Health inspection·November 19, 2021

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on interview and record review, the facility failed to ensure the hospice interdisciplinary team participated in the initial care plan for one (Resident 14) of nineteen sampled residents to address Resident 14's hospice care needs. This deficient practice had the potential to result in not receiving a person-centered hospice plan of care. Findings: Review of the admission Minimum Data Set - (MDS - an assessment screening tool used to guide care) dated 5/28/21, indicated Resident 14's diagnoses included respiratory failure (serious lung and breathing disorder). Resident 14 was on hospice care. Review of the Resident Care Conference dated 5/24/19, indicated Resident 14 was readmitted from home on 5/21/21 to the facility for hospice care. Further review of Resident 14's Resident Care Conference dated 5/24/21, indicated the interdisciplinary team members who participated in the care plan development did not include hospice representatives. During an interview on 11/18/21 at 12:31 p.m., Social Services Director (SSD) stated she coordinated Resident 14's 5/24/21 care plan conferences with the hospice care team but they did not attend. SSD could not provide Resident 14's coordinated plan of care between the facility, hospice agency, and resident/family care plan conference. The facility policy and procedure titled, Hospice Program (undated) indicated, when a resident participates in the hospice program, a coordinated plan of care between the facility, hospice agency and resident/family will be developed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056260 If continuation sheet Page 2 of 6 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 056260 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/19/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bayberry Skilled Nursing & Healthcare Center 1800 Adobe Street Concord, CA 94520 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 0685 Assist a resident in gaining access to vision and hearing services. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to follow-up for one (Resident 62) of 19 sampled residents prescribed eyeglasses order for three months. Residents Affected - Few This deficient practice resulted in Resident 62 having difficulty reading, prevented her from fully enjoying her pastime activities and seeing her surroundings clearly. Findings: During a concurrent observation and interview on 11/16/21, at 8:22 a.m., Resident 62 stated she was concerned about her eyeglasses that have not arrived yet and has been months. Resident 62 had two pairs of over-the-counter (OTC) eyeglasses from the Dollar store on the overbed table. Resident 62 stated the OTC eyeglasses do not help her vision. During an interview on 11/17/21, at 9:50 a.m., with the Social Services Director (SSD), SSD stated Resident 62 was seen by the optometrist (eye doctor) and started the order for Resident 62's eyeglasses back in August 2021. SSD stated she usually calls to follow-up with an order but could not provide documentation reflecting having checked the status of Resident 62's prescription eyeglasses. During an interview on 11/19/21, at 8:50 a.m. with Resident 62, Resident 62 stated it was difficult to read the daily paper, watch television, and had to hold on to everything to the portable bedside commode at the right side of the bed. During a review of Resident 62's optometry notes which indicated Resident 62 was seen on 8/23/21 and had a Final Spectacle (eyeglass) Rx (prescription). During a review of the email sent by (name of eye company) to SD dated 11/17/21 which indicated Resident 62 had a high Rx with a tint and polycarbonate eyeglasses. During a review of the facility's policy and procedure (P&P) titled, Vision Care (not dated)indicated, Social services staff shall assist in contacting the resident's ophthalmologist/optometrist for the necessary service.Documentation shall be maintained in the resident's medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056260 If continuation sheet Page 3 of 6 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 056260 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/19/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bayberry Skilled Nursing & Healthcare Center 1800 Adobe Street Concord, CA 94520 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, for one of five sampled residents (Resident 24) reviewed for unnecessary medications use, the facility failed to act upon the Consultant Pharmacist's (CP) report of a medication irregularity when an approved change in medication directions was not implemented. This failure did not ensure safe medication administration and had the potential for adverse side-effects. Findings: Review of Resident 24's admission Record indicated Resident 24 was admitted to the facility on [DATE] with diagnoses that included chronic pain. Review of CP's titled, Note To Attending Physician/Prescriber dated 9/10/21 indicated; This resident has an order for Lidocaine Patch 4% (treats pain) order needs to be clarified. Current directions of 2 patches is indicated for Lidocaine 5% (max of 3 patches) not indicated for Lidocaine 4%. Lidocaine 4% direction typically is 'apply 1 patch topically to affected area for up to 12 hours; max 1 patch on body at a time; usually limit use to 1 week'. CP's recommendation were: 1. Change from Lidocaine 4% to 5% (retain 2 patches application) or 2. Retain Lidocaine 4% (change directions to max 1 patch application). The note also indicated the Attending Physician signed and wrote agree on 10/4/21. Review of CP's Note To Attending Physician/Prescriber dated 10/7/21 indicated the same recommendation as before on 9/10/21. The note reflected the Attending Physician had signed again and wrote agree' on 11/1/21. During an interview and concurrent review of Resident 24's Medication Administration Record (MAR) for October 2021 and November 2021 with the Director of Nursing (DON), on 11/19/21 at 10:47 a.m., DON stated Resident 24's previous order for Lidocaine 4% patch indicated the licensed nurse could give up to two patches whereas the recommendation from the Consultant Pharmacist suggested only one patch could be given. Review of Resident 24's MAR for October 2021 did not indicate the physician's order dated 10/4/21 was carried out. During a follow-up interview and review of Resident 24's MAR with DON, on 11/19/21 at 11:36 a.m., DON stated the physician's order dated 10/4/21 was not carried out as expected on the same day the order was written. Consequently, the order dated 10/4/21 was carried out on 11/2/21 (28 days later). During a telephone interview with CP on 11/19/21 at 12:26 p.m., CP stated the recommendation to limit Lidocaine 4% to only one patch at a time, in a 24-hour period, was made in accordance with the Lidocaine manufacturer's specification. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056260 If continuation sheet Page 4 of 6 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 056260 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/19/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bayberry Skilled Nursing & Healthcare Center 1800 Adobe Street Concord, CA 94520 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, record review, the facility failed to ensure the medication rate was less than 5% for two of 19 sampled residents (Resident 23 and Resident 317). Residents Affected - Some 1. For Resident 317, Licensed Vocational Nurse 5 (LVN 5) administered inhaler medications, Incruse Ellipta and Symbicort, for chronic obstructive pulmonary (lung) disease (COPD) and DuoNeb (treats COPD or wheezing and shortness of breath caused by asthma (airways become inflamed and narrow). Resident 317 was not instructed to rinse and spit after receiving Incruse Ellipta and Symbicort which were not administered in the correct sequence. 2. LVN 4 administered Tetrahydrozoline HCI (hydrochloride) (decongestant eye drop for eye irritation and redness). However, the physician ordered Pataday Solution eye drops (antihistamine for itchy, red eyes due to allergies) for Resident 23. Instructions for closing the eyes, and rotating the eyeball were not provided. These failures had the potential for Resident 317 to develop oral thrush (fungus) from not rinsing and spitting. Resident 23 received the wrong eye drops that had a different therapeutic action. No instructions were provided to Resident 23 during eye drop administration which had the potential for under dosage and did not meet standards of practice. Findings: 1. During an observation on 11/16/21, at 8:37 a.m., LVN 5 first administered two puffs of Symbicort (combination steroid anti-inflammatory and long-acting medication that relaxes the muscles around the airways), then Incruse Ellipta (anticholinergic that relaxes muscles in the airways) and the DuoNeb (bronchodilator, opens up the airways) via nebulizer (machine that delivers the medication in a fine mist to breathe in) to Resident 317. During an interview on 11/17/21, at 1:03 p.m., LVN 5 stated bronchodilators should be administered before administering other breathing/inhaler treatments. LVN 5 stated bronchodilators would help to open up the airway for better absorption of other medications. LVN 5 stated she was not sure if she administered the inhalers in the correct order. During a record review of the facility's policy and procedure (P&P) titled, Specific Medication Administration Procedures dated 5/16/18, indicated, Sequence of Inhaler Medications; 1) bronchodilators (Duoneb) administered first, 2) anticholinergic (Incruse Ellipta) or long-acting bronchodilator administered second, and 3) steroid inhaler (Symbicort) administered last .). 2. During a record review of Resident 317's physician orders dated 11/17/21, indicated Resident 317 was to receive Incruse Ellipta Aerosol Powder Breath Activated (umeclidinium Bromide) one inhalation, inhale orally every 12 hours related to COPD with (acute) exacerbation, rinse mouth after use. During record review of Resident 317's physician orders, dated 11/17/21, indicated Resident 317 was to receive Symbicort Aerosol 160-4.5 MCG/ACT (microgram/actuation) (Budesonide-Formoterol Fumarate) 2 puffs inhale orally two times a day related to COPD with(acute) exacerbation, rinse and spit after use. During a record review of Resident 317's physician orders, dated 11/17/21, indicated Resident 317 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056260 If continuation sheet Page 5 of 6 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 056260 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/19/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bayberry Skilled Nursing & Healthcare Center 1800 Adobe Street Concord, CA 94520 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some was to receive DuoNeb Solution 0.5-2.5 (3) MG(milligram)/3 ML (milliter) (Ipratropium-Albuterol) 1 application inhale orally every 4 hours for SOB (shortness of breath) related to COPD with (acute) exacerbation, rinse mouth after use. During an observation on 11/16/21, at 8:37 a.m., LVN 5 administered two puffs of Symbicort, Incruse Ellipta and DuoNeb via nebulizer to Resident 317. LVN 5 did not ask Resident 317 to rinse/ spit after administration of Incruse Ellipta and Symbicort. During an interview on 11/16/21, at 2:17 p.m., LVN 5 stated she did not ask Resident 317 to rinse and spit after administering the inhaler treatments. LVN 5 stated it was important to rinse and spit after each inhaled medication to prevent oral thrush. 3. During an observation on 11/16/21, at 9:59 a.m., LVN 4 administered one drop of Tetrahydrozoline HCI eye drop (a medication for eye irritation and redness) to left and right eye of Resident 23. During a record review of Resident 23's physician orders, dated 11/18/21, indicated Resident 23 was to receive Pataday Solution 0.2%, instill 1 drop in both eyes one time a day for itchy eyes related to other chronic allergic conjunctivitis (inflammation or infection of the outer membrane of the eyeball) for 6 weeks. During a record review of the facility's undated P&P titled, Administering Medications indicated, medications will be administered in a timely manner and as prescribed by the resident's attending physician or the facility's medical director. 4. During an observation on 11/16/21, at 9:59 a.m., LVN 4 administered one drop of Tetrahydrozoline HCI eye drop to the left and right eye of Resident 23. LVN 4 did not ask Resident 23 to keep his eyes closed after administering the eye drops. During an interview on 11/17/21, at 12:23 p.m., LVN 4 stated it was important to ask Resident 23 to keep his eyes closed after administering eye drops so the medication would stay in his eyes for better absorption. During a record review of the facility's undated P&P titled, Eye Drops which indicated, After instilling drops ask resident to close his/her eye and rotate his/her eyeball. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056260 If continuation sheet Page 6 of 6