Health inspection·May 22, 2023

F 0919 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Assistant 1 (CNA 1), in Resident 7 and 10's shared room, CNA 1 pressed the call buttons and stated, the bulb outside their shared room should light up and it did not. CNA 1 stated, Resident 7 and 10's call lights were not working. CNA 1 stated, she was not aware that Resident 7 and 10's call lights were not working. During a concurrent observation and interview on 4/28/23, at 9:18 a.m., CNA 1 pushed Resident 5, 6, and 9's call light and stated, call lights were not functional and they did not have alternative call bells. CNA 1 stated, she reported to the maintenance department that the call light was not working for Residents 5, 6, and 9, but did not know the exact date it began malfunctioning and/or when she reported it to maintenance. During an interview on 4/28/23, at 9:20 a.m., with Maintenance Supervisor (MS), MS stated, the facility was in the process of changing the call lights because the current system had issues. MS stated, the call light for Residents 7, 10, 18, 20, 21, and 26 were broken for over a month now. MS stated, he did not know how many resident rooms were affected in total. During a concurrent observation and interview on 4/28/23, at 9:29 a.m., while in Resident 4's room, MS stated, Residents 4, 18, 20, and 35 were without a functioning call light for over a month. MS stated, Resident 4 did not have an alternate call bell at the bedside. During a concurrent interview and record review, on 4/28/23, at 9:33 a.m., at the Nursing Station 1, with MS, the facility's Maintenance Binder was reviewed. The Maintenance Binder had, Maintenance Request Log with columns titled, Date, Room #, Location, Problem/Issue, Requested By, Completion Date, and Initials. The MS stated the facility staff was responsible to log date, room #, location, and problem/issue that needed the maintenance department's attention. The MS stated, he was responsible to fix the issue and log the completion date and initial it. The MS stated, the facility had call light malfunction issues since September 2022; however, he didn't sign the entries for call light malfunction in December 2022 and January 2023 because the call light malfunction could not be fixed. The MS stated, the reported malfunctions were escalated to the ADM. The MS continued by stating, a contractor recently visited the facility to assess the call light system malfunction and a full rewiring or replacement of the call light system was required. During a record review, on 4/28/23, at 10:36 a.m., while the presence of the Social Services Director (SSD), an Email Correspondence from Resident 26's daughter, dated 4/24/23, with responses dated 4/25/23 and 4/26/23, was reviewed. According to the email correspondence Resident 26's daughter indicated that the call light was again not working when she visited on 4/23/23 and wanted to know what it would take to fix the call button issue permanently. During an interview on 4/28/23, at 10:57 a.m., the SSD stated, malfunctioning call lights and/or staff not answering call lights or attending to residents' needs placed residents at risk for anxiety (nervousness) and could impact their psychosocial wellbeing. During a concurrent observation and interview on 4/28/23, at 11:10 a.m., with Resident 2, in Resident 2 and 13's shared room, Resident 13 did not have a call bell. Resident 2 stated, he used his call bell to call staff for his roommate (Resident 13), when Resident 13 called out to staff for assistance. During an interview on 4/28/23, at 11:15 a.m., with the MS, outside of Resident 13's room, the MS stated, he gave a list of residents affected by the call light system malfunction to the ADON and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056021 If continuation sheet Page 2 of 5 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 05/22/2023 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 0919 will get a call bell for Resident 13. Level of Harm - Immediate jeopardy to resident health or safety During a concurrent interview and record review on 4/28/23, at 11:16 a.m., with the ADON, an undated pink sticky note titled Call Lights Not Working, was reviewed. The ADON stated, the facility identified nonfunctioning call lights for Room A (Residents 27 and 28), Room B (Resident 31), Room D (Residents 2 and 13), Room E (Residents 8 and 29), Room F (Residents 30 and 32), Room G (Residents 1, 3, 14, and 33), Room H (Residents 12, 16, 19, and 34), Room I (Residents 7, 10, 21, and 26), and Room J (Residents 4, 18, 20, and 35). Residents Affected - Some During an interview on 4/28/23, at 11:45 a.m., Certified Nursing Assistant 3 (CNA3) stated, Resident 11 has a call bell because the call light was not working. Resident 11's room was not written on the Call Lights Not Working list provided by the ADON. During an observation and interview on 4/28/23, at 11:54 a.m., with Case Manager 1 (CM 1), in the hall outside of Resident 2 and 13's room, CM 1 closed Resident 2 and 13's door without offering assistance after one of the residents rang the call bell. CM 1 stated, she did not hear the call bell. During an observation on 4/28/23, at 1:15 p.m., in Resident 12's room, Resident 12 did not have a functioning call light nor a call bell present at her bedside. During an observation on 4/28/23, at 1:20 p.m., in Residents 2 and 13's room, the bathroom call light was not working. During a concurrent observation and interview on 4/28/23, at 1:21 p.m., with Residents 1 and 3, in Resident 1, 3, and 14's shared room without a functioning call light system, a call bell was missing for all three residents. Resident 1 stated, she got up and walked out to the nursing station when she needed assistance because her call light or bell was not answered. Resident 3 stated, when her call light or bell wasn't answered she called out or waited for staff to come help her. During an observation on 4/28/23, at 1:28 p.m., in Resident 11's room, the bathroom call light was not working. During a concurrent observation and interview on 4/28/23, at 1:28 p.m., with Certified Nursing Assistant 2 (CNA2), while in Residents 1, 3, and 14's shared room, each resident was missing a call bell. CNA 2 stated, she would get call bells for Residents 1, 3, and 14. During a follow up observation on 4/28/23, at 1:29 p.m., while in Resident 13's room, Resident 13 did not have a call bell since 11:10 a.m. During a concurrent observation and interview on 4/28/23, at 1:29 p.m.,while in Residents 8 and 29's room, Resident 29 stated, the bathroom call light was not working. Resident 29 stated, he had to call out for help while in the bathroom. During an observation on 4/28/23, at 1:30 p.m., while in Residents 27 and 28's room, the bathroom call light was not working. During an interview on 4/28/23, at 1:31 p.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated, the facility had been using bells for a month or so. LVN 1 stated, it was hard to know which resident rang the bell and staff had to go room by room to check on residents. LVN 1 stated, a call (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056021 If continuation sheet Page 3 of 5 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 05/22/2023 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 0919 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some light or bell was important for residents to communicate their needs or if they had an emergency like a breathing difficulty or heart problem. During an interview on 4/28/23, at 2:51 p.m., CNA 6 stated, a bathroom call light was important for residents to have privacy, prevent falls and get assistance when needed. During a concurrent interview and record review on 4/28/23, at 11:29 a.m., with the ADM, a document titled Contract, dated 4/01/23, was reviewed. The ADM stated the contract indicated it was an estimate for a call light system and was unsigned. ADM stated, he was aware a new call light system was needed for the whole facility and the old system could not be repaired. The ADM stated the contract was not signed yet and only a verbal authorization was given to the company to install a new nurse call light system. The ADM also stated, there was no specific start date to replace the facility-wide call light system. During an interview on 4/28/23, at 1:09 p.m., Licensed Vocational Nurse (LVN 2) stated, residents needed functioning call lights to notify staff of needs or serious medical conditions, such as chest pain. LVN 2 further stated, residents feel isolated or stressed without call lights. During an interview on 4/28/23, at 2:06 p.m., with Central Supply and Maintenance Supervisor (CSM), the CSM stated, the contractor installing the call light system did not show up when scheduled a month ago to check the wiring. The CSM stated, the call light malfunction affected both sides of the building. During a concurrent interview and record review on 4/28/23, at 2:22 p.m., with the CSM in the conference room and MS on the phone, the facility's Quarterly Preventative Maintenance Log was reviewed. The Quarterly Preventative Maintenance Log sheet had a list of inspection items that maintenance department was responsible for. The MS stated, the item titled, Inspect residents' rooms/bathrooms for needed repairs and proper operation of all equipment included inspection of the call light system. The MS also stated the quarterly preventative maintenance inspections had not been completed since 12/30/22. The MS stated, the facility had call light malfunctions dating back to September 2022. The MS further stated, the facility did not complete a quarterly preventative maintenance log after December 2022. During a concurrent interview and record review on 5/01/23, at 1:34 p.m., with the Director of Nursing (DON),the facility's document titled, Cognitively and Physically Impaired Residents Who Are Unable to Utilize The Call System, undated, was reviewed. The DON stated, the facility had 12 residents who were cognitively or physically impaired and unable to use a call bell, including Residents 6, 9, 16, 17, 18, 20, 22, 23, and 24. The DON stated, the facility was doing increased rounds to monitor those 12 residents every 15 minutes, but was unable to provide documentation of increased monitoring in residents' clinical records and/or direct care staff's training records on increased resident monitoring . The DON stated facility purchased five baby monitors (an electronic device used to hear someone in another room) for residents who were unable to use the call bells, but none of them were deployed yet. During a concurrent interview and record review on 5/2/23, at 9:22 a.m., with ADM, facility's untitled document containing a list of cognitively and physically impaired residents, undated, was reviewed. ADM stated, facility identified and added Residents 10, 21, 25, and 26 to the list of cognitively and physically impaired residents the facility identified as incapable of using the call bell, indicating the facility had a total of 16 residents who were not able to use the call bell, which was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056021 If continuation sheet Page 4 of 5 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 05/22/2023 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 0919 the facility's alternative for malfunctioning call lights. Level of Harm - Immediate jeopardy to resident health or safety During an interview on 5/02/23, at 10:14 a.m., Certified Nursing Assistant (CNA 4) stated, the facility had two shower rooms (Shower rooms [ROOM NUMBERS]). CNA 4 stated, Occupational Therapy used Shower 1 for rehabilitation and to train residents with activities of daily living. Residents Affected - Some During a concurrent observation and interview on 5/02/23, at 10:16 a.m., with CNA 4 and Occupational Therapist 1 (OT 1), in Shower 1, OT 1 tested the call light. OT 1 stated it was not working. During an interview on 5/02/23, at 10:43 a.m., in Shower 2, Certified Nursing Assistant (CNA 5) stated, she was the designated shower staff for the day. CNA 5 stated two emergency call lights in Shower 2 were not working. CNA 5 stated, she had to yell out or schedule staff to pick up residents after 15 minutes because she didn't have a pager or other way to contact staff. During an interview on 5/2/23, at 12:14 p.m., with the Director of Rehabilitation (DOR), the DOR stated, she did not know the call light system was malfunctioned in Shower 1. The DOR stated, staff yelled out for help when help was needed. During a review of the facility's policy and procedure (P&P) titled Answering the Call Light, dated October 2010, the P&P indicated, the purpose of this procedure is to respond to the resident's requests and needs . The policy indicated staff are to report all defective call lights to the nurse supervisor promptly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056021 If continuation sheet Page 5 of 5