident 9's admission Record, dated 6/21/22, indicated Resident 9 was admitted to the facility on [DATE]. A record review of Resident 9's MDS, dated [DATE], indicated Resident 9 needed one staff's limited assistance to maintain personal hygiene and grooming. The MDS assessment further indicated Resident 9's Brief Interview of Mental Status (BIMS- an assessment for cognition status) score was 15 out of 15 which indicated Resident 9 was cognitively intact. During a concurrent observation and interview on 6/20/22, at 10:13 a.m., Resident 9 was observed lying in bed. Resident 9 had long toenails on both feet. Resident 9 stated, don't like it long while pointing at her toenails. Resident 9 further stated had pain in her toenails. During an interview on 6/21/22, at 3:08 p.m., with RN, RN stated Resident 9's toenails were a bit long, sharp and needed to be trimmed. RN further stated Resident 9 could cut herself with long toenails. During a concurrent interview and record review on 6/21/22, at 3:13 p.m., with CNA 6, ADL [Activities of Daily Living] binder was reviewed. CNA 6 stated there was no documentation when staff recorded Resident 9's toenails were last trimmed. During an interview on 6/21/22, at 3:18 p.m., with CNA 8, CNA 8 stated nursing assistants were responsible for trimming Resident 9's toenails. CNA 8 stated she did not notice Resident 9's long and sharp toenails and did not offer to cut the toenails recently. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055677 If continuation sheet Page 11 of 25 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 06/24/2022 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 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm Based on observation, interview, and record review, the facility failed to ensure staffing information was posted and readily available, when the daily staffing ratio information was not posted for two consecutive days on 6/22/22 and 6/23/22, and the staffing ratio data was not maintained for 26 days for the month of 5/2022 and five days for the month of 6/2022 for at least 18 months. Residents Affected - Some This failure resulted in staffing information not being readily available to residents and visitors at any given time. Findings: During an observation on 6/22/22, at 9:34 a.m., with Registered Nurse (RN), Nursing Hours Per Patient Day (NHPPD) document was posted above the time clock at the entrance of the facility with a date of 6/21/22. The document included the total number and the hours worked by RNs, licensed vocational nurses (LVNs), and Certified Nursing Assistant (CNAs) during morning, evening, and night shift. The document also indicated the total resident census and calculation of CNA NHPPD and total NHPPD for 6/21/22. During an observation on 6/23/22, at 10:15 a.m., with Director of Staff Development (DSD), NHPPD document dated 6/22/22 was posted above the time clock at the entrance of the facility. The document included the total hours worked and the total number of RNs, LVNs, and CNAs during each shift. The document also indicated resident census and calculation of CNA NHPPD and total NHPPD for 6/22/22. During an interview on 6/22/22, at 9:32 a.m., with Administrator (ADM), ADM stated DSD was responsible for posting daily staffing ratio. ADM further stated DSD did not work full time and DSD's workdays varied from week to week depending on the facility's need and DSD's availability. During an interview on 6/23/22, at 10:07 a.m., with DSD, DSD stated she was primarily responsible for posting the NHPPD data on her working days. DSD stated the NHPPD was typically posted between 6 a.m. to 9 a.m. DSD stated, on her days off, ADM was responsible for posting the updated NHPPD. DSD further stated ADM does not do it all the time. During a follow-up interview on 6/23/22, 11:40 a.m., with ADM, ADM stated he knew he was responsible for posting the daily staffing ratio or NHPPD in the absence of DSD but did not always remember to do so. During a concurrent interview and record review with DSD, on 6/23/22, at 10:45 a.m., NHPPD binder dated June 2022 and May 2022 were reviewed. The DSD stated she was unable to find staffing ratio sheets from 6/11/22 through 6/15/22. The DSD further stated she was unable to find staffing ratio sheets from 5/1/22 through 5/12/22 and from 5/18/22 through 5/31/22. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055677 If continuation sheet Page 12 of 25 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 06/24/2022 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 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 observation, interview, and record review, the facility failed to ensure medications were dated and labeled, emergency medications were replaced, and emergency medications and controlled substances (medications with high abuse or misuse potential) were correctly logged when: 1. One 2.5 mL (milliliter, unit of measurement) bottle of bimatoprost (medication to treat glaucoma) ophthalmic solution was opened but not dated and one Multi-Dose Inhaler (MDI) of budesonide 80 mcg (microgram, unit of measuring weight)/formoterol fumarate dihydrate 4.5 mcg (medication used to help with breathing) was opened but not dated or labeled with resident identifier; 2. The opened Oral Emergency Kit (E-Kit, a box with emergency medications) was not replaced by the pharmacy within 24 hours; 3. Emergency Drug Kit Use Log had inaccurate medication usage records; 4. The controlled substances disposition record did not indicate a method of destruction, witness signature, or date of disposal. These failures had the potential to result in residents receiving wrong or expired medications, residents not receiving medications during an emergency, medication errors or drug diversion of controlled substances. Findings: 1. During a concurrent observation of Medication (Med) Cart 1 and interview with Licensed Vocational Nurse (LVN) 1, on 6/21/22, at 9:41 a.m., one MDI of budesonide 80 mcg/formoterol fumarate dihydrate 4.5 mcg and one bottle of bimatoprost ophthalmic solution were open but not dated. LVN 1 stated the bottle of bimatoprost was unlabeled with an open date and MDI budesonide/formoterol did not have a resident's name labeled. During an interview with Director of Nursing (DON), on 6/23/22, at 9:54 a.m., with Administration (Admin) present, DON stated opened eye drops should be labeled and used within 28 days per facility policy. A policy review of Medication Administration General Guidelines, dated 09/18, indicated, .multi-use eye drops and ointments should be disposed of 28 days after initial use. Policy also indicated, the nurse shall place a 'date opened' sticker on the medication if one is not provided by the dispensing pharmacy and enter the date opened. 2. A review of Emergency Drug Kit Usage Report slip, dated 6/18/22, indicated two tablets of azithromycin (medication used to treat infection) 250 mg (milligram, unit of measuring weight) were removed from the E-Kit. During a concurrent observation of E-Kit and interview with LVN 3, the E-Kit medications were reviewed. LVN 3 confirmed two tablets of azithromycin 250 mg were used and not replaced from the E-Kit. LVN 3 further stated the E-Kit medication should be replaced within 72 hours of opening. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055677 If continuation sheet Page 13 of 25 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 06/24/2022 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 0755 Level of Harm - Minimal harm or potential for actual harm A review of Oral Emergency Kit drug manifest, undated, indicated E-Kit should contain four tablets of azithromycin 250 mg. During an interview with DON, on 6/23/22, at 9:54 a.m., with Admin present, DON stated opened E-Kits are replaced within 24 hours. Residents Affected - Some During a policy review of Emergency Pharmacy Service and Emergency Kits, dated 01/20, indicated that .the nurse replaced the medication in the appropriate area of the kit within 24 hours of opening or next scheduled delivery, or as required by state regulation . 3. During concurrent review of Emergency Drug Kit Use Log binder and interview with LVN 3, on 6/22/22, at 10:11 a.m., the log indicated 19 uses of facility E-Kit. The log contained 24 Emergency Drug Kit Usage Report slips, of which four were not dated and one slip consisting of both pharmacy and facility copy. During an interview with DON, on 6/23/22, at 9:54 a.m. with Admin present, DON acknowledged inaccurate documentation of Emergency Drug Kit Use Log. During a policy review of Emergency Pharmacy Service and Emergency Kits, dated 01/20, indicated, Upon removal of any medication or supply item from the emergency kit, the nurse documents the medication or item used on an emergency kit log . Items to be documented on the log include: .c. Date and time of medication removal . 4. During a concurrent review of Medication Disposition Record, signed 5/25/22, and interview with RN and DON, on 6/23/22, at 8:52 a.m., the record indicated controlled substances had one licensed nurse witness signature and one pharmacist signature. Record did not indicate who submitted controlled substance, method of destruction, and witness to destruction of medication. RN stated licensed nurse signature was for the witness receipt of the medication and not disposal of medication. RN stated the pharmacist signature indicated disposal of controlled substances. DON acknowledged record sheet being used did not have needed fields to indicate method of destruction and signature of witness to destruct medication. During an inspection of disposed controlled substances storage area on 6/23/22, at 8:57 a.m., container labeled For Incineration Only was found inside a closet labeled Janitor. RN stated this container was used to store destroyed controlled substances. Bags containing various whole pills (not dissolved) were found inside the container. RN stated controlled substances are disposed of by putting medications in a bag and water is poured into the bag. RN stated she waited until medications are dissolved before she placed a bag into For Incineration Only container. Review of facility policy titled, Discarding and Destroying Medications, dated April 2007, indicated, medication disposition record must contain, as a minimum, the following information: .b. date medication destroyed, f. quantity destroyed; g. method of destruction; h. reason for destruction; and i. Signature of witnesses. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055677 If continuation sheet Page 14 of 25 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 06/24/2022 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. During a review of Resident 27's admission Record dated 6/23/22, the record indicated Resident 27 was admitted to the facility on [DATE] with unspecified dementia with behavioral disturbance and major depressive disorder. During a review of Resident 27's Physician's order summary report dated 6/22/22 indicated Resident 27 received one tablet of 50 milligrams (mg) of Quetiapine Fumarate [a psychotropic medication used to treat mental disorders] by mouth at bedtime for unspecified dementia with behavioral disturbance manifested by seeing, feeling or hearing things that are not there since 11/30/2019. During a record review and interview with RN, on 6/24/22, at 8:30 a.m., facility's document titled, Consultant Pharmacist Medication Regimen Review . dated 4/1/22 through 4/26/22 for Resident 27 was reviewed. RN stated, for Resident 27, the consultant pharmacist recommended to indicate the appropriate clinical situation to support the continued use of quetiapine fumarate. RN further stated facility did not follow up on this recommendation since 4/2022. During a phone interview on 6/23/22, at 4:21 p.m., with facility's Pharmacy Consultant (PC 1), PC 1 stated facility was expected to act upon pharmacist's recommendations within 30 days from the day recommendations were made. PC 1 also stated there was a potential for harm if the recommendations were not acted upon within the time frame. A review of the facility's Policy and Procedure (P&P) titled, Medication Management Policy, dated 04/2007, indicated, The primary purpose of this review is to help the facility maintain each resident's highest practicable level of functioning by helping them utilize medications appropriately and prevent or minimize adverse consequences related to medication therapy to the extent possible. Based on interview and record review, the facility failed to act upon consultant pharmacist's recommendations for three of seven residents (Resident 9, 28, and 27) when: 1. Resident 9 was not re-evaluated while taking aripiprazole(medication to treat schizophrenia, depression, or irritability) and quetiapine (medication to treat schizophrenia, bipolar disorder, and depression); 2. Resident 28's phenytoin (a compound found in blood and an anticonvulsant [treat epileptic seizure] medication) and albumin (compound in blood can help determine if you have liver or kidney disease or if your body is not absorbing enough protein) levels were not assessed; and 3. Resident 27 was not re-assessed to continue the use of quetiapine fumarate. This failure had the potential for Resident 9, 28, 27 and 29 to receive unnecessary medications or medications without an appropriate clinical indication. Findings: 1. During a review of Resident 9's admission Record, dated 6/21/22, the record indicated Resident 9 was admitted to the facility on [DATE] with unspecified dementia (loss of memory, language or problem-solving) with behavioral disturbance, major depressive disorder (persistently depressed mood), (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055677 If continuation sheet Page 15 of 25 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 06/24/2022 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 0756 and brain injury. Level of Harm - Minimal harm or potential for actual harm During a review of Resident 9's Physician's Order Summary Report, dated 6/21/22, the report indicated Resident 9 took one tablet of 10 milligrams (mg) aripiprazole related to unspecified dementia with behavioral disturbance manifested by paranoia (persistent feeling people are 'out to get you') such as uncontrollable yelling and screaming since 9/4/19. The report also indicated Resident 9 took two tablets of 25 mg quetiapine in the morning, and five tablets in the evening related to unspecified dementia with behavioral disturbance manifested by physical aggression that is danger to self or others since 10/11/20. Residents Affected - Some During a concurrent interview and record review on 06/21/22, at 1:18 p.m., with Registered Nurse (RN), facility's document titled, Consultant Pharmacist Medication Regimen Review ., dated 4/1/22 through 4/26/22 was reviewed. The document indicated the consultant pharmacist's recommendations for Resident 9, This resident is currently receiving the atypical antipsychotic [medications to treat mental conditions] [aripiprazole] and [quetiapine] for dementia with behavioral disturbances .Please evaluate current therapy and indicate below the appropriate option for this resident . RN stated facility was expected to communicate pharmacist's recommendations with the physician, however, facility did not follow up on pharmacist's medication regimen review recommendations for Resident 9. When asked about the timeframe the facility had to act upon consultant pharmacist's recommendations, RN did not say anything. 2. During a review of Resident 28's admission Record, dated 6/21/22, the record indicated Resident 28 was admitted to the facility on [DATE] with Parkinson's Disease (progressive disorder affecting movement and often include tremors), unspecified dementia with behavioral disturbance, and major depressive disorder. During a review of Resident 28's Physician order summary, dated 6/21/22, the record indicated Resident 28 received phenytoin 100 mg capsule by mouth two times a day for muscle pain since 10/29/19. During a concurrent interview and record review on 06/21/22, at 2:34 p.m., with RN, facility's document titled, Consultant Pharmacist Medication Regimen Review . from 4/1/22 through 4/26/22 was reviewed. RN stated the pharmacist made recommendation to consider a phenytoin level and albumin level every six months to monitor therapy because the resident is receiving phenytoin medication. During a concurrent interview and record review with RN, on 6/21/22, at 2:37 p.m., Resident 28's progress notes and physician orders were reviewed. RN stated she was unable to find documentation if facility followed up on pharmacist's recommendations made in 4/2022. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055677 If continuation sheet Page 16 of 25 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 06/24/2022 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 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 failed to ensure the medication error was not five percent or greater for two of six sampled residents (Resident 19 and 8) when: Residents Affected - Some 1. Resident 19 was administered lactobacillus acidophilus (medication helps with digestive issues) 75 million cells (unit of measure) instead of 500 million cells, as prescribed; and 2. Resident 8 was administered sennosides (medication to treat constipation) 8.6 milligram (mg, unit of measure) tablet as a whole tablet and not crushed. This failure resulted in two medication errors out of 28 opportunities, resulted in a medication error rate of 7.14%, and put the residents at risk of receiving a subtherapeutic dose of medication or increased risk of aspiration (accidentally inhaling food or liquid into airway) and choking. Findings: 1. During a medication pass observation on 6/21/22, at 8:21 a.m., with Registered Nurse (RN), RN was observed administering to Resident 19, one 8.6 mg tablet of lactobacillus acidophilus with pectin containing 140 mg calcium, 100 mg pectin, and 75 million live cells per serving. During an interview with RN, at 6/21/22, at 1:59 p.m., RN identified and verified the bottle labeled Lactobacillus acidophilus contained 75 million cells per capsule. RN stated the physician's order was 500 million cells per capsule. A review of Resident 19's Medication Review Report, dated 06/22/22, indicated acidophilus capsule was to be administered twice a day for supplement and one capsule is 500 million cells. 2. During a medication pass observation on 6/22/22, at 8:29 a.m., with Licensed Vocational Nurse (LVN) 3, at Resident 8's bedside, LVN 3 administered to Resident 8, one uncrushed tablet of sennosides 8.6 mg. Resident 8 was observed coughing and showing a hard time swallowing the pill as a whole tablet. During an interview with LVN 3, on 6/22/22, at 8:58 a.m., LVN 3 stated according to the cheat sheet provided, Resident 8's tablet medication were to be crushed before administration. LVN 3 further stated Resident 8 was alert, on a regular diet, and would be able to take whole pill. During an interview with LVN 1, on 6/22/22, at 9:04 a.m., LVN 1 stated Resident 8 is normally confused and has his medications crushed. LVN 1 stated the physician's order determines whether medications are crushed or not. A record review of Resident 8's Medication Review Report, dated 6/22/22, indicated Resident 8's physician order for Do not force feed if not fully awake and alert and Dysphagia [difficulty swallowing] Mechanical Soft texture, thin consistency cardiac diet for diet d/t [due to] chewing & swallowing difficulties was ordered. During a review of the policy titled, Medication Administration General Guidelines, dated 09/18, indicated Medications are administered in accordance with written orders of the prescriber .Verify medication is correct three times before administering medication. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055677 If continuation sheet Page 17 of 25 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 06/24/2022 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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. Based on observation, interview, and record review, the facility failed to ensure medications were stored and labeled appropriately when: 1. the medication room (MR) temperature was out of range; 2. the refrigerator containing controlled medications was unlocked; 3. loose pills were found in two medication carts (Medication Cart 1 and 2); 4. medications not administered were stored unlabeled in a drawer in the med carts; 5. controlled medications to be disposed were store in a single locked, not permanently affixed drawer; and 6. disposed controlled substances were kept in an openly accessible container. These failures had the potential for administration of medication to the wrong resident, temperature sensitive medications to degrade, diversion of medications, and miscount of medications. Findings: 1. During a concurrent observation of MR and interview with Licensed Vocational Nurse (LVN) 1, on 6/21/22, at 1:51 p.m., MR temperature was observed to be 79° F (Fahrenheit, unit for measuring temperature). LVN 1 confirmed the MR temperature was 79°F and medication room temperature was out of range. LVN 1 stated she was unsure what to do if room temperature was out of range. During an observation of MR, record review of Temperature Log, dated June 2022, and interview with LVN 3, on 6/22/22, at 10:11 a.m., MR was observed to be 80°F. LVN 3 confirmed the MR temperature was 80°F. Review of Temperature Log indicated MR temperatures at 7AM was greater than 77°F for 15 out of 21 days in June 2022. Temperature Log further indicated, maintain MR temperature between 68°F -77°F. During an interview with Director of Nursing (DON), on 6/23/22, at 9:54 a.m., with Admin present, DON acknowledged findings regarding MR temperature. During a policy review of Medication refrigerator policy and procedure, dated 10/2021, indicated, medication room will be maintained at the temperature of 68 to 77° Fahrenheit .if medication room temperature is too warm, open medication room and place fan in room Licensed Nurse needs to stay by room until temperature decreases and the door can be shut and locked again. Check temperature every 15 minutes until temperature decreases. 2. During an observation of MR, on 6/21/22, at 8:24 a.m., medication refrigerator was observed to be unlocked. Refrigerator contained an emergency medication kit box which contained three one mL (milliliter, unit of volume measurement) lorazepam (medication to treat anxiety) vials. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055677 If continuation sheet Page 18 of 25 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 06/24/2022 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 0761 Level of Harm - Minimal harm or potential for actual harm During a concurrent observation of MR and interview with LVN 1, on 6/21/22, at 1:51 p.m., medication refrigerator was observed to be unlocked. LVN 1 stated medication refrigerator should be locked. During an interview with DON, on 6/23/22, at 9:54 a.m., with Administrator (Admin) present, DON acknowledged refrigerator should be locked at all times. Residents Affected - Some Review of the facility policy titled, Controlled Substances, dated April 2007, indicated, Controlled substances [medication with high risk of abuse and addiction] must be stored in the medication room in a locked container, separate from containers for any non-controlled medications. This container must remain locked at all times, except when it is accessed to obtain medications for residents. 3. During a concurrent inspection of Medication Cart (Med Cart) 2 and interview with LVN 1, on 6/21/22, at 9:56 a.m., four loose pills were found in Med Cart 2 drawer. LVN 1 verified four loose pills were found and stated loose pills should not be found in the Med Cart drawer. During a concurrent inspection of Med Cart 1 and interview with RN, on 6/21/22, at 2:12 p.m., six loose pills were found in the Med Cart 1 drawer. RN verified six loose pills were found in Med Cart 1. RN stated loose pills should not be found in the Med Cart drawer. During an interview with DON, on 6/23/22, at 9:54 a.m. with Admin present, DON acknowledged loose pills should not be found in medication cart drawers. Review of facility policy Medication Administration General Guidelines, dated 09/18, indicated, Once removed from the package/container, unused medication doses shall be disposed of according to the nursing care center policy. Review of facility policy Storage of Medications, dated April 2007, indicated, nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe and sanitary manner. 4. During a concurrent inspection of Med Cart 1 and interview with RN, on 6/21/22, at 2:07 p.m., three unlabeled medication cups containing medications and a handwritten note were found. Two cups contained various pills and the third cup contained medication mixed in apple sauce. RN stated the note indicated residents' room number and weight for the morning. RN stated the medications were to be disposed later and they belonged to two other residents. RN stated it was necessary to label unused medications to avoid administering medications to the wrong resident. RN stated the note can cause confusion as to which medication belonged to which resident. During an inspection of Med Cart 2 and interview with LVN 1, on 6/21/22, at 9:41 a.m., one unlabeled medication cup containing medications was found. LVN 1 stated medications were refused by resident and were to be disposed. LVN 1 stated medication cup should be labeled to avoid administering medications to the wrong resident. During an interview with DON, on 6/23/22, at 9:54 a.m. with Admin present, DON acknowledged unused medications need to be labeled and stored properly or disposed of immediately. Review of facility policy Medication Administration General Guidelines, dated 09/18, indicated, Medications are to be administered at the time they are prepared .the person who prepares the dose for the administration is the person who administers the dose. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055677 If continuation sheet Page 19 of 25 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 06/24/2022 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of facility policy Administering Medications, dated April 2010, indicated, .medications may not be prepared in advance and must be administered within one hour of their prescribed time, unless otherwise specified . Review of facility policy Storage of Medications. dated April 2007, indicated .each resident's medications shall be assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications of several residents . 5. During an inspection of controlled substances storage area in DON's unlocked office, on 6/23/22, at 8:52 a.m., controlled substances were observed in the bottom drawer of a wooden, two drawer cabinet. The bottom drawer had a metal hinge affixed on it, and a key pad lock. The screws used to affix the hinge appeared to be loose. The top drawer was unlocked and could be an access point to the bottom drawer. The cabinet was observed to be unaffixed to a permanent fixture. During an interview with DON, on 6/23/22, at 8:52 a.m. with RN present, DON acknowledged controlled substances need to be kept in a double locked container that is affixed to a permanent structure. Review of facility policy Controlled substances, dated April 2007, indicated .controlled substances must be stored in the medication room in a locked container, separate from containers for any non-controlled medications. This container must remain locked at all times, except when it is accessed to obtain medications for residents. Review of facility policy Discarding and Destroying Medications, dated April 2007, indicated All controlled substances shall be retained in a securely locked area with restricted access until authorized individuals destroy them. 6. During a concurrent inspection of disposed controlled substances storage area and interview, with RN, on 6/23/22, at 8:57 a.m., container labeled For Incineration Only was found inside a closet labeled Janitor. RN stated this container was used to store destroyed controlled substances. Container was observed to have a loosely fitted lid that was easily removed. Janitor closet door was unlocked. The janitor closet key hung on the wall near the nursing station. Bags containing various whole pills (not dissolved) were found inside the For Incineration Only container. RN 1 stated controlled substances are disposed of by putting medications in a bag and water is poured into the bag. RN stated she waited until medications were dissolved before placing bag into For Incineration Only container. RN further stated the container is removed after it is full. During an interview with DON, on 6/23/22, at 9:00 a.m. with RN present, DON acknowledged disposed controlled substances should be stored in a location accessible only to authorized individuals. Review of facility policy Discarding and Destroying Medications, dated April 2007, indicated unless otherwise instructed, flush tablets, capsules, liquids, and contents of vials and ampules down the toilet in the medication room. The policy also indicated All controlled substances shall be retained in a securely locked area with restricted access until authorized individuals destroy them. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055677 If continuation sheet Page 20 of 25 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 06/24/2022 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 0791 Provide or obtain dental services for each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of 14 sampled residents (Resident 28) received dental care services when Resident 28 did not receive treatment for tooth extraction for over three consecutive months. Residents Affected - Few This failure resulted in Resident 28 to experience teeth pain and placed Resident 28 at potential risk for inability to eat or chew well. Findings: During a review of Resident 28's admission Record, dated 6/21/22, the record indicated Resident 28 was admitted to the facility on [DATE] with chronic pain syndrome. During a record review of Resident 28's Minimum Data Set (MDS, a resident assessment tool used to guide care) dated 4/25/22, the MDS Section B indicated Resident 28 was usually understood by others and was able to make herself understood. During a concurrent observation and interview on 6/20/22, at 10:19 a.m., with Resident 28, Resident 28 stated she needed three left upper teeth pulled out. Resident 28 opened her mouth, she had brownish black colored material attached to left upper gum. Resident 28 stated she still had the tooth roots which bothered her and caused pain in her mouth. During a concurrent interview and record review on 6/21/22, at 01:01 p.m., with Social Services Director (SSD), Resident 28's dental consult titled, Physicians Medical Order Release, dated 3/11/22, was reviewed. SSD confirmed the dental consult indicated a proposed treatment for Resident 28's dental issue was Extraction. During a review of facility's Policy & Procedures (P&P) titled, Dental Services, revised 02/2014, the P&P indicated, routine and emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessment and plan of care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055677 If continuation sheet Page 21 of 25 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 06/24/2022 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 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 store, prepare, and serve food under sanitary conditions when: Residents Affected - Some 1. four packages of bread in the freezer were unlabeled and undated; 2. four pieces of pie crust were undated; 3. the dietary aide did not wear a face mask; 4. two white electric fans were brownish and dusty; and 5. the condiment rack was brownish and sticky. These failures had the potential to cause food contamination and food borne illness to 34 residents who received food from the kitchen. Findings: 1. During s concurrent initial tour of the kitchen on 6/20/22, at 9:15 a.m., and interview with the Dietary Services Supervisor (DSS), four packages of garlic bread and four pieces of pie crust in the freezer were unlabeled and undated. The DSS stated all items in the kitchen needed to have a received date. A review of the facility's policy and procedure titled, Labeling and Dating of Foods, dated 2018, indicated, Food delivered to the facility needs to be marked with a received date. 2. During the initial kitchen tour observation on 6/20/22, at 9:25 a.m., the Dietary Aide (DA) was not wearing a face mask. DSS stated all staff in the dietary department are required to use a face mask at all times. A review of the undated policy and procedure titled, Policy and Procedure for use of Mask in Dietary Department indicated, Dietary staff will have to follow the prescribed mask depending on the COVID status of the facility. 3. During an observation and concurrent interview with the DSS, on 6/20/22, at 9:40 a.m., the condiment rack was brownish and sticky, and two white electric fans were brownish and dusty. The DSS stated the condiment rack, and the electric fans must be included in the cleaning schedule. A review of the policy and procedure titled, Sanitation, dated 2018, indicated, 7. The FNS [Food and Nutrition Services] director will write the cleaning schedule in which he designates by job title and/or employee who is to do the cleaning task . 9. All utensils, counters, shelves and equipment shall be kept clean . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055677 If continuation sheet Page 22 of 25 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 06/24/2022 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 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 maintain an effective infection control program when one of three sampled residents (Resident 8) did not have a date on the tubing of the nebulizer (a small machine that turns liquid medicine into a mist, and the tip of the tubing with the mouthpiece was on the floor. Residents Affected - Some This failure placed Resident 8 at risk for healthcare-associated infections. Findings: During observation on 6/24/22, at 9:20 a.m., at Resident 8's bedside, Resident 8 had two nebulizers on the nightstand by his bedside. Each nebulizer was set up with a tube connected to the machine, while the other tip of the tube was connected to a mouthpiece. The tube did not have a date, and the tip of the tube with the mouthpiece was on the floor behind the nightstand. During an interview on 6/24/22, at 9:30 a.m., with the Registered Nurse Supervisor (RN), RN stated the tubes must be dated when they were changed every seven days, and they must be rolled and put in a plastic bag when not in use. A review of the facility's policy and procedure titled, Care of Oxygen Equipment, dated 10/20, indicated, tubing should be dated and replaced every seven days tubing must be rolled and stored in a clean plastic bag when not in use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055677 If continuation sheet Page 23 of 25 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 06/24/2022 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, and 20). The failure had the potential for reduced space for staff to deliver care and lack of sufficient space for storage of residents' belongings. Findings: Based on an observation on 6/22/22, at 8:34 a.m., with the Facility's Maintenance Personnel (MP), the following 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. ft. of space per resident. room [ROOM NUMBER] was a total of 225.36 sq. ft. and had three beds making for 75.1 sq. ft. of space per resident. room [ROOM NUMBER] was a total of 225.36 sq. ft. and had three beds making for 75.1 sq. ft. of space per resident. room [ROOM NUMBER] was a total of 225.36 sq. ft. and had three beds making for 75.1 sq. ft. of space per resident. room [ROOM NUMBER] was a total of 225.36 sq. ft. and had three beds making for 75.1 sq. ft. of space per resident. room [ROOM NUMBER] was a total of 225.36 sq. ft. and had three beds making for 75.1 sq. ft. of space per resident. room [ROOM NUMBER] was a total of 225.36 sq. ft. and had three beds making for 75.1 sq. ft. of space per resident. room [ROOM NUMBER] was a total of 225.36 sq. ft. and had three beds making for 75.1 sq. ft. of space per resident. room [ROOM NUMBER] was a total of 225.36 sq. ft. and had three beds making for 75.1 sq. ft. of space per resident. room [ROOM NUMBER] was a total of 225.36 sq. ft. and had three beds making for 75.1 sq. ft. of space per resident. room [ROOM NUMBER] was a total of 225.36 sq. ft. and had three beds making for 75.1 sq. ft. 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 24 of 25 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 06/24/2022 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. ft. of space per resident. During observation of care and services from 6/20/22 through 6/24/22, there was sufficient space for provision of care for 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. Granting of room size waiver recommended. Event ID: Facility ID: 055677 If continuation sheet Page 25 of 25