Health inspection·April 9, 2025

F 0584 Level of Harm - Minimal harm or potential for actual harm Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observation, interview and record review, the facility failed to ensure a clean, orderly homelike environment when: Residents Affected - Some -Resident rooms had build-up of white crumbs on the floor and personal items like disposable briefs and pillows were piled on a chair at the bedside. -There was insufficient supply of bath towels, face towels, and bed linens available for residents to use. Based on observation, interview and record review, the facility failed to ensure a clean, orderly homelike environment when: -Resident rooms had build-up of white crumbs on the floor and personal items like disposable briefs and pillows were piled on a chair at the bedside. -There was insufficient supply of bath towels, face towels, and bed linens available for residents to use. This failure had resulted in unsanitary and uncomfortable environment for residents and negatively impact their dignity, comfort and safety. Findings: During a concurrent observation and interview on 3/20/25 at 10:32 a.m. with Resident 3, Resident 3 stated there were not enough supplies at the facility. There were white crumbs on the floor, three pillows and a disposable brief piled on a regular chair at Resident 3's bedside rather than stored appropriately or used for resident comfort. During a review of Resident 3's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 2/14/25, the MDS indicated a Brief Interview for Mental Status (BIMS, a scoring system used to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information. A BIMS score of thirteen is an indication of intact cognitive status) score of 15. A BIMS score of 13-15 is an indication of intact cognitive status. During a concurrent observation and interview on 3/20/25 at 12:25 p.m. with Resident 3, Resident 3 stated they have not cleaned the room yet. The lunch trays were at the bedside, there was still a pile of pillows and disposable brief in the chair. Page 1 of 8 055775 055775 04/09/2025 Orinda Care Center, LLC 11 Altarinda Road Orinda, CA 94563

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 4/9/25 at 11:19 a.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated there has been shortage of linens and towels since December 2024. CNA 1 stated using disposable dry wipes to dry the residents after shower. She also stated finding mattress covers for eight of her residents was also a challenge, and out of the eight beds she had to make today, CNA 1 stated only three beds were made. During an observation on 4/9/25 at 11:24 a.m., the clean linen closet had several gowns, three pillowcases, three mattress covers, and several top sheets but there were no towels. During an interview on 4/9/25 at 11:32 a.m. with Director of Staff Development (DSD), DSD stated the CNAs have been complaining of not having enough supplies like towels. DSD stated some scheduled showers were moved to the pm shift and pm shift CNAs have complained they did not have enough towels to use for the residents. During a concurrent observation and joint interview and review of monthly inventory on 4/9/25 at 11:42 a.m. with Laundry Aide (LA) and Housekeeping Manager (HM), HM stated there were four scheduled laundry delivery for the resident care areas, first three at 7 a.m., 9:00 a.m., 11 a.m. for the morning shift, and 2 p.m. for the pm shift. LA stated there were no bath and face towels delivered at 7 a.m., 9 a.m., and 11 a.m. because she did not have anything in the laundry. There were two clean, folded bath towels on the folding table, LA stated that was all she had in addition to whatever was in the drier. LA then pulled out the clean and dried laundry from the drier and found four bath towels and two face towels. LA stated she would have 6 bath towels and 2 face towels to deliver to the resident care areas. Review of the Monthly Linen Inventory dated 4/1/25 indicated, for a resident census of 46, the facility needed: 276 bath towels, the facility had total of only 14 towels; 460 wash cloths, facility had 109 wash cloths; 92 bedspreads, facility had 6 bed spreads; 92 blankets, facility had 66 blankets; 138 bath blankets, facility had 62 bath blankets. 055775 Page 2 of 8 055775 04/09/2025 Orinda Care Center, LLC 11 Altarinda Road Orinda, CA 94563

F 0660 Plan the resident's discharge to meet the resident's goals and needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, for one of three sampled residents (Resident 2), the facility failed to develop and implement an effective discharge planning process that focuses on resident's effective transition to post-discharge care when Resident 2 was discharged to a friend's home without the friend's consent. Residents Affected - Few This failure had led to Resident 2 going to a homeless shelter after police were called to remove Resident 2 from the friend's home. Findings: During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility in June 2017. The admission Record indicated the name and contact number of Friend (FR) who was listed as other. There was no diagnosis information in the admission Record. During a review of Resident 2's discharge care plan initiated on 11/15/24, the care plan indicated Resident discharged is unknown or uncertain this time, and the following interventions included: Resident will continue in long term care .IDT (interdisciplinary team, a group composed of individuals representing different departments of the facility) will re-evaluate DC (discharge) plan and discuss with resident/family every 3 months or as needed . The care plan did not indicate it was ever revised to reflect updates on Resident 2's discharge location. During a concurrent interview and record review on 4/8/25 at 11:13 a.m. with Social Services Director (SSD), Resident 2's clinical record was reviewed. SSD stated Resident 2 has not been paying his share of cost (SOC, a monthly amount a beneficiary is required to pay towards their medical expenses before Medi-Cal begins covering costs. This is essentially a deductible for Medi-Cal beneficiaries, similar to a private insurance plan's out-of-pocket deductible.) since before September 2024. SSD stated several options of Board and Care were offered to Resident 2. SSD also stated Resident 2 had a friend, FR, who would come to visit Resident 2 at the facility. SSD stated, as Resident 2's discharge date approached, the plan was for Resident 2 to be discharged to FR's home. SSD stated she did not discuss the plan with FR but assumed FR was agreeable to it. SSD stated Resident 2 was dropped off at FR's home on [DATE] via the facility's van. During a review of Resident 2's Psychosocial Note, the Psychosocial Note indicated documentation that included the following. - 11/27/24 SSD provided a copy of 30-day eviction notice to Resident 2 due to Resident 2 not paying for stay in the facility. SSD will assist Resident 2 and provide resources in finding placement. -12/10/24, SSD asked Resident 2 if he had a place to go home to by 12/27/24, Resident 2 stated I don't know .I have credit card to pay. -12/24/24, Social Worker (SW) wrote, Wrote down 3 options for resident .has three options with dedicated bed and ready on 12/27 . The note indicated SW presented three addresses that included FR's home address, Resident 2 was out of the building at the time, options were discussed via phone, Resident 2 hung up. -12/27/24, Met with resident to discuss [discharge] today, Resident said no. Again, emphasized with 055775 Page 3 of 8 055775 04/09/2025 Orinda Care Center, LLC 11 Altarinda Road Orinda, CA 94563

F 0660 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few resident that [Resident 2] has been accepted to two facilities and is within reason and within [Resident 2's] budget. Resident refused to listen. Transportation has been arranged for resident to be picked up at 1 pm. -12/27/24, Resident 2 Agreeing to go to [FR's] house .also gave resident resource for shelter through [Core of Contra [NAME]]. Was told that if [Resident 2] calls the number at 4 pm they will pick [Resident 2] up and take him to shelter that has availability. Number written on post it for [Resident 2] on [discharge] paperwork. -12/27/24, Resident discharge today .to home with a friend [FR] .Resident was [dropped off] by the facility driver via van . During a telephone interview on 4/8/25 at 11:25 a.m. with FR, FR stated not being told by staff that Resident 2 was going to be dropped off at FR's home. FR stated visiting Resident 2 a month prior to being discharged from the facility and this idea has never been brought up. FR stated she was surprised to find Resident 2 in the home's garage without prior notice, prompting FR to call law enforcement. Police arrived at the home, took Resident 2, but after few hours, Resident 2 returned to FR's home. Police were called again and escorted Resident 2 out of the property. FR stated Resident 2 spent a night in jail before being taken to a homeless shelter. FR stated Resident 2 did not have a garage door opener, the garage door was left unlocked, and Resident 2 was able to open it. During a review of the facility's policy and procedure (P&P) titled Transfer or Discharge, Facility-Initiated last revised October 2022, the P&P indicated, For significant changes, such as a change in the transfer or discharge destination, a new notice will be given that clearly describes the changes (s) and resets the transfer or discharge date in order to provide 30-day advance notification and permit adequate time for discharge planning. During a review of Resident 2's Discharge Instruction Form dated 12/24/24, the Discharge Instruction Form did not indicate emergency contact information/numbers and symptoms for which to call the doctor, housing arrangements, primary physician and pharmacy information. 055775 Page 4 of 8 055775 04/09/2025 Orinda Care Center, LLC 11 Altarinda Road Orinda, CA 94563

F 0661 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, for one of three sampled residents (Resident 2) the facility failed to complete a discharge summary that included the following information: A recapitulation (a concise summary of the resident's stay and course of treatment in the facility) of Resident 2's stay that includes diagnoses, course of illness/treatment or therapy, pertinent laboratory, radiology and consultation results. A final summary of Resident 2's status at the time of discharge and reconciliation of all pre-discharge medications with the resident's post-discharge medications. This failure had the potential to result in the lack of information affecting continuity of care. Findings: During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility in June 2017. There was no diagnosis information in the admission Record. During a review of Resident 2's discharge care plan initiated on 11/15/24, the care plan indicated Resident discharged is unknown or uncertain this time, and the following interventions included Resident will continue in long term care .IDT (interdisciplinary team, a group composed of individuals representing different departments of the facility) will re-evaluate DC (discharge) plan and discuss with resident/family every 3 months or as needed . The care plan did not indicate it was ever revised to reflect updates on Resident 2's discharge location. During a concurrent interview and record review on 4/8/25 at 11:13 a.m. with Social Services Director (SSD), Resident 2's clinical record was reviewed. SSD stated, as Resident 2's discharge date approached, the facility's plan was for Resident 2 to be discharged to FR's (Friend) home. SSD stated she did not discuss the plan with FR but assumed FR was agreeable to it. SSD stated Resident 2 was dropped off at FR's home on [DATE] via the facility's van. During a review of Resident 2's Psychosocial Note, the Psychosocial Note indicated documentation that included the following: -11/27/24 SSD provided a copy of 30-day eviction notice to Resident 2 due to Resident 2 not paying for stay in the facility. SSD will assist Resident 2 and provide resources in finding placement. -12/27/24, Resident discharge today .to home with a friend [FR] .Resident was [dropped off] by the facility driver via van . During a review of Resident 2's Discharge Summary signed and dated 12/30/24, the Discharge Summary indicated Resident 2's discharge date as 12/27/24, and indicated the following admitting diagnoses: aphasia (a language disorder that impairs a person's ability to communicate due to brain damage), cardiomyopathy (a disease that affects the heart muscle, making it harder for the heart to pump blood to the rest of the body), CHF (Congestive Heart Failure, a condition where the heart is unable to pump blood effectively, leading to fluid buildup in the lungs and other parts of the body), Paroxysmal Afib (atrial fibrillation, an intermittent type of irregular heartbeat in the upper chambers of the heart), hypertension (a condition where the force of blood pushing against the artery walls is consistently too high), fatty liver (a condition where excess fat accumulates in the liver, often with 055775 Page 5 of 8 055775 04/09/2025 Orinda Care Center, LLC 11 Altarinda Road Orinda, CA 94563

F 0661 Level of Harm - Minimal harm or potential for actual harm no symptoms, but can lead to complications like cirrhosis and liver cancer if left untreated), hyperlipidemia (a condition characterized by abnormally high levels of fats (lipids) in the blood, including cholesterol and triglycerides), morbid obesity and benign prostatic hyperplasia (BPH, refers to the non-cancerous enlargement of the prostate gland). The Discharge Summary also indicated the following information: COURSE in SNF: Other: Home with friend, Discharge Status: Home, Discharge Diagnosis: Same as above. Residents Affected - Few The facility was not able to show documentation of post-discharge plan. During a review of the facility's policy and procedure (P&P) titled Discharge Summary and Plan last revised December 2016, the P&P indicated when the facility anticipates to discharge a resident to a private residence, a discharge summary and a post-discharge plan will be developed which will assist the resident to adjust to his or her new living environment. The discharge summary will include a recapitulation of the resident's stay at the facility and shall include course of illness/treatment since entering the facility, physical and mental functional status. 055775 Page 6 of 8 055775 04/09/2025 Orinda Care Center, LLC 11 Altarinda Road Orinda, CA 94563

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, for one of three sampled residents (Resident 3), the facility failed to ensure Resident 2 received treatment and care in accordance with professional standards of practice when: Residents Affected - Few -A stage 2 pressure ulcer (also known as bedsores or pressure sores, are localized skin and soft tissue injuries caused by prolonged pressure, often over bony areas, resulting in reduced blood flow and potential tissue damage) on a bony prominence (a part of the skeleton where a bone is close to the surface of the skin) was assessed as a skin tear. This failure had the potential to result in delayed management of the wound. -Resident 2's foley catheter (a thin, flexible tube inserted into the bladder through the urethra to drain urine) was changed from F16 to F18 (Foley catheters are sized using the French (Fr) system, F18 catheter is larger than a F16 catheter) without a physician's order. This failure had the potential to result in unnecessary tissue trauma. Findings: During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE] with diagnoses that included cord compression (occurs when pressure is applied to the spinal cord, the central nervous system pathway connecting the brain to the rest of the body) and benign neoplasm of pituitary gland (a noncancerous growth, also known as a pituitary adenoma, on the pituitary gland. These tumors are extremely common and usually don't spread beyond the pituitary gland). During a review of Resident 3's Braden Scale for Predicting Pressure Sore Risk dated 2/17/25 indicated a score of 13. A score of 13 is an indication of moderate risk to develop pressure sore. During an interview on 3/20/25 at 2:23 p.m. with Treatment Nurse (TN), TN stated, on 2/18/25, a Certified Nursing Assistant (CNA) told her Resident 3 had a wound on the coccyx. TN stated, at the time, the skin on the area appeared thin and had darkened area surrounding the wound, TN thought it was a skin tear. TN stated, two days later, the wound doctor was in the facility and assessed Resident 3's wound as a stage 2 pressure ulcer. During a review of Resident 3's Health Status Note dated 2/18/25, the Health Status Note indicated Resident 3 had a skin tear on the coccyx that measured 7 centimeters (cm) x 7 cm. During a review of Resident 3's Skin & Wound Evaluation dated 3/14/25 (almost 4 weeks later), the Skin & Wound Evaluation indicated Resident 3's coccyx (tailbone) pressure ulcer was a Stage 4 that measured 5.7 cm x 5.7 cm. During an interview on 3/20/25 at 1:29 p.m. with Director of Nursing (DON), DON stated there was no care plan to address Resident 3's risk for development of a pressure ulcer despite the moderate risk and Resident 3's limited mobility. DON also stated the stage 2 pressure ulcer that developed on Resident 3's coccyx was incorrectly identified as a skin tear. During a review of Resident 3's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 2/14/25, the MDS indicated a Brief Interview for Mental Status (BIMS, a scoring system 055775 Page 7 of 8 055775 04/09/2025 Orinda Care Center, LLC 11 Altarinda Road Orinda, CA 94563

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few used to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information. A BIMS score of thirteen is an indication of intact cognitive status) score of 15. A BIMS score of 13-15 is an indication of intact cognitive status. During an interview on 3/20/25 at 11:54 a.m. with Resident 3, Resident 3 stated feeling concerned about the staff not being able to care for Resident 3's foley catheter. Resident 3 stated the licensed staff did not seem to know what to do with the foley catheter that Resident 3 had to be transferred to the hospital catheter issues. During a joint interview on 4/8/25 at 2:45 p.m. with DON and TN, TN stated when she came to work on 2/25/25, Resident 3's foley catheter was a different size than what was ordered. TN stated a Progress Note dated 2/22/25 indicated, the foley catheter change to a F18 was ordered by a Nurse Practitioner (NP) who was in the facility. TN stated writing the order for F18 and transcribed in the Treatment Administration Record (TAR). Review of the TAR for February 2025 indicated both F16 and F18 foley catheter were signed off every shift by licensed nurses. DON stated there was no written physician's order for the change in foley catheter size in the clinical record. DON also stated the order for F16 should have been discontinued and should have been reflected in the TAR. DON stated having two orders of different sizes of foley catheter could be confusing because licensed nurses would not know which one to use the next time the foley catheter had to be changed. During a telephone interview on 4/10/25 at 10:56 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated the NP told Resident 3 that the foley catheter would be changed to F18. LVN 1 confirmed changing Resident 3's foley catheter to a F18 but could not recall how she wrote the verbal order, or if it was written and transcribed at all. LVN 1 stated she did not discontinue the previous order because she did not think the order needed to be discontinued. LVN also stated she did not clarify the order because the NP was Rushing to leave. 055775 Page 8 of 8