Health inspection·April 15, 2021

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to provide the appropriate signaling device for one (Resident 66) of eight sample residents when a call bell was not provided to accomodate Resident 66's limited range of motion. Residents Affected - Few This failure prevented Resident 66 access from the device to alert staff of assistance or emergency. Findings: During a review of the admission Record for Resident 66, the admission Record indicated Resident 66 was admitted to the facility with multiple diagnoses that included Hemiplegia (paralysis of one side of the body) and muscle wasting on right and left upper arms. During a review of Resident 66's care plan, dated 12/27/19 , the care plan indicated The resident . unable to use standard call light . Intervention, alternative call bell, encourage the resident to use bell to call for assistant . During an observation on 04/14/21, at 10:50 a.m., Resident 66 was in bed and asked for water to drink. The call light was not reachable and no other alternative device was accessible. During an interview with Resident 66 on 04/14/21, at 10:50 a.m., Resident 66 stated she was not able to use the standard call light because she did not have strength to push the call light. Resident 66 stated she always had to wait for the nurses to come to her room. Resident 66 stated when the nurses visited she was able to ask for whatever she needed. She stated there are times she was unable to reach anyone. Resident 66 stated the facility never provided any other alternative for her. During an interview on 4/14/21, at 11:00 a.m., with Director of Nursing ( DON) who was present in Resident 66's room, DON agreed Resident 66 was not able to use the standard call light and stated all the residents should be able to have an access to some type of call lights for their needs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056021 If continuation sheet Page 2 of 14 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 056021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/15/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lone Tree Post Acute 4001 Lone Tree Way Antioch, CA 94509 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 two (Residents 6 and 30) of three sampled residents, the facility failed to provide necessary services to maintain personal hygiene when Resident 6 and Resident 30 did not receive morning shift incontinent (having no or insufficient voluntary control over urination or defecation) care. Residents Affected - Few This deficient practice resulted in Resident 6 and Resident 30 lying in foul smelling adult briefs soaked with urine. Findings: 1. Review of the admission Record for Resident 6, dated 4/15/21, the admission Record indicated Resident 6 was admitted on [DATE] to the facility with multiple diagnoses that included hemiplegia (paralysis of one side of the body), hemiparesis (muscular weakness to one side of the body) and cerebral infarction (stroke-damage to tissues in the brain due to a loss of oxygen to the area). During a review of Resident 6's quarterly Minimum Data Set (MDS - a resident assessment tool used to guide care) dated 3/29/21, the MDS indicated Resident 6 was not able to repeat words, did not know the correct year, month and day, and was not able to recall words. The MDS also indicated Resident 6 was totally dependent and required two plus persons physical assist for personal hygiene care and was totally dependent and required one person physical assist for bathing. Further review of the MDS, indicated Resident 6 was always incontinent of urine and bowel. During a review of Resident 6's care plan titled ADL Self-Care Performance Deficit, date initiated 11/29/16, the care plan indicated Resident 6 was Totally dependent with all ADLS. 2. Review of the admission Record for Resident 30, dated 4/15/21, the admission Record indicated Resident 30 was initially admitted on [DATE] to the facility and then readmitted on [DATE] with multiple diagnoses that included contractures (a condition of shortening and hardening of muscles or tendons) of right upper arm and right hand, acquired absence of right leg above knee, and muscle weakness. During a review of Resident 30's quarterly Minimum Data Set (MDS) for Resident 30, dated 2/2/21, the MDS indicated Resident 30 was able to recall and repeat words. The MDS also indicated Resident 30 needed extensive assistance and required two plus persons physical assist for personal hygiene and was totally dependent and required one person physical assist for bathing. Further review of the MDS, indicated Resident 30 was always incontinent of urine and bowel. 'During a review of Resident 30's care plan titled, ADL Self-Care Performance Deficit and Limited Mobility Impaired Balance, date initiated 10/9/19, indicated Resident 30 required Extensive assistance with personal hygiene, and total assistance with bathing/showering.' During an initial tour observation on 4/12/21, at 11:40 am., Resident 6 and Resident 30's room had a strong and unpleasant odor. During an interview with Licensed Vocational Nurse (LVN) 1 on 4/12/21, at 12:05 p.m., LVN 1 stated Resident 6 and Resident 30's room had a strong urine odor. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056021 If continuation sheet Page 3 of 14 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 056021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/15/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lone Tree Post Acute 4001 Lone Tree Way Antioch, CA 94509 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 - Few During an observation and concurrent interview with LVN 1, Certified Nursing Assistant (CNA) 2 and CNA 4 on 4/12/21, at 12:06 p.m., CNA 2 and CNA 4 removed Resident 30's adult brief. Resident 30's brief was soaked with foul smelling urine and, the brief had a brown stain. Resident 30 had redness on his buttocks. CNA 2 and CNA 4 stated Resident 30's brief needed to be changed. CNA 4 stated she had not changed Resident 30's brief that morning. CNA 4 stated she had been too busy too change Resident 30's brief. CNA 2 stated he was assigned to Resident 30 at the beginning of the shift but had not changed Resident 30's brief. CNA 4 stated the brown stain on Resident 30's brief was dried stool. During an observation and concurrent interview with LVN 1 and CNA 4 on 4/12/21, at 12:10 p.m., LVN 1 removed Resident 6's adult brief. Resident 6's brief was soaked with foul smelling urine. CNA 4 stated she had not changed Resident 6's brief that morning. Review of the facility's policy and procedure titled Activities of Daily Living (ADLs), Supporting revised 3/18, indicated, Appropriate care and services will be provided for residents who are unable to care out ADLs independently with the consent of the resident and in accordance with the plan of care including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming and oral care); c. Elimination (toileting). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056021 If continuation sheet Page 4 of 14 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 056021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/15/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lone Tree Post Acute 4001 Lone Tree Way Antioch, CA 94509 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - 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 (Resident 24) of one sampled residents did not develop a pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure) and provide the necessary assessment, treatment and services to promote healing of a pressure ulcer when: Residents Affected - Few Resident 24 developed a pressure ulcer over the buttocks and sacrum (large triangular bone in the lower back) on 12/24/20 and was not assessed or treated until 1/1/21, which resulted in Resident 24 developing a pressure ulcer and later development into a stage 4 (a wound with full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed). Resident 24 was sent to the acute hospital for wound debridement (the removal of damaged and/or infected skin tissue to help a wound heal) and treatment of osteomyelitis (inflammation of bone or bone marrow, usually due to infection). Findings: Review of the admission Record dated 4/14/21, indicated Resident 24 was initially admitted on [DATE] to the facility and then readmitted on [DATE] with multiple diagnoses that included dementia ( progressive memory loss), diabetes mellitus (a disease in which the body's ability to produce or respond to insulin is impaired), muscle wasting, and muscle weakness. During a review of quarterly Minimum Data Set (MDS-an assessment tool used to guide care) dated 10/6/20, the MDS indicated Resident 24 was totally dependent and required two plus persons physical assist to position body while in bed, move to and from lying position, and turn side to side. The MDS also indicated Resident 24 was always incontinent of bowel. Further review of the MDS, it indicated Resident 24 had no unhealed pressure ulcers, but was at risk for developing pressure ulcers. During a review of the quarterly Braden Scale Observation/Assessment (BSOA) (a tool for assessing a resident's risk for developing a pressure ulcer) dated 10/16/20, the BSOA indicated a score of 13 which meant moderate risk for pressure ulcer development. During a review of a care plan titled Potential for Pressure Ulcer Development initiated on 4/17/19, the care plan indicated Follow facility policies/protocols for the prevention/treatment of skin breakdown. Review of the facility's policy and procedure titled, Prevention of Pressure Injuries revised 4/2020, indicated Skin Assessment- 3. Inspect the skin on a daily basis when performing or assisting with personal ADLS. a. Identify any signs of developing pressure injuries (i.e., non-blanchable erythema). b. Inspect pressure points (sacrum, etc.). Mobility/Repositioning-1. Reposition all residents with or at risk for pressure injuries on an individualized schedule, as determined by the interdisciplinary care team. Monitoring-1. Evaluate, report and document potential changes in the skin. During a review of the Progress Notes (PN) for Resident 24, dated 12/24/20, the PN indicated the charge nurse reported an open wound on the buttocks area with eschar (devitalized tissue that can appear as a dry dark scab) and described as an unstageable (UTD, a full thickness tissue loss in which the wound bed is completely obscured by dead tissue). The notes did not include the measurement and description of the wound. The notes further indicated the physician was notified for wound care orders (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056021 If continuation sheet Page 5 of 14 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 056021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/15/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lone Tree Post Acute 4001 Lone Tree Way Antioch, CA 94509 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 0686 Level of Harm - Actual harm Residents Affected - Few During a review of a facility document titled FAX for Resident 24, dated 12/24/20, the document indicated the facility staff sent a request regarding Resident 24 to the Medical Doctor (MD) on 12/24/20 for a treatment order for an open wound buttocks and sacral area. During a review of the Doctor's Progress Note (DPN), dated 12/31/20, the DPN indicated a physician's order for wound care for bilateral buttocks and sacral area and a wound MD consult. During an observation and concurrent interview with Licensed Vocational Nurse (LVN) 2 on 4/15/21 at 8:26 a.m., Resident 24 was given wound care to sacral area pressure ulcer by LVN 2. Resident 24's pressure ulcer bed had pink tissue with small amount of yellow tissue. The skin surrounding Resident 24's pressure ulcer was discolored. Resident 24's sacral pressure ulcer had light brown drainage. LVN 2 stated Resident 24's pressure ulcer bed had slough (dead tissue that may have a yellow or white appearance) and red tissue. LVN 2 stated the sacral pressure ulcer was a stage 4. LVN 2 measured Resident 24's sacral pressure ulcer and stated the length was 12 centimeters (cm), width was 10.5 cm and had no depth. LVN 2 measured and stated Resident 24's pressure ulcer had 1 cm tunneling (a passageway underneath the skin through soft tissue with potential for abscess formation) at the twelve o'clock position, 1.3 cm tunneling at the three o'clock position, and 1.8 cm tunneling at the seven o'clock position. During a review of the care plan titled Impaired Skin Integrity-Pressure Ulcer of the Sacrum for Resident 24, dated 12/31/20, the care plan indicated it was implemented seven days after Resident 24's pressure ulcer was observed. During a review of Treatment Administration Record (TAR) for Resident 24, dated 1/1/21-1/31/21, the TAR indicated Resident 24 received his first treatment for open wounds on bilateral buttocks and sacral area on 1/1/21. During a phone interview with RN 2 on 4/15/21 at 11:20 a.m., RN 2 stated on 12/24/20, a CNA told her Resident 24 had a black area on his buttocks. RN 2 stated she could not leave the red zone (area for COVID 19 positive residents), so she took a picture of Resident 24's pressure ulcer from her cell phone and sent it to RN 3. RN 2 stated she made a recommendation for the treatment of Resident 24's pressure ulcer, and RN 3 faxed the information about her recommendation to the doctor. RN 2 stated she did not measure Resident 24's wound. During an interview with RN 3 on 4/15/21 at 7:35 a.m., RN 3 stated RN 2 discovered Resident 24's pressure ulcer on 12/24/20. RN 3 stated RN 2 took a picture of Resident 24's wound and showed it to him. RN 3 stated Resident 24's wound bed had eschar (dark dead skin). RN 3 stated Resident 24's pressure ulcer was one big wound that included both buttocks and sacral areas. RN 3 stated he did not have time to measure the pressure ulcer. RN 3 stated he should have measured the pressure ulcer on 12/24/20 since it was newly discovered. RN 3 stated he did not call MD's office to confirm that the fax was received, and he did not call the facility's Medical Director when did not get a timely response from MD. Review of the facility's policy and procedure titled, Pressure Ulcers/Skin Breakdown-Clinical Protocol revised 4/2018, indicated Assessment and Recognition-2. In addition, the nurse shall describe and document/report the following: a. Full assessment of pressure sore including location, stage, length, width and depth and presence of exudates or necrotic tissue. Monitoring-1. During resident visits, the physician will evaluate and document the progress of wound healing-especially for those with complicated, extensive, or poorly-healing wounds. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056021 If continuation sheet Page 6 of 14 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 056021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/15/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lone Tree Post Acute 4001 Lone Tree Way Antioch, CA 94509 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 0686 Level of Harm - Actual harm Residents Affected - Few During an interview and concurrent record review with DON on 4/15/21 at 1:20 p.m., DON reviewed Resident 24's record and stated MD documented on 1/12/21 that Resident 24 had a large sacrum stage 4 wound with probable osteomyelitis. During a phone interview with MD on 4/15/21 at 11:10 a.m., MD stated Resident 24 had a bad pressure ulcer during the time of the facility's COVID 19 outbreak. MD stated Resident 24 was a high risk for pressure ulcers because he had malnutrition, diabetes, could not turn himself and could not control his bowel. MD stated Resident 24 had a history of having wounds and maybe an old wound had reopened. During a review of a Doctor's Progress Notes (DPN) for Resident 24, dated 1/12/21, the DPN indicated Resident 24 had a Sacrum area large stage IV decubitus, 2 inches deep, with probable osteomyelitis. During a review of the Hospital Discharge Summary (HDS) dated 1/18/21, the HDS indicated Resident 24 was admitted to the hospital on [DATE] and discharged on 1/18/21. The HDS also indicated Resident 24 had diagnoses of a large sacrum ulcer with infection and osteomyelitis (infection of the bone). Further review of the HDS indicated that an antibiotic to treat bacterial infections was started on 1/13/20, debridement of the sacral decubitus ulcer was done 1/13/21 and a wound vacuum (a device to treat wounds) was placed on 1/14/21. The HDS indicated on 1/14/21 Resident 24 had a Large open wound of coccyx 14 x 14 cm. wound vac in place. The HDS indicated the Computerized Tomography Scan (CT scan, a medical imaging technique used in radiology to get detailed images of the body noninvasively) showed extensive decubitus ulceration with large pocket of gas and fluid -filled collection within the pelvis to the left of the rectum measuring 9.8x4.9x6.1 cm. There was further indication of extensive tissue swelling. The HDS also indicated Hand size large ulcer, covered with black color mole, pus drainage and inch deep to use finger probe. Minimal erythema (reddening of the skin) around the wound and, odor smell strong. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056021 If continuation sheet Page 7 of 14 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 056021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/15/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lone Tree Post Acute 4001 Lone Tree Way Antioch, CA 94509 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, two (Resident 19 and 66) of eight sampled residents who had limited range of motion, the facility failed to ensure range of motion (ROM) exercises were provided as ordered for Resident 19 and Resident 66 did not receive ROM exercise and splinting of the right hand. This failure had the potential to result in further decline in Resident 19 and 66's range of motion. Findings: During review of admission Record for Resident 19, the admission Record indicated Resident 19 was admitted to the facility on [DATE] with diagnoses that included abnormalities of gait and mobility and muscle weakness. During an interview on 4/12/21, at 1:14 p.m.,with Resident 19, Resident 19 stated he was not able to walk anymore and was having a hard time moving both legs. During a review of Medication Review Report(MRR) for Resident 19, dated , 4/14/21, the MRR indicated an order was dated 11/11/20 for Resident 19 to have RNA (Restorative Nursing) program: BUE (Bilateral Upper Extremities, upper arm, forearm and hand also extends from the shoulders to the fingers) AROM (Active Range of Motion, moving a joint on your own by contracting your muscles) 3x/week- BLE (Bilateral Lower Extremities, lower part of the body, from the hip to the toes) PROM (Passive Range of Motion, when someone physically moves or stretches a part of your body) 3x/week. During a review of Resident 19's care plan, ,dated 11/12/20, the care plan indicated to address risk of decline in range of motion and risk of decreased muscle strength and decreased functional use of extremity. The care plan also indicated interventions that included RNA program to do active range of motion exercises both upper extremities and passive range of motion exercises on both lower extremities three times weekly. During a review of Resident 19's Documentation Survey Report(DSR) , dated 3/21, the DSR indicated Resident 19 received RNA program five out of 12 times for the month. During a review of Resident 19's DSR dated 4/21, the DSR indicated Resident 19 received RNA program three times from 4/1/21-4/13/21. During an interview on 4/14/21, at 10:53 a.m., with Restorative Nursing Assistant (RNA) , RNA stated, active range of motion exercises were done on both upper extremities and passive range of motion exercises were done on Resident 19's lower extremities twice weekly as opposed to three times weekly that was ordered. RNA stated passive range of motion exercises were done on the lower extremities because Resident 19 had difficulty moving her legs on her own. RNA stated Resident 19 used to be able to move both legs without help from staff. 2. During a review of admission Record for Resident 66, it indicated Resident 66 was admitted to the facility with multiple diagnoses including Hemiplegia (paralysis of one side of the body). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056021 If continuation sheet Page 8 of 14 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 056021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/15/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lone Tree Post Acute 4001 Lone Tree Way Antioch, CA 94509 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an observation on 04/12/21, 11:02 a.m. until 3:00 p.m., of Resident 66, the surveyor observed Resident 66 a few times in bed with right hand deformity and no splint or any other support device was applied. Further observations on 04/13/21, at 8:30 a.m. until 12:00 p.m., Resident 66 did not have a splint or support/wash cloth on her right hand . Resident 66's hand had an 80-degree flexion. During an interview with Director of Nursing (DON), on 04/15/21, at 10:09 a.m., DON stated the Rehab Director ordered splints and RNA for Resident 66 in 8/19. Resident 66 was transferred to the hospital on 9/4/19, and readmitted to the facility on [DATE]. The DON stated Resident 66 was never re-evaluated by OT (occupational therapy) since then. The DON stated there was a missed communication from last Rehab Director who did not informed the staff about continuing with the rehab, splint use and RNA program. During an interview with the facility's Director of Rehab (DOR), on 04/15/21, at 10:15 a.m., the DOR agreed they should had re-evaluated Resident 66 after re-admission to the facility. The DOR stated, The residents get worse with their situation when staff don't follow up with the resident's orders and therapy. During an interview with Certified Nurse Assistant (CNA)1, on 4/13/21, at 1:00 p.m., CNA 1 stated she never did ROM on Resident 66 because she did not receive any orders from the licensed nurses or therapist. CNA 1 stated usually RNAs do ROM for the residents and she had no idea if Resident 66 had a splint for right hand or not. During a review of Occupational Therapy Daily Treatment Note(OTDTN) for Resident 66, dated 8/29/19, the OTDTN indicated .OT facilitated positioning techniques in bed utilizing pillows and washcloths to maintain right (R) wrist/hand in natural positioning . plan for next session: Awaiting resting hand splint to arrive-once in begin wear tolerance and splinting schedule . During a review of the facility's policy and procedure Range of Motion Exercises revised 2010 indicated .if there is no order for treatment, contact the attending physician to obtain treatment orders . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056021 If continuation sheet Page 9 of 14 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 056021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/15/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lone Tree Post Acute 4001 Lone Tree Way Antioch, CA 94509 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to follow its policy and procedure for one (Resident 47) of six sampled residents with a feeding tube (medical device used to provide liquid nourishments, fluids and medications by bypassing oral intake) when the facility did not evaluate the termination of the intake and output for Resident 47. This deficient practice may result in an inadequate assessment of Resident 47's hydration and feeding needs. Findings: During a review of the admission Record, dated 4/15/21 ,for Resident 47, the admission Record indicated Resident 47 was admitted to the facility on [DATE] with a diagnosis of Parkinson's disease (a brain disorder that leads to shaking, stiffness, and difficulty with walking, balance, and coordination). During a review of the comprehensive Minimum Data Set( MDS)(an assessment tool used to guide care.) for Resident 47, the MDS indicated Resident 47 was on a feeding tube. During a review of Resident 47's Clinical Physician Orders , dated 4/19/21, the Clinical Physician's Orders indicated a doctor's order on 2/11/21 for Intake and output every shift for 4 weeks, record intake and output in supplemental documentation and every night shift every, Sunday for 4 weeks and record weekly total intake and output for prior week. During an interview on 4/14/21, at 1:13 p.m., with DON, DON stated there was no documentation that the interdisciplinary team evaluated the termination of intake and output monitoring. A review of the facility document titled, Intake and Output, undated, indicated, Residents will be placed on intake and output if on enteral feedings, indwelling catheters, restricted fluids, other medical catheters/devices which place a resident at risk for dehydration and require monitoring, also in special cases such as high doses of diuretics, illnesses, and if order by a Physician. Thirty (30) Day evaluation for Continuation of Monitoring b. Decision to terminate I&O monitoring will be documented in the medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056021 If continuation sheet Page 10 of 14 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 056021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/15/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lone Tree Post Acute 4001 Lone Tree Way Antioch, CA 94509 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, for one (Resident 79) of two sampled residents receiving dialysis, the facility failed to document daily weights as ordered. Residents Affected - Few This deficient practice may result in staff being unaware of any unusual weight gain for Resident 79. Findings: During a Review of the admission Record, dated 4/15/21, for Resident 79, the admission Record indicated Resident 79 was admitted to the facility on [DATE] with a diagnosis of acute respiratory failure with hypoxia (not enough oxygen in the blood). During a review of Resident 79's Clinical Physician Orders, dated 4/15/21, the Clinical Physician Orders indicated a doctors order on 3/14/21 for daily weights. During a concurrent review and interview of Resident 79's Treatment Administration Record on 4/15/21 at 12:45 p.m., with RN 3, RN 3 stated Resident 79's daily weight was not documented on 4/11/21 and 4/12/21. He further stated the daily weight for Resident 79 should be monitored and documented daily because Resident 79 is a dialysis patient and is at risk for fluid weight gain from one day to the next. The facility policy and procedure titled, Intake and Output, undated, indicated Residents will be placed on intake and output if on enteral feedings, indwelling catheters, restricted fluids, other medical catheter/devices which place a residents at risk for dehydration and require monitoring, also on special cases such as high does of diuretics, illness .: FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056021 If continuation sheet Page 11 of 14 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 056021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/15/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lone Tree Post Acute 4001 Lone Tree Way Antioch, CA 94509 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 - Few 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 one of four medication carts (Med Cart A-1) and one of four wound care treatment carts (Treatment cart A-2) were secured when Med Cart A-1 and Treatment Cart A-2 were left unlocked and unattended in the hallway. This failure had the potential to result in unauthorized access by residents and visitors to medications and supplies stored in Med Cart A-1 and Treatment Cart A-2. Findings: During an observation, on 4/13/21, at 11:42 a.m., Treatment Cart A-2 was unlocked and unattended, parked in hallway A-2. During an observation and interview, on 4/13/21, at 11:47 a.m., with Registered Nurse (RN 1), RN 1 stated treatment cart A-2 had wound care medications and supplies stored in it. RN 1 stated she forgot to lock the Treatment Cart A-2. During an observation and interview, on 4/13/21, at 11:55 a.m., with Registered Nurse (RN 2), the Medication Cart A-1 was unlocked and unattended parked in Hallway A-1. RN 2 stated she forgot to lock the cart. During an interview, on 4/13/21, at 12:01 p.m., with the Director of Nursing (DON), DON stated the medication and treatment carts needed to be locked when not in use for safety. During a review of the facility's policy and procedure titled, Security of Medication Cart, dated 04/2007, indicated, Medication carts must be securely locked at all times when out of the nurse's view. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056021 If continuation sheet Page 12 of 14 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 056021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/15/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lone Tree Post Acute 4001 Lone Tree Way Antioch, CA 94509 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 follow proper food storage practices when several food items were stored unlabeled with the received date. Residents Affected - Some This failure had the potential to result in foodborne illnesses. Findings: During the initial kitchen tour observation and concurrent interview with Dietary Manager (DM) on 4/12/21, at 10:11 a.m., the following observations were found: a. Inside the Meat freezer, two packs of beef cubes and one tray of frozen stuffed green peppers had no received date labels. b. Inside the Vegetable freezer, three-4 pound bags of green beans, one- 2 pound bag of Italian cut green beans, four-32 ounce bags of cauliflower and three-4 pound bags of tater tots had no received date labels. During an interview on 4/12/21, at 10:11 a.m., with (Dietary Manager (DM), DM stated the frozen products were good for six months from the received date. DM stated in order to know if the products were good to use, the received date needed to be on the products. DM stated the frozen items should have had received dates. Review of the facility's policy and procedure titled Food Storage, dated 2017, indicated 15. Frozen Foods: c. All foods should be be covered, labeled and dated. All food will be checked to assure that foods will be consumed by their safe use by dates or discarded. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056021 If continuation sheet Page 13 of 14 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 056021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/15/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lone Tree Post Acute 4001 Lone Tree Way Antioch, CA 94509 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 follow infection prevention and control policy and procedure for COVID-19 (a respiratory condition which can lead up to and including death), when Activity Director (AD) entered a shared room for Resident 45 and 245, designated for residents who were exposed to COVID-19, without an isolation gown. Residents Affected - Few This failure had the potential to spread the COVID-19 infection within the facility. Findings: During a concurrent observation and interview with Licensed Vocational Nurse/Infection Preventionist (LVN/ IP), on 4/12/21, at 9:00 a.m., at the main entrance, a signage stating STOP/ YELLOW ZONE/STOP was posted at the main door. LVN/IP stated all the residents residing at the facility were exposed to COVID-19 infection. During a concurrent observation and interview on 4/12/21, at 12:41 p.m., the Activities Director (AD) walked in Hallway A-2, entered the shared room of Resident 45 and 245 without donning an isolation gown, moved Resident 45's bedside table with bare hands, and removed the lunch tray and came back in Hallway A-2. AD initially stated she did not think staff needed to gown up to only pick up a lunch tray. The AD stated all residents residing at the facility were exposed to COVID-19. The AD stated she needed to have isolation gown and gloves on prior to entering Resident 45's room. During an interview, on 4/13/21, at 9:00 a.m., LVN/IP, LVN/IP stated all staff entering a resident room who was exposed to COVID-19 infection needed to don a new isolation gown and gloves. During a record review, on 4/15/21, at 1:00 p.m., with LVN/ IP, facility's Policy and Procedure (P&P) titled, Coronavirus Disease (COVID-19) - Infection Prevention and Control Measures ,dated 04/2020, . indicated, For a resident with known or suspected COVID-19: a. Staff wear gloves, isolation gown, eye protection and an N95 or higher-level respirator if available (a facemask is an acceptable alternative if a respirator is not available) . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056021 If continuation sheet Page 14 of 14