Health inspection·April 10, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A review of Resident 56's admission Record, printed on 4/9/25, indicated Resident 56 was readmitted to the facility on [DATE] with diagnoses of schizoaffective disorder (a mental health problem with psychosis as well as mood symptoms) and morbid obesity (too much body fat). A review of Resident 56's Minimum Data Set (MDS, a resident assessment tool used to guide care), dated 2/23/25, indicated Resident 56 was able to make herself understood and had the ability to understand others. The MDS indicated resident required substantial/maximal assistance (Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) during shower/bathing self, upper body dressing, and lower body dressing. During an observation on 4/7/25, at 9:20 a.m., inside Resident 56's room, a fully occupied four-bed room, with Resident 56's bed situated along the left side of the room closest to the door as you enter. Resident 56's privacy curtain was not pulled completely to either side, one toward the wall, and the other, toward the dividing curtain of Resident 56's next-bed neighbor. There was at least a three-feet gap for complete enclosure to the wall and a two-feet gap for complete enclosure to the end of the bed. Resident 56 lay flat in bed with exposed body below the hip and lower extremities as resident was being assisted by Certified Nursing Assistant 1 (CNA 1) during dressing after a shower. Resident 56's bed was visible to the two other residents across Resident 56's bed and to anyone who walked into the room. During a follow-up interview on 4/7/25, at 11:30 a.m., with CNA 1, CNA 1 stated the privacy curtain should be pulled completely around the resident bed to provide visual privacy during activities of daily living (ADLs, basic self-care tasks an individual does on a day-to-day basis) care. During an interview on 4/7/25, at 12:15 p.m., with Resident 56, resident stated the privacy curtain should be closed completely when a CNA is assisting the resident with personal care. During an interview on 4/9/25, at 2:13 p.m., with the Director of Staff Development (DSD), DSD stated during ADL care, privacy curtains should be closed completely around the bed or shut the room door if occupied by just one resident, for patient privacy and dignity. A review of the facility's policy and procedure (P&P) titled, Resident Rights, dated 2001, indicated, Employees shall treat all residents with kindness, respect, and dignity. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence . Page 1 of 22 056021 056021 04/10/2025 Lone Tree Post Acute 4001 Lone Tree Way Antioch, CA 94509

F 0550 Level of Harm - Minimal harm or potential for actual harm A review of the facility's P&P titled, Dignity, dated 2001, indicated, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem .1. Residents are treated with respect and dignity at all times .11. Staff promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures . Residents Affected - Few Based on observation, interview, and record review the facility failed to ensure residents' privacy and dignity rights were respected for two of two sampled residents (Resident 49 and Resident 56). Resident 49 and 56 did not have privacy during activities of daily living (ADL) care. This failure resulted in not providing privacy for Resident 49 and Resident 56, and Resident 49 feeling neglected. Findings: 1. A record review of Resident 49's admission record, printed on 4/9/25, indicated Resident 49 was admitted to the facility on [DATE]. During a record review of Resident 49's Minimum Data Set (MDS, an assessment used to guide care) dated 3/21/25, indicated Resident 23 ' s Brief Interview for Mental Status (BIMS, an assessment used to assess mental status) score was 14 out of 15, indicated intact cognition. The assessment indicated Resident 49 was able to make self-understood and was able to understand others. The assessment indicated Resident 49 needed some help performing self-care. The assessment indicated Resident 49 needed partial/moderate assistance (Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort) to perform oral care and personal hygiene. During an observation and concurrent interview on 4/7/25 at 10:03 a.m. Resident 49's privacy curtain and door were wide open, while Resident 49 was lying in bed. Resident 49 stated lack of privacy made him feel neglected as a resident. During an observation and concurrent interview on 4/9/25 at 09:25 a.m. Resident 49 was up in his wheelchair on the right side of his bed, brushing teeth, flossing and washing hair with damp towel, with curtain open and door open. Resident 49 stated he felt his privacy was invaded again as he expected the staff to close the privacy curtain/ door to his room while they assisted him to set him up for ADL care. During an observation and concurrent interview on 4/9/25 at 9:34 a.m. Licensed vocational nurse (LVN 5) stated Resident 49 did not have privacy at that time because the curtain and the door was open. LVN 5 it was important for Resident 49 to have privacy because it shows respect and dignity and residents have rights to privacy. During an observation and concurrent interview on 4/9/25 at 9:40 a.m. Certified nursing assistant (CNA 3) stated at that time, since Resident 49 was doing oral care and hygiene care/ ADLs and did not have privacy because of opened door and privacy curtain. CNA 3 stated it was important for all residents to have privacy to uphold dignity and their personal space. During a record review of the facility ' s policy and procedure (P&P) titled Dignity dated 2001 indicated, staff promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. 056021 Page 2 of 22 056021 04/10/2025 Lone Tree Post Acute 4001 Lone Tree Way Antioch, CA 94509

F 0559 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Note: The nursing home is disputing this citation. Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility falied to provide a written notice with reason for room change to one of one sampled resident (Resident 14)/ resident representative prior to changing Resident 14's room. This failure had the potential for Resident 14 to experience emotional distress. Findings: A review of Resident 14's admission Record (which includes the resident's basic personal information) indicated that Resident 14 was admitted to the facility on [DATE] to Room A. A review of Resident 14's Minimum Data Set (MDS- a set of assessments used to guide resident care) indicated that Resident 14's Brief Interview for Mental Status (BIMS-a scoring system used to evaluate a resident's cognitive status in terms of attention, orientation, and ability to register and recall information) score was seven (7) out of 15, indicating Resident 14 was severely impaired with mental status. During an interview on 04/07/25 at 12:14 a.m., in Resident 14's new room (Room B), Resident 14's Representative (RR) stated that the facility changed Resident 14's room from Room A to Room B on 04/01/25 without notifying her. During concurrent interview and record review on 04/09/25 at 09:30 a.m., with Social Services Assistant (SSA), email communication between SSA and RR was reviewed. SSA stated on 04/01/25 at 11:32 a.m., she sent an email to RR notifying them about Resident 14's room change. The SSA stated email read as We did some room changes that includes [Resident 14], [Resident 14] will be now in room B. On 04/01/25 at 12:02 PM, the RR responded, Why did (Resident 14)'s room get changed? On 4/1/25 at 12:13 p.m., in response to RR's concern regarding Resident 14's sudden room change, SSA responded back to RR stating, facility needed Room A for male residents and they were anticipating Resident 14 would be staying as a long term resident in the facility. During an interview on 04/09/25 at 2:28 p.m., in Resident 14's room, RR stated they were upset for not being informed about the room change prior to changing the rooms and the dissatisfaction with the new room. RR stated in Rroom A, Resident 14 had only one roommate, had a personal phone, better view from the window; whereas in current room (Room B) Resident 14 had three roommates, there was no phone in the current room, and the view from the window was limited to bushes. During a concurrent interview and record review on 04/10/25 at 10:33 a. m., Resident 14's Interdisciplinary Team (IDT- a team includes nursing, dietary, therapy, and activity who work together to create and implement care plan to meet each resident's needs.) conference notes dated 04/01/25 were reviewed. SSD stated he participated and organized thiscare conference with Resident 14's family representative and the IDT. SSD stated he lead the conference and Resident 14's RR joined in via phone, while facility staff including SSD, dietary supervisor, a nurse, activity director and therapy staff joined in the conference in his office. SSD stated the care conference notes indicated what was discussed during the conference among staff and with Resident 14's RR. SSD stated he was unable to find any documentation if staff and or Resident 14's RR talked about Resident 14's room change that 056021 Page 3 of 22 056021 04/10/2025 Lone Tree Post Acute 4001 Lone Tree Way Antioch, CA 94509

F 0559 Level of Harm - Minimal harm or potential for actual harm happened on that day. SSD stated if the IDT had discussed the room change, it would have been documented in the IDT notes. During an interview on 04/09/25 at 10:14 a.m., Social Services Director (SSD) stated that notifying the RR of a room change was not only Resident14's right but it was also a matter of dignity. Residents Affected - Few Note: The nursing home is disputing this citation. During an interview and record review on 4/10/25 at 10:25 a.m., with facility Administrator (ADM), facility's policy and procedure titled Room Change/Roommate Assignment, revised in May 2017 was reviewed. The ADM stated that it was the facility's policy to obtain agreement from residents or their representatives before making any room changes. The policy and procedure specify that, prior to changing a room or roommate assignment, all parties involved (e.g., residents and their representatives or sponsors) must be provided with advance notice of the change. 056021 Page 4 of 22 056021 04/10/2025 Lone Tree Post Acute 4001 Lone Tree Way Antioch, CA 94509

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 ensure the Minimum Data Set (MDS-an assessment and care screening tool used to guide care), was accurate for one of one sampled resident (Resident 146) when Resident 146's admission MDS was not coded accurately to reflect resident's use of continuous oxygen (O2) therapy. Residents Affected - Few This deficient practice resulted in an inaccurate reflection of Resident 146's admission assessment and had the potential for resident to not receive appropriate care and treatment necessary to meet the needs for her identified conditions. Findings: A review of Resident 146's admission Record, printed on 4/9/25, indicated Resident 146 was admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease (COPD, constricted airways making it difficult to breath), chronic respiratory failure (a condition where there is not enough O2 or too much carbon dioxide in the body), and hypoxia (low level of O2 in the blood). A review of Resident 146's admission MDS, dated [DATE], indicated Resident 146 was able to make herself understood and had the ability to understand others. The MDS indicated resident required substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) with activities of daily living (ADLs, basic self-care tasks an individual does on a day-to-day basis) care. Further review of Resident 146's MDS, indicated the facility marked resident's Section O-Special Treatment, Procedure, and Programs .A. On admission - no, to oxygen therapy and on B. While a Resident - no, to oxygen therapy . During an observation on 4/7/25, at 9:35 a.m., in Resident 146's room, an O2 sign was posted at the doorway and Resident 146's O2 concentrator (a medical device to provide supplemental O2) was on and provided supplemental O2 at a rate a little over 2 (two) liters per minute (LPM) via nasal canula. A review of Resident 146's Physician Order, dated 3/29/25, the Order Summary indicated, Oxygen at two 2 liters per minute via nasal canula every shift for shortness of breath (SOB) or peripheral oxygen saturation (SPO2, measurement of oxygen in the blood) of 90 percent (%) or less. A review of Resident 146's Care Plan - Focus on Oxygen, dated 3/29/25, indicated resident required the use of O2 related to acute respiratory failure, asthma (a chronic condition that narrow the airways in the lungs), and COPD. The Goal indicated, .Oxygen saturation will remain within 94% to 100% .and the Interventions indicated, Administer oxygen at 2 LPM via nasal canula .Oxygen use per physician order . During a concurrent interview and record review on 4/10/25, at 8:45 a.m., with Minimum Data Set Coordinator 1 (MDSC 1), Resident 146's admission MDS was reviewed. MDS Section O on oxygen therapy indicated an answer no, to both, on admission and while a resident at the facility. MDSC 1 stated Section O was coded incorrectly and did not reflect Resident 146's oxygen use. MDSC 1 stated she assessed Resident 146 on 3/31/25 and did not remember resident was on oxygen at that time, but did recall resident had an oxygen concentrator at bedside. A review of the Resident Assessment Instrument (RAI)Version 3.0 Manual, dated October 2024, 056021 Page 5 of 22 056021 04/10/2025 Lone Tree Post Acute 4001 Lone Tree Way Antioch, CA 94509

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few indicated, Section O .The intent of the items in this section is to identify any special treatments, procedures, and programs that the resident received or performed during the specified time periods .Steps for Assessment - 1. Review the resident's medical record to determine whether or not the resident received or performed any of the treatments, procedures, or programs within the assessment period defined for each column .Column a. On admission - Check all treatments, procedures, or programs received by, performed on, or participated in by the resident on days 1-3 .Column b. While a Resident - Check all treatments, procedures, or programs that the resident received or performed after admission/entry or reentry to the facility and within the last 14 days .Oxygen therapy - Code continuous (delivered continuously for 14 hours or greater per day) or intermittent (not continuously for at least 14 hours per day) oxygen administered via mask, canula, etc., delivered to a resident to relieve hypoxia in this item . 056021 Page 6 of 22 056021 04/10/2025 Lone Tree Post Acute 4001 Lone Tree Way Antioch, CA 94509

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 the facility failed to provide oral and fingernail care to one of one sampled Resident when Resident 23 had dry mouth, and black matter under fingernails. Residents Affected - Few Note: The nursing home is disputing this citation. This failure resulted in compromised daily care and appearance for Resident 23; and placed her at risk for compromised dignity and infections. Findings: A record review of admission record, printed on 4/8/25, indicated Resident 23 was admitted to the facility on [DATE]. During record review of Resident 23 ' s Minimum Data Set (MDS, an assessment used to guide care) dated 3/29/25, indicated Resident 23 ' s Brief Interview for Mental Status (BIMS, an assessment used to assess mental status) score was 4 out of 15, indicating severely impaired cognition. The assessment indicated Resident 23 was able to make self-understood and was able to understand others. The assessment indicated Resident 23 was dependent in oral and personal hygiene. The assessment indicated Resident 23 had an active diagnosis of Non-Alzheimer ' s Dementia and dysphagia. During an observation on 4/7/25 at 09:47 a.m. Resident 23 had dry lips and white, sticky like oral secretions in both corners of mouth. Resident 23 ' s upper lip was lined with white and red, crusty, dead skin with yellow dental plaque on teeth. Resident 23 ' s upper and lower eyelid appeared red with thick, yellow, crusty, mucus-like matter surrounding both eyes. Resident 23 had black matter under fingernails. During an observation and concurrent interview on 04/07/25 at 09:49 a.m. Licensed Vocational Nurse (LVN 3) stated Resident 23 ' s mouth is always dry as Resident 23 does not always drink fluids but is encouraged. LVN 3 stated Resident 23 gets a lot of eyes build up regularly. LVN 3 stated Resident 23 ' s mouth was dry and in need of oral care. LVN 3 stated it is important to perform oral and hygiene care to maintain good oral hygiene and uphold resident dignity. LVN 3 stated facility does provide Chapstick for dry lips, but there was none at Resident 23 bedside. LVN 3 stated Resident 23 ' s fingernails are dirty. LVN 3 stated fingernails should be clean to prevent infection. During an observation and concurrent interview on 04/09/25 at 10:15 a.m. Certified Nursing Assistant (CNA 2) stated Resident 23 ' s nails are not clean. CNA 2 stated Resident 23 mostly uses hands to eat. CNA 2 stated Resident 23 had cotton mouth and dry eyes. CNA 2 stated Resident 23 ' s eyes are always dry, and staff clean with damp wash cloth. CNA 2 stated Resident 23 is a total care resident and CNAs and LVNs are responsible for oral and eye care daily and as needed. CNA 2 stated it was important to do oral care because Resident 23 had dry mouth, and mouth needs cleaning after meals. CNA 2 stated facility does provide Chapstick for dry lips, but there was none at Resident 23 bedside. During an observation and concurrent interview on 04/09/25 at 10:32 a.m. LVN 4 stated Resident 23 needs Chapstick, upper lip needs to be wiped due to white patches on upper lip, and cotton mouth in corners. LVN 4 stated it was important for Resident 23 to have oral care to take care of teeth and prevent dry mouth and to stay hydrated. LVN 4 stated Resident 23 ' s eyes lids are red and dry. LVN 4 stated it was important to have good eye hygiene to help with vision and prevent eyes from being irritated from dryness. 056021 Page 7 of 22 056021 04/10/2025 Lone Tree Post Acute 4001 Lone Tree Way Antioch, CA 94509

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Note: The nursing home is disputing this citation. During an interview on 04/09/25 at 12:16 p.m. LVN 4 stated it is important for residents to have proper oral care and Chapstick to keep lips moist and prevent cracks in lips leading to wounds. During an observation and concurrent interview on 04/10/25 at 09:18 a.m. Director or Nursing (DON) stated important for total care residents to receive activities of daily living (ADL) care to prevent skin breakdown. DON stated oral care should be completed every shift and as needed by direct care staff. DON stated the importance of clean finger snails is to prevent infection and uphold residents ' dignity. During record review of Resident 23 ' s ADL care plan dated 09/21/23 goals indicated Resident 23 will have needs anticipated and met by staff. Interventions include AM and PM care: Assist of 1 person .Bathing assistance: Assist of 1 person .Hygiene: Assist of 1 person .Nails: trim nails with bathing schedule. During record review of Resident 23 ' s nail care task administration record (TAR) from dates 03/1/25 to 04/07/25 indicated nail care was, not applicable. During record review of the facilities P&P titled Oral Care stated, nursing staff responsible to provide assistance with daily oral care to residents who need help with brushing, flossing, or denture care, observe for signs of oral health issues (e.g. sores, gum swelling, cavities, dry mouth .residents at risk of oral health problems (e.g. those with diabetes, poor diet, or cognitive impairment) will have oral care monitored more closely and will receive additional preventative care .a structured oral care routine will be established and staff will use verbal cues and gentle redirection to assist residents. A calm and patient approach will be taken to reduce anxiety and resistance. During record review of the facilities P&P titled Care of Fingernail/Toenails dated 2001, indicated nail care includes daily cleaning and regular trimming .proper nail care can aid in the prevention of skin problems around the nail bed .trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin .stop and report to the nurse supervisor if there is evidence of ingrown nails, infections, pain, or if nails are too hard or too thick to cut with ease. 056021 Page 8 of 22 056021 04/10/2025 Lone Tree Post Acute 4001 Lone Tree Way Antioch, CA 94509

F 0687 Provide appropriate foot care. 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 provide foot care to two of three sampled residents, (Resident 34 and Resident 35). Facility did not provide podiatry services (the treatment of the feet and their ailments) to address their long, and thick toenails. Residents Affected - Few This failure resulted in Resident 34 feeling uncomfortable while wearing shoes and walking for too long and Resident 35 being in pain due to thick toenails. Findings: 1. A record review of Resident 34 ' s admission record, printed on 4/8/25, indicated Resident 34 was admitted to facility on 03/22/25. During a record review of Resident 34 ' s Minimum Data Set (MDS, an assessment used to guide care) dated 3/26/25, indicated Resident 34 ' s Brief Interview for Mental Status (BIMS, an assessment used to assess mental status) score was 11 out of 15, indicated moderately impaired cognition. The assessment indicated Resident 34 was able to make self-understood and was able to understand others. The assessment indicated Resident 34 was able to perform personal hygiene with supervision or touching assistance. The assessment indicated Resident 34 had a listed active diagnosis of pre-diabetes (higher than normal blood sugar) and need for assistance with personal care. During record review of Resident 34 ' s physician orders, dated 3/25/25, indicated podiatry (the treatment of the feet and their ailments) service for treatment of hypertrophic toenails (abnormal thickening of the nail plate on the feet or hands). During an observation and concurrent interview on 4/7/25 at 11:17 a.m. Resident 34 stated her toenails were too long on both feet, making walking very uncomfortable ability due to pain while wearing shoes for too long. Resident 34 ' s stated she felt angry because she cannot tolerate physical therapy (PT) for as long as she would like due to discomfort. Resident 34 ' s toenails appeared white and yellow in color with dry, flaky skin and heels. Resident 34 had thick, rigid toenails, about one inch in length curving to the side and over nail bed and onto skin. During an observation and concurrent interview on 4/7/25 at 11:22 a.m. with Certified Nursing Assistant (CNA 4) Resident 34 ' s toenails were observed. CNA 4 stated Resident 34 really needs toenails cut and she will remind assigned nurse about podiatry appointment. CNA 4 stated podiatry comes one time in a month and will be in facility on 4/18/25. CNA 4 stated Resident 34 ' s feet were dry, and toenails were overgrown. CNA 4 stated Resident 34 ' s toenails may cause pain. CNA 4 stated it is important to perform toenail care to prevent skin tears and wounds. During an observation and concurrent interview on 4/9/25 at 11:53 a.m. with Social Service Director (SSD) Resident 34 ' s toenails were observed. SSD stated Resident 34 had a referral for podiatry and if residents had emergency podiatry needs, nurses, team lead and transportation coordinate care to private/outside podiatry services. SSD stated she was unsure what constitutes emergency podiatry care. SSD stated Resident 34 ' s toenails need cutting because it was not sanitary and they were very long. SSD stated Resident 34 was pre-diabetic (elevated blood glucose levels, regarded as indicative that a person is at risk of progressing to Type 2 diabetes) so nurses should not manage toes at bedside. SSD stated podiatry referral is placed for all short-term residents at the time of admission. 056021 Page 9 of 22 056021 04/10/2025 Lone Tree Post Acute 4001 Lone Tree Way Antioch, CA 94509

F 0687 SSD stated Resident 34 should have emergency outpatient services to address long toenails. Level of Harm - Minimal harm or potential for actual harm During observation and concurrent interview on 04/09/25 at 02:06 p.m. Licensed Vocational Nurse (LVN 2) stated Resident 34 should have had an outpatient referral for podiatry services to prevent infection. Residents Affected - Few During record review and concurrent interview on 04/10/25 at 08:53 a.m. Director of Nursing (DON) stated SSD schedule appointments for podiatry services, if podiatry cannot come in facility, staff can schedule resident to see podiatry of choice or podiatrist available in community outpatient. DON stated if resident is admitted after monthly podiatrist visit in facility, resident should be offered to be seen by podiatry before next monthly visit outpatient. DON stated it is the resident ' s choice to accept outpatient podiatry services. DON stated skin assessments should be done every shift and abnormalities should be addressed by medical doctor (MD), If residents have long nails they should be added to podiatry During an interview on 4/10/25 at 9:11 a.m. DON stated team lead nurse who completed assessment on admission should have set podiatry services up immediately. DON stated it is important for residents to receive podiatry care to ensure good skin hygiene, and to ensure residents feel good about themselves. During an interview on 04/10/25 at 11:55 a.m. Resident 34 stated toenails were impacting walking and feels she would walk better in PT if her toenails were cut. Resident 34 stated she would have liked her toenails cut sooner. During record review of the facility ' s policy and procedure (P&P) dated 2022, titled Care of Fingernail/Toenails dated 2022 indicated nail care includes daily cleaning and regular trimming .proper nail care can aid in the prevention of skin problems around the nail bed .trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin .stop and report to the nurse supervisor if there is evidence of ingrown nails, infections, pain, or if nails are too hard or too thick to cut with ease. During record review of the facility ' s P&P titled Podiatry Services dated 2002 indicated residents requiring foot care who have complicated disease process will be referred to qualified professionals such as Podiatrist, Doctor of Medicine, and/or Doctor of Osteopathy .employees should refer any identified need for foot care to social worker or designer .the social worker or designer will assist residents in making appointments and arranging transportation to obtain needed services. 2.During a record review of Resident 35's Facesheet (FC), the FC indicated Resident 35 is [AGE] years old, admitted to the facility since 2023. The FC further indicated Resident 35 has diagnosis of Atrial Fibrillation (abnormal rapid and irregular heart beating), Unsteadiness (balance problem) on feet, need for assistance with personal care, Essential Hypertension (chronic high blood pressure with no known cause), and localized edema (swelling in specific area of the body). During an observation on 4/7/2025 at 10:18 a.m., Resident 35 lying in bed on his back, resting. Resident 35 stated he was concerned about podiatry care; he had not received podiatry care for a while over months. Resident 35's toes, bilateral (both) great toes and middle toes were very long, thick and hard. Resident 35 had two to three blankets over his toenails. During an interview on 4/10/2025 at 11:28 a.m., with Resident 35, Resident 35 stated it would have 056021 Page 10 of 22 056021 04/10/2025 Lone Tree Post Acute 4001 Lone Tree Way Antioch, CA 94509

F 0687 been nice if he had received a podiatry visit and it not taken so long get one. Level of Harm - Minimal harm or potential for actual harm During a review of resident 35's podiatry notes, titled, Resident Evaluation and Treatment, dated 4/8/2024, the podiatry notes indicated subjective (complaints/HP/significant/PMH) COPD, HTN, long thick painful toenails . Objective, skin atrophy . Hypertrophic, yellow, brittle, thickened, subungual debris with pain . Assessment, Onychomycosis (fungi infection of the nail), onychodystrophy (any abnormality or disease of the nail) x5 . Plan at risk foot care needed, trim of non-dystrophic nail(s), trim of dystrophic nail(s). Residents Affected - Few During a record an interview on 4/9/2025 at 10:33 a.m., with Social Services Assistant (SSA), SSA stated there is an order for Resident 35 to have podiatry care. SSA stated Resident 35 had not received podiatry care since his last podiatry visit on 4/8/2024. SSA stated Resident 35 have Medical and he should be covered for podiatry care. SSA stated the old podiatry provider was not keeping up with his schedule appointments with the facility to see residents. SSA stated Resident 35 is supposed to see podiatry care every 3 months. SSA stated it is important to provide podiatry care for residents as it is important to the resident and it is part of the resident care, part of taking care of the whole psychosocial and wellbeing of the resident. During an interview on 4/10/2025 at 11:10 a.m., with Director of Nursing (DON), DON stated it is important to provide podiatry care for residents, for the resident's dignity, to be clean, facility staff do not want residents to have any foot problems, skin breakdown, and discomfort on their foot. During a record review of Facility's policy and procedures (P&P), P&P titled, Activities of Daily Living (ADL), Supporting, dated 2001, the P&P indicated, Policy statement . Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs) . Resident who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and oral hygiene . Policy interpretation . 3. Care and services to prevent and/or minimize functional decline will include appropriate pain management, as well as treatment for depression and symptoms of depression. During a record review of Facility's policy and procedures (P&P), P&P titled, Podiatry Services, dated 2023, the P&P indicated, Policy . It is the policy of this facility to ensure residents receive proper treatment and care within professional standards of procedures and state scope of practice, as applicable, to maintain mobility and good foot health . 2. Residents requiring foot care who have complicated disease processes will be referred to qualified professionals such as Podiatrist, Doctor of Medicine, and/or Doctor of Osteopathy . 5. The social worker or designer will assist residents in making appointments and arranging transportation to obtain needed services. 056021 Page 11 of 22 056021 04/10/2025 Lone Tree Post Acute 4001 Lone Tree Way Antioch, CA 94509

F 0695 Provide safe and appropriate respiratory care for a resident when needed. 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 one of one sampled resident (Resident 146), the facility failed to ensure appropriate oxygen (O2) therapy was administered when resident received continuous O2 at a flow rate of three liters per minute (3 LPM) instead of two (2) LPM, as ordered by the physician. Residents Affected - Few This deficient practice to administer excessive O2 administration on a chronic obstructive pulmonary disease (COPD, a lung condition caused by damage to the airways and other parts of the lungs) patient has placed Resident 146 at risk for compromised breathing which may lead to further adverse effects. Findings: A review of Resident 146's admission Record, printed on 4/9/25, indicated Resident 146 was admitted to the facility on [DATE] with diagnoses of COPD, chronic respiratory failure (a condition where there is not enough O2 or too much carbon dioxide in the body), and hypoxia (low level of oxygen in the blood). A review of Resident 146's admission MDS, dated [DATE], indicated Resident 146 was able to make herself understood and had the ability to understand others. The MDS indicated resident required substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) with activities of daily living (ADLs, basic self-care tasks an individual does on a day-to-day basis) care. A review of Resident 146's Physician Order, dated 3/29/25, the Order Summary indicated, Oxygen at 2 liters per minute via nasal canula (NC) every shift for shortness of breath (SOB) or peripheral oxygen saturation (SPO2, measure of amount of oxygen in the blood) of 90 percent (%) or less. A review of Resident 146's Care Plan - Focus on Oxygen, dated 3/29/25, indicated resident required the use of oxygen related to acute respiratory failure, asthma (a chronic condition that narrow the airways in the lungs), and COPD. The Goal indicated, .Oxygen saturation will remain within 94% to 100% .and the Interventions indicated, Administer oxygen at 2 LPM via nasal canula .Oxygen use per physician order . During a concurrent initial observation and interview on 4/7/25, at 9:35 a.m., in Resident 146's room, an oxygen sign was posted at the doorway. Resident 146 was lying in bed with head of the bed up at 45 degrees, awake, and verbal with some confusion and/or forgetfulness noted. Resident's O2 concentrator (a medical device to provide supplemental oxygen) was on with O2 administered at a flow rate a little over 2 LPM via NC. During a follow-up observation on 4/8/25, at 8:10 a.m., in Resident 146's room, Resident 146 was asleep with pursed lips, lying on her back with head of the bed up at 45 degrees. Resident's O2 concentrator was on at continuous O2 flow rate of two and a half (2.5) LPM via NC. During a concurrent observation and interview on 4/9/25, at 2:30 p.m., with Licensed Vocational Nurse 1 (LVN 1), Resident 146's physician orders were reviewed. Physician's Order dated 3/29/25, indicated O2 order at 2 LPM via NC for SOB, COPD, and chronic respiratory failure. LVN 1 stated Resident 146 was checked during the start of LVN 1's morning shift and at least four to five times during the 056021 Page 12 of 22 056021 04/10/2025 Lone Tree Post Acute 4001 Lone Tree Way Antioch, CA 94509

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few shift. Inside Resident 146's room, resident was noted asleep in bed again. When resident's O2 concentrator was assessed, LVN 1 stated O2 concentrator was set at a flow rate a little more than 3 LPM via NC. LVN 1 stated Resident 146 should only receive continuous O2 at 2 LPM, per physician order, and should be followed at all times. During an interview on 4/9/25, at 2:38 p.m., with the Assistant Director of Nursing (ADON), Resident 146's physician order was reviewed. ADON stated resident's O2 administration should be given as ordered at 2 LPM via NC. ADON stated if a COPD resident is on excessive O2 administration, it may lead to adverse effects such as a decrease in respiratory drive leading to potential carbon dioxide retention. A review of the facility's policy and procedure (P&P) titled, Oxygen Administration, dated 2001, indicated, The purpose of this procedure is to provide guidelines for safe oxygen administration .Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration . 056021 Page 13 of 22 056021 04/10/2025 Lone Tree Post Acute 4001 Lone Tree Way Antioch, CA 94509

F 0732 Post nurse staffing information every day. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and document review, the facility failed to post direct care daily staffing data on a daily basis. Residents Affected - Many This failure resulted in nurse staffing data not being posted in a visible and prominent place where it was accessible to residents and visitors. Note: The nursing home is disputing this citation. Findings: During multiple observations on 4/7/25, and 4/8/25, there was no staffing data posted in facility's reception, nursing station and/or hallways area. During an interview and record review on 4/9/25 at 12:07 p.m., with the Staff Scheduler (SS 1), facility's Nursing Staff Sign in Binder was reviewed. The binder had a document titled the census and direct care services hours per patient day (DHPPD). DHPPD had the estimated and actual total direct care hours for direct care staff (Registered Nurse, (RN), Licensed Vocational Nurses (LVN), Certified Nurse Assistant (CNAs) and beginning patient census, for day, evening and night shift. SS 1 stated the DHPPD was only kept in a binder, and was not posted anywhere in the facility; and the binder was kept at the nurse's station. During an observation and interview on 4/9/25 at 12:21 p.m., SS1 stated she was working as facility's staffing scheduler for past five years. SS 1 stated she was responsible for creating the DHPPD document on a daily basis. SS 1 stated she had never posted and or had seen the DHPPD being posted on facility's premises. SS1 then walked around the facility's hallways, including nursing station, and looked through glass doors into facility's reception area. SS 1 stated she was unable to find the DHPPD being posted anywhere. SS 1 stated since she was responsible for creating the DHPPD, she would be responsible to post it. SS 1 also stated she was not even aware of such requirement that DHPPD must be posted in an area visible to residents and visitors. During a concurrent observation and interview on 4/9/25 at 12:28 p.m., with Director of Nursing (DON), facility's notice board with licensing information was reviewed. The DON stated he had seen DHPPD data posted on the notice board, but he could not recall when was the last time he had seen it being posted. The DON stated he was unable to find the DHPPD posting on the notice board. The DON stated SS 1 must know about DHPPD posting. A record review of facility's Policy and Procedure titled 'Posting Direct Care Daily Staffing Numbers dated 2001, indicated, within two (2) hours of the beginning of each shift, the charge nurse or designee computes the number of direct care staff and completes the Nurse Staffing Information form. The charge nurse, or designee, completes the form and places the staffing information in the location (s) designated by the administrator. the form may be typed or handwritten.If the information is handwritten, it must be legibly printed in black ink and written so that staffing data can be easily seen and read by residents, staff and visitors who are interested in our facility's daily staffing information. 056021 Page 14 of 22 056021 04/10/2025 Lone Tree Post Acute 4001 Lone Tree Way Antioch, CA 94509

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, facility failed to ensure one of four Residents Affected - Some sampled residents (Resident 83) received a combination tablet of Calcium and Vitamin D per physician's order and Fluticasone nasal spray per manufacturer's recommendation. 1.Licensed Vocational Nurse (LVN) 1 administered 600mg+400 units of Calcium + Vitamin D instead of 600mg +200 units of Calcium + vitamin D. 2.LVN 1 did not shake and/or prime (remove the air from the applicator/nasal piece and fill the applicator/nasal piece with medication) prior to administering the nasal spray. Facility's medication error rate was 6.6.%. This failure resulted in Resident 83 not receiving Calcium/ Vitamin D supplement per physician's orders and placed Resident 83 at risk of not receiving the correct dose and concentration of the nasal spray. Findings: A record review of Resident 83's admission Record (record with residents' basic personal information) indicated Resident 83 was admitted to the facility on [DATE]. A review of Resident 83's Physician orders dated 04/2025 indicated Resident 83 was to receive Calcium-Vitamin D Tablet 600-200 mg-units [mg=milligrams] one tablet by mouth two times day for supplementation and Fluticasone Propionate Nasal Suspension 50 mcg/act two spray in each nostril one time a day for nasal allergy. During a medication administration observation on 04/08/25 at 08:11 a.m., with LVN 1, LVN 1 administered Calcium 600 mg + Vitamin D 10 [micrograms] mcg (10 mcg containing 400 units of Vitamin D) one tablet by mouth to Resident 83. LVN 1 also brought a new bottle of Fluticasone Propionate (Flonase) nasal spray from her medication cart into Resident 83's room. After removing the plastic seal from the spray applicator, without shaking and priming the nasal spray, LVN 1 administered two sprays into Resident 83's nostril. During an observation on 04/08/25 at 10:50 a.m., with LVN 1, medication cart containing Resident 83's medication was inspected. LVN 1 stated she did not have correct and prescribed dose of Calcium and Vitamin D supplement/ medication for Resident 83, stocked in the medication cart. During an interview on 04/09/25 at 10:01 a.m., LVN 1 stated that she should prime the new bottle and gently shake the Flonase bottle before administration. During an interview with the Director of Nursing (DON) on 04/09/25 at 09:51 a.m., DON stated that nurses should gently shake the Flonase bottle and prime a new nasal spray applicator before administration to ensure the resident received the correct dose of medication. During an interview and record review on 04/10/25 at 10:16 a.m., with Assistant Director of Nursing 056021 Page 15 of 22 056021 04/10/2025 Lone Tree Post Acute 4001 Lone Tree Way Antioch, CA 94509

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some (ADON), pharmaceutical instructions for Flonase nasal spray were reviewed. The ADON stated the instructions emphasized the need to gently shake the Flonase bottle before each use. The ADON stated that failure to shake the bottle could result in the resident receiving either overly diluted or overly concentrated medication, potentially compromising its effectiveness. During review facility's policy and procedure titled Administering Medications dated 04/2019, indicated Medications are administered in accordance with prescriber orders. 056021 Page 16 of 22 056021 04/10/2025 Lone Tree Post Acute 4001 Lone Tree Way Antioch, CA 94509

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Note: The nursing home is disputing this citation. 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, facility failed to ensure one of one medication storage room, had unexpired resident care and treatment supplies. Expired items including two wound swab tubes, six blood test tubes, three syringes, and two covid test kits, five packs of Intravenous Antibiotics (IV ATB- medication used to treat infections, given directly into the veins) medication for a discharged resident, were kept with ready to use supplies. This failure placed facility's residents at risk for getting exposed to expired treatment supplies, inaccurate lab test results. Findings: During an observation and interview, in facility medication storage room on [DATE] at 10:29, with Director of Nursing (DON), following items were found stored in medication storage cabinets around the room: 1. Six light purple-top vacutainers (a sterile glass or plastic test tube with a color-coded stopper that creates a vacuum seal inside, allowing a predetermined volume of blood to be drawn directly into it), with expiration date on [DATE]. 2. Two BD Eswab transport system (a tool used in medical labs to collect and move samples from a patient to the lab for testing), with expiration date on [DATE]. 3. Three five (5) cc syringes (without needles) with expiration date on [DATE]. 4. Two Covid test kits with expiration date on [DATE]. 5. A ziplock bag with five piggy bags of Invanz (an ATB medication for infection) IV one gram/100 mellites (1gm/100ml), with Resident 347's name on it. The ziplock bag did not indicate if medication belonged to an active resident or a discharged resident. During an interview on [DATE] at 10:40 a.m., DON stated using expired vacutainers, syringes may cause inaccurate test results, contamination, and potentially impacting patient care. The DON stated Resident 347 was discharged from the facility on [DATE] and the IV Invanz medication should not be kept in the medication storage room. The DON grabbed all the expired items and placed in the bin designated for discontinued/discarded medication kept in the medication storage room. The DON stated government had issued a memorandum that even expired covid test kits were usable beyond their expiration date; however, was unable to provide any supporting guidance for that. During review facility policy titled Storage of Medication revised on [DATE], indicated The nursing staff is responsible for maintain medication storage and preparation areas in a clean, safe, and sanitary manner, and Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. 056021 Page 17 of 22 056021 04/10/2025 Lone Tree Post Acute 4001 Lone Tree Way Antioch, CA 94509

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to prepare, distribute, serve food in a safe, clean, and sanitary manner for 97 out of 97 residents, not following professional standards for food service safety and not following their facility policy and procedures, when: 1. staff failed to wear hair covering in the food preparation (the series of operational processes involved in prepping foods for serving, such as: washing, mixing ingredients, cutting, slicing, washing etc ) area. 2. Kitchen staff failed to use and maintain cutting board in a good condition to chop up and prepare food for the residents. 3. Facility did not maintain the kitchen ceiling in good, repaired condition. 4. Facility failed to maintain ceiling vent above tray line area in a clean condition, free from dust and other air particles. 5. Staff placed contaminated soiled rag, personal drinking cup, personal phone and charger on the food preparation area. 6. Staff did not follow correct cleaning and (sanitation) process when cleaning the food preparation area (kitchen counter tops and shelves). These failures had the potential for residents to get foodborne illnesses (illness caused by ingestion of contaminated food or beverages), cross contamination (the transfer of harmful substances or disease-causing microorganisms to food by hands, food contact surfaces, sponges, cloth towels, or utensils) of diseases, spread of infection, and possible hospitalization. Findings: 1.During an observation on 04/07/2025 at 09:09 AM, Certified Nursing Assistant (CNA) 5 came into the food prep area, past the red line marked on the floor (that means staff should not go beyond without hair net covering), and was standing by the coffee stands, near the tray line area, in-between the food shelves areas without hair net covering. During an interviewed on 4/7/2025 09:09 a.m., with CNA 5 and Dietary Manager (DM), CNA 5 stated red line means do not cross. CNA 5 also stated she does not have her hair net on, and she was supposed to have put one on because it's food area. DM stated [NAME] means staff should not cross that line because of sanitation, so that hair does not get into the food. 2.During an observation on 4/10/2025 at 09:53 a.m., Kitchen [NAME] (KC) was cutting lettuce and carrots on a worn out (unrepaired) cutting board for lunch preparation. 3.During an observation on 4/7/2025 at 09:05 a.m., with DM, ceiling area around the kitchen hood cracked on different angles and open on one spot above the stove. The cracked ceiling had some patch work to it. The open part on the ceiling was where the patch work had been done. 056021 Page 18 of 22 056021 04/10/2025 Lone Tree Post Acute 4001 Lone Tree Way Antioch, CA 94509

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an observation on 4/7/2025 at 11:22 a.m., ceiling around kitchen hood had cracked areas at different angles and an open area on one spot above the stove where staff was cooking beef stew. During an interview with the DM, the DM stated she and the facility Administrator (Admin), are aware of the cracked ceiling. DM stated Maintenance had done the patch work to the ceiling some few months ago. DM stated the reason the cracked ceiling should be fully repaired to a good condition is because the stove is right below the cracked area, anything can fall from it, into the meal being prepared for residents, and also because it's open. 4.During an observation and interview on 4/10/2025 at 09:36 a.m., with Admin and DM, vent area right above the tray line area had cracked lines on it, and had dust, and cluster of dust particles attached and dangling from the vent Admin stated he had been informed about the cracked ceiling first week of February 2025. DM stated the vent above the tray line is called a swap cooler, and the facility uses the swap cooler to get air from outside to the inside. During a review of facility's document emailed on 4/16/2025, titled E&G Handyman . Project Proposal, dated 4/7/2025, the project proposal had no schedule date and receipt of payment to repair the facility's kitchen. 5.During an initial observation and an interview on 4/7/2025 at 08:42 a.m., with the Dietary Manager (DM), Kitchen Chef (KC), in the kitchen, a used cup half filled with water, placed on the same food prep counter, near the mixing bowl filled with wiped cream. A staff's personal phone and charger placed on food prep area, near the microwave used for reheating resident's meals. KC stated he had used the cup to take his medication and had left the cup on the counter. DM stated the used cup was not supposed to have been placed near the food mixer or on the food preparation area/counter, for sanitation purposes. DM also stated the microwave was used to reheat resident trays, drinks, or meals that facility hold in the kitchen, like a late tray if they had gone out of the facility for medical appointments or like for dialysis. During an observation and an interview on 4/7/2025 at 08:42 a.m., with DM, soiled, wet rag was placed on the food prep counter right next to the open food mixer filled with wiped cream. The DM stated the wet rag was used to wipe down the kitchen counter during food prep. 6.During an observation and an interview on 4/7/2025 at 2:17 p.m., with DM, the DM sprayed Clorox spray onto a dry rag and wiped the food counter surface, then later sprayed a solution in a bottle labeled QUAT, directly to the counter surface. The Quat was mixed from a built in Quat tubing system/solution at the kitchen sink. The DM stated this is the facility's process she has been using. DM stated staff are trained to use Clorox spray from the original manufacturer's bottle to clean the counter surfaces and all other kitchen surfaces. DM stated, first, staff would spray the Clorox onto the dry rag, wipe the counter after spraying the Clorox, then spray the QUAT spray directly on the kitchen surface counters, leave to air dry, and walk away. DM stated staff will check the strips for chlorine levels only when the QUAT bottle is empty and needs to be refilled. During a review of facility's policy and procedure (P&P), the P&P titled, Tray Line Area Cleaning . Cleaning Procedure. The P&P indicated, 1. Grab clean cart, plastic container. Fill container w/hot water & comet/bleach. Use clean rag . 2. Submerge clean rag into water ring out. Rinse rag . 3. Wipe off self . 11. Dump bleach water . 14. Put dirty rag in bucket. During a review of facility's P&P, the P&P titled, Kitchen Equipment and Maintenance, dated 2001. 056021 Page 19 of 22 056021 04/10/2025 Lone Tree Post Acute 4001 Lone Tree Way Antioch, CA 94509

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some The P&P indicated, Policy Statement . It is the policy of the facility to ensure that all the kitchen equipment used in the preparation and service of food is maintained in a safe and sanitary condition to provide high-quality meals for residents. This policy outlines the necessary procedures for the regular inspection, cleaning, and maintenance of kitchen equipment to minimize the risk of accidents, foodborne illnesses, and operational disruptions . Purpose . The purpose of this policy is to . maintain kitchen equipment in optional working condition . ensure the safety of kitchen staff, residents, and visitors . comply with regulatory requirements regarding food safety and sanitation . Procedure . 1. Regular inspection and prevention maintenance . All kitchen equipment will be inspected at least monthly by the kitchen manager or designated staff . A maintenance checklist will be used to record the inspection results, including a review of the following . Cleanliness of the equipment, proper functioning of all components (e.g. burners, buttons, doors, thermometers), no visible damage or wear . 3. Cleaning and sanitizing equipment, all kitchen equipment must be cleaned and sanitized daily, following the manufacturer's instruction. This includes cleaning filters, vents, and exhaust fans . 5. Equipment repairs and replacement, when equipment is identified as malfunctioning or requiring repair, it will be evaluated for possible repair or replacement . Priority repairs will be made immediately to avoid disruptions of food service . Review and Evaluation . This policy will be reviewed annually to ensure its effectiveness and compliance with current regulations .Modification will be made as needed based on feedback from kitchen staff, maintenance personnel, or regulatory changes. 056021 Page 20 of 22 056021 04/10/2025 Lone Tree Post Acute 4001 Lone Tree Way Antioch, CA 94509

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 ensure staff followed proper standard precautions to prevent the spread of infection when: Residents Affected - Some 1. Laundry Staff 1 stored her personal clothing item in the clean linen/laundry area. 2. Licensed Nurse brought original packaging of Resident 73's inhaler and Resident 83's nasal drops into the residents' respective rooms and then stored the packaging back to the medication cart. These deficient practices created a risk for cross-contamination (transfer of bacteria or other microorganisms from one substance to another) that could result in spread of infection to the residents in the facility. Findings: 1. During a concurrent observation and interview on 4/8/25, at 9:38 p.m., with the Environmental Services Manager (EVSM) and Laundry Staff 1, inside the clean side of the Laundry Room, Laundry Staff 1 stated and showed she hung her black-colored jacket inside the designated Resident Clean-Clothes Rack. Laundry Staff 1 was unable to answer when asked what risk that could have brought to the residents' health. EVSM however stated mixing staff clothing and other personal belongings with residents' clothes/linens could cause cross-contamination and spread of infection. EVSM also stated Laundry Staff 1 had a designated locker in the breakroom to store her personal item during work. During an interview on 4/10/25, at 8:30 a.m., with the Director of Staff Development (DSD), DSD stated the facility did not have a policy and procedure on Personal Belongings Storage, nor was it listed on their facility Employee Handbook, but all staff were made aware lockers were available in the breakroom for employee-use, for staff to stow away personal belongings during working hours. 2. A record review of Resident 73's Order Summary Report (a document or tool that provides an overview of orders) printed on 04/08/25 indicated Resident 73 had an order of Fluticasone 100 mcg/62.5 mcg/25 mcg (Ellipta) one puff inhale orally one time a day for COPD (chronic obstructive pulmonary disease, refers to a group of diseases that cause airflow blockage and breathing-related problems. It includes emphysema and chronic bronchitis) rinse mouth with water after each use. During an observation on 04/08/25 at 08:00 a.m., Licensed Vocational Nurse (LVN) 1 took Resident 73's Fluticasone inhaler along with its original packaging container into Resident 73's room. LVN 1 placed the container on Resident 73's bedside table, administered the inhaler to Resident 73, put the inhaler into the container, and then brought the container back to store in the medication cart. A record review of Resident 83's Order Summary Report printed on 04/08/25 indicated Resident 83 had an order of Fluticasone Propionate Nasal suspension 2 spray in each nostril one time a day for nasal allergy. During an observation on 04/08/25 at 08:11 a.m., LVN 1 brought Resident 83's Fluticasone Propionate nasal spray bottle along with its original packaging to the Resident 83's room. LVN 1 placed the package on Resident 83's bedside table without utilizing any appropriate barrier between the package and the bed side table, administered one spray to Resident 83's each nostril, repacked the bottle into its original package, and then returned the package to the medication cart. 056021 Page 21 of 22 056021 04/10/2025 Lone Tree Post Acute 4001 Lone Tree Way Antioch, CA 94509

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 04/08/25 at 10:42 a. m., LVN 1 stated she could see how the original packages could become contaminated from Resident 73 and Resident 83's bed side tables. LVN 1 stated to avoid further contaminating the medication cart, she would take the bottle into the residents' room for use and then return it to the original package afterward. During an interview on 04/09/25 at 10:00 a.m. with Assistant Director of Nursing (ADON), the ADON stated bringing the original package for medications into the resident's room without utilizing an appropriate barrier had potential to contaminate the medication cart. 056021 Page 22 of 22