Inspection·June 28, 2024

F 0803 Level of Harm - Minimal harm or potential for actual harm Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview, and facility document review, the facility failed to provide pureed vegetables according to the menu for residents receiving pureed diets. Residents Affected - Some This failure had the potential to result in decreased satisfaction with food and/or decreased nutrient intake for four out of five (Residents 29, 54, 3, 30) residents who received pureed diets. Findings: An observation in the kitchen and interview with the Dietary Supervisor (DS) and [NAME] (C) 1 on 6/24/24 at 10:25 a.m., showed metal pans in the oven. C1 stated the food in the metal pans included pureed carrots. C1 stated he placed the pureed food in the oven about 9:50. DS stated tray line normally started about 11:45 a.m. Review of the Diet Spreadsheet dated Monday Week 2 Cycle 17, showed the vegetables served for lunch on 6/24/24 were sliced carrots, and the pureed textured diets received pureed sliced carrots. During an observation and interview with DS on 6/24/24 at 12:45 p.m., test trays were conducted, and the regular textured and pureed textured food served to residents for lunch were sampled. The pureed carrots were flavorless and had an unpleasant gummy/sticky texture. The regular carrots tasted well-seasoned. DS confirmed the texture of the pureed carrots were gummy. DS also agreed the pureed carrots lacked flavor. During an interview on 6/25/24 at 9:35 a.m., C1 confirmed he prepared the carrots for served for lunch yesterday (6/24/24). C1 stated the regular textured carrots were cooked in the steamer then he put seasoning on the carrots including salt, pepper, paprika, and some garlic powder. C1 stated the for the pureed carrots, the carrots were boiled and pureed, and seasoning was not added. C1 stated he did not usually add seasoning to pureed vegetables. During an interview and concurrent document review of recipes on 6/25/24 at 9:40 a.m., DS stated the regular textured carrots should be pureed rather than preparing a separate batch of carrots for the pureed texture. DS confirmed according to the recipes the regular carrots were prepared, then pureed. Review of the recipe for sliced carrots dated 2/2/23 showed to ingredients included frozen sliced carrots, and seasoning - Signature Blend, Salt Free. Review of the recipe for Sliced Carrots (Puree) dated 1/7/2017, showed to prepare Sliced Carrots according to the recipe, then puree in a food processor. Review of the policy and procedure titled, Standardized Recipes, dated 2023, indicated standardized recipes will be used when preparing menu items. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056260 If continuation sheet Page 2 of 11 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 06/28/2024 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Based on observation, interview and facility document review, the facility failed to provide the texture of food prescribed for one resident (Resident 62). This failure had the potential to cause one Resident 62 to choke on the food provided out of 80 residents who received food from the kitchen. Findings: During a record review, Resident 62's admission Record showed Resident 62 was diagnosed with oropharyngeal phase dysphagia (swallowing problems occurring in the mouth and/or throat. During a record review for Resident 62, the Speech Therapy Treatment Encounter Note(s) dated 6/19/24 and 6/24/24 showed Resident 62 was assessed by SLP and current foods in both reports were Soft + Bite-Sized Foods SB6. A concurrent observation and document review during tray-line food service on 6/24/24 at 12:25 p.m., showed staff placed food on resident trays according to the physician prescribed diet printed on a tray ticket and the Diet Spreadsheet dated Monday Week 2 Cycle 17. The tray ticket for Resident 62 showed he was prescribed a Soft & Bite-Sized SB6, Mildly Thick Liquids, Renal diet. The spreadsheet showed the dessert for Soft & Bite Sized diets was Red Gelatin (cubes) and the dessert for Renal diets was 5 each Vanilla Wafers. Kitchen staff placed a cup filled with red gelatin and a cup filled with vanilla wafers broken up into bite-sized pieces, on Resident 62's tray then began placing food on the next resident tray. During a consecutive interview on 6/24/24 at 12:27 p.m., the Dietary Supervisor (DS) was asked if vanilla wafers were an appropriate texture for soft & bite sized diets. DS stated she needed to ask the Registered Dietitian. During an interview on 6/24/24 at 12:35 p.m., DS stated she spoke with the Speech Language Pathologist (SLP) who said Resident 62 should receive applesauce instead of cookies because the cookies might me too hard. During a virtual interview on 6/26/24 at 9:54 a.m., SLP stated vanilla wafers were not appropriate for as Soft & Bite Sized diet. SLP stated normally the wafers were soaked in milk to make them softer for the Soft & Bite Sized diet but milk was not appropriate for the Renal diet. SLP stated Resident 62 was edentulous (having to teeth) and if the resident attempted to eat the wafers he could have trouble chewing and might spit the wafers out or in the worst case scenario, could choke. SLP stated she noticed the menu spreadsheet used in the kitchen did not have IDDSI (International Dysphagia [difficulty swallowing] Diet Standardization Initiative; a global standard with terminology and definitions to describe texture modified foods and thickened liquids used for individuals with dysphagia of all ages, in all care settings, and for all cultures) for the Renal diet. Review of the facility's Dietary Manual dated 2020 and approved by the Administrator, Dietitian, Medical Director, and Director of Nursing in 2024, showed the IDDSI Soft and Bite Size (level 6, Blue) diet is indicated for the resident who has difficulty chewing or swallowing the food items included in the Regular diet . and is intended for residents who would benefit from foods that can be easily and safely chewed and swallowed. Food offered on this diet are soft, tender and moist with no separate thin liquids. Refer to a speech-language pathologist as needed. A RDN [Registered Dietitian (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056260 If continuation sheet Page 3 of 11 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 06/28/2024 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 0805 Level of Harm - Minimal harm or potential for actual harm Nutritionist] can individualize this diet to provide resident preferences in a modified form. The description of the diet showed foods should be soft enough to cut with a spoon, foods are to be moistened with small amounts of added liquid such as milk, to avoid hard or crunchy foods which may be difficult to chew. In addition, dry cookies were listed under the foods to avoid. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056260 If continuation sheet Page 4 of 11 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 06/28/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and facility document review, the facility failed to ensure food was stored and prepared in a safe and sanitary environment when: Residents Affected - Many 1. Kitchen Floors were not clean and maintained in good condition; 2. Chicken was not thawed safely; 3. The ice machine was not clean and was not cleaned according to manufacturer's instructions; 4. A can opener was not clean; and 5. Cutting boards were not clean and were in poor condition These failures had the potential to result in contamination of food, food preparation equipment, and utensils used for food, leading to food borne illness and/or food related illness for 80 residents who received food from the kitchen out of a census of 80. 1. An observation in the kitchen on 6/24/24 at 10:09 a.m., showed the floor between the reach in refrigerator and the warewashing sink with broken and missing tiles. The floor had an uneven surface. During an interview with the Maintenance Supervisor (MS) and a concurrent observation in the kitchen on 6/25/24 at 12:39 p.m., MS stated he was aware of the broken tiles throughout the kitchen floor. MS stated the floor was so old he could not get the same tiles to replace the cracked and missing tiles, so tried to replace with white tiles. Some of the smooth white tiles, MS used to replace the older tiles, were also cracked. Some tiles were loose. A loose tile on the floor between the warewashing sink and a reach-in refrigerator was moved and there were at least 7 insects under the tile. The insects were not identified but were long and thin, about an inch long. An observation in the kitchen and concurrent interview with DS on 6/25/24 at 12:52 p.m., showed black and brown residue build-up on the floor under the warewashing sink, closer to the wall. The tile floor under the sink did not come into contact with the wall so there was a gap of over an inch between floor tiles and the wall in some areas. DS stated the dark residue looked like food residue. DS stated the floor under the warewashing sink did not get cleaned. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056260 If continuation sheet Page 5 of 11 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 06/28/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many During an observation in the kitchen on 6/26/24 at 10:17 a.m., the floor under the warewashing sink was wiped with a white napkin and a significant amount of black/brown, sticky residue wiped off onto the napkin. During an interview on 6/26/24 at 10:25 a.m., the Administrator (Admin) stated she was aware of the condition of the floor in the kitchen and the floors were and ongoing project and the floors were part of QAPI (Quality Assurance and Performance Improvement). Admin was unable to state how long the floors were monitored in QAPI. Then Admin stated the kitchen floors were not picked up as an active PIP (Performance Improvement Project). Admin stated, the things being worked on in QAPI were things we know definitely need improvement which were typically related to clinical. Admin stated the facility did receive bids to fix the floor but there was no evidence provided by Admin to show the facility was moving forward with either of the two bids provided (flooring bids dated 2/15/24 and 2/20/24). On 6/26/24 at 11:17 a.m., MS stated he worked in the facility for seven years and the floor in the kitchen was already in poor condition when he started. MS stated the floors have gotten worse over time. Review of the facility's P&P titled Floor Safety dated 2023, showed floors will be maintained to maximize safety. Floors should be kept clean. According to the 2022 Federal Food Code, floors are to be designed, constructed, and installed so they are smooth and easily cleanable. In food establishments in which cleaning methods other than water flushing are used floor cleaning floors, the floor and wall junctures are to be coved and closed to no larger than one millimeter. Floors in which water flush cleaning methods are used, the floor and wall junctures shall be coved and sealed. In addition, premises are to be maintained free of insects. 2. An observation during the initial tour of the kitchen on 6/24/24 at 9:48 a.m., showed a large pan of raw chicken stored in a reach-in refrigerator. The label on the pan showed the preparation date was Sunday 6/23/24 and the use by date was 6/26/24. The label also showed SL: 3 days. The chicken was very soft to the touch and felt thawed. During an observation and interview with the Dietary Supervisor (DS) and [NAME] (C) 1 on 6/24/24 at 10:10 a.m., DS looked at the thawed chicken with the preparation date 6/23/24 and stored in the walk-in refrigerator. DS stated C1 placed the chicken in the refrigerator to thaw on Saturday 6/22/24 but changed the label on Sunday to show a preparation date of 6/23/24. Then DS stated if the chicken was placed in the refrigerator on Saturday, the label should show Saturday 6/22/24. C1 explained the chicken was leftover chicken from what was not used from a prior meal. DS and C1 explained the staff used a label making machine and the machine could only print a label showing the current date, not a past date. So, if staff used the label maker to make a new label for a food already being stored on a past date, such as the chicken, the label showed the current date, not the actual date the chicken was placed in the refrigerator. DS stated, in cases like this, staff had to make a handwritten label to show the correct date. During an interview on 6/24/24 at 10:17 a.m., C1 stated he remembered he had two batches of chicken thawing and the chicken he thawed on Saturday was already used and he placed a second batch of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056260 If continuation sheet Page 6 of 11 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 06/28/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many chicken to thaw in the refrigerator on Sunday. C1 stated he thawed the chicken with the preparation date label 6/23/24 under running water then he placed it back in the refrigerator to use on Tuesday 6/26/24. During an interview with C1 and DS on 6/25/24 at 8:55 a.m., C1 stated he was marinating the chicken observed in the refrigerator yesterday with the preparation date 6/23/24. Then he stated he thawed the chicken under running water this morning. C1 stated he did not measure the temperature of the running water when he thawed the chicken under the water. C1 stated it could take up to an hour to thaw raw chicken under running water. When C1 was asked if there was time/temperature documentation for the chicken for when he stated he thawed it under runner water the prior day and placed back in the refrigerator, C1 stated no. Then C1 stated he did not thaw the chicken under running water and only thawed the chicken in the refrigerator. Then DS confirmed she did hear C1 say he (C1) thawed the chicken under running water on Sunday (6/23/24) and placed it back in the refrigerator. DS confirmed there were no critical control points measured (time/temperature) to ensure the chicken was thawed and stored safely after being thawed under running water then placed back in the refrigerator to use on a future date. DS told C1 to discard the chicken from 6/23/24 which was being marinated for lunch and to thaw another batch of chicken. An observation and interview with C1 and DS on 6/25/24 at 9:46 a.m., showed C1 placed frozen chicken pieces in a metal pan and placed the pan in the food preparation sink and turned the water on so water flowed into the pan with the chicken. The chicken pieces did not fully fit inside the pan. So, when the water ran into the pan, the chicken was not submerged. The chicken pieces stuck out of the water over four inches. When C1 was asked if he measured the water temperature, he confirmed he did, and it was about 75 degrees Fahrenheit (F). When C1 and DS were asked if the chicken was being thawed appropriately, DS stated yes, because the chicken was under running water. When the surveyor pointed out the chicken was not fully submerged in the water. Then DS confirmed the chicken needed to be fully submerged in the water. DS measured the temperature of the water with a thermometer and stated the water was 76 degrees F. DS measured the running water temperature again with a different thermometer and stated the temperature was 75.4 degrees F. DS confirmed only the cold water was on and this was the coldest the water would get. Review of the facility's policy & procedure (P&P) titled General HACCP Guidelines for Food Safety, dated 2017, the P&P showed the time-temperature connection was limiting the time food is in the temperature danger zone (TDZ). Food must be held above 135 degrees F or below 41 degrees F. Limit the time that food is in the TDZ to no more than four hours combined total for all preparation (thawing, preparation, and re-handling). In addition, the P&P showed two safe thawing practices - a. thaw meat, fish and/or poultry in a refrigerator; b. completely submerge the item in clean running water (below 70 degrees F) that is running fast enough to agitate and float off loose ice particles. 3. During an observation in the kitchen with the Maintenance Supervisor (MS) on 12/25/24 at 12:26 p.m., MS described how he cleaned the ice machine. MS stated the ice machine was scheduled for cleaning once a month, but he actually cleaned it once a week. MS stated he sanitized everything on the ice machine. MS stated he opened the ice machine and wiped the evaporator plate (a metal grid inside the ice machine where water runs over then freezes to make ice cubes). Then MS stated a deep cleaning was done every six months. MS showed the chemical used for what he stated was sanitizing. The container of the chemical showed it was a Scale Remover for Ice Machines. MS showed the chemical container he stated he used for monthly cleanings. This chemical was Ice Machine Sanitizer. MS stated he did (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056260 If continuation sheet Page 7 of 11 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 06/28/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many the last weekly cleaning last Friday. MS stated he did not have the ice machine manufacturer's manual to show directions for cleaning the machine. As the observation and interview of the ice machine continued on 12/25/24 beginning at 12:26 p.m., MS opened the top of the ice machine and removed the evaporator plate cover. A white wire was attached to a plastic, rectangle piece attached to the plastic to the side of the evaporator plate. MS stated the plastic rectangle piece was a sensor. There was dark brown residue along the entire crevice of the wire and the and there was dark brown/black residue around the area of the sensor. MS stated he did not touch the sensor or wire when he cleaned the ice machine because it was very sensitive. It was noted the wire and the sensor were inside the ice machine over opening to the ice bin, where the ice was stored, and moisture droplets were formed on the parts of the upper inside area and could drip down into the ice. Review of the undated manufacturer's manual provided by MS for the ice machine titled [Ice machine brand] Installation and User's Manual for Modular Cuber [model numbers], showed to pour the ice machine scale remover into the reservoir and the unit will circulate the scale remover, then drain and flush. The directions also showed to locate two sensors, an ice thickness sensor as well as the water level sensor. The directions showed how to clean both sensors. The directions showed to thoroughly wash all surfaces of the ice thickness sensor and water level sensor with a sanitizer solution. In addition, all interior surfaces of the freezing compartment (excluding evaporator cover and right side panel liner) with sanitize solution. It was noted the directions did not indicate to wipe the evaporator with scale remover. According to the 2022 Federal Food Code, food-contact surfaces of equipment are to be clean to sight and touch. Nonfood-contact surfaces are to be kept free of an accumulation of dust, dirt, and other debris. 4. An observation and interview at 9:50 a.m., showed an industrial can opener held in a base attached to a food preparation table. The green insert inside the base had black, brown, and white residue and particles on the subsurface. In addition, the can opener blade had black and brown, sticky residue imbedded line crevice where the blade attached to the base of the can opener. DS stated the can opener was just cleaned this morning by running it through the dish machine. DS stated she did not consider the blade clean, and the dishwasher could rerun it through the machine if it did not come out clean. DS confirmed the base was not clean. DS also stated the can opener holder was cleaned every three months but if it was soiled prior to three months it needed to be cleaned as needed. Review of the facility's P&P titled Cleaning Instructions: Can Opener dated 2023, showed the can opener will be cleaned after each use. To clean a handheld can opener, clean in sink filled with soapy water. Pay special attention to the blade and moving parts. Use a brush to get into the crevices. Rinse, sanitize, and air dry. In addition, remove the rubber insert. Clean in a sink filled with soapy water. Rinse, sanitize, and air dry. According to the 2022 Federal Food Code, food-contact surfaces of equipment are to be clean to sight and touch. Nonfood-contact surfaces are to be kept free of an accumulation of food residue and other debris. 5. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056260 If continuation sheet Page 8 of 11 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 06/28/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many An observation in the kitchen and concurrent interview with DS on 6/24/24 at 11:40 a.m., showed seven acrylic cutting boards stored in a rack. Three of seven cutting boards were significantly scratched with plastic coating peeling off the surfaces. One of the three scratched cutting boards had black residue imbedded in the surface of both sides of the board. Another of the three scratched cutting boards, which was green, had white residue build-up on the surface which scraped off. This board was so scratched almost the entire board appeared white. DS stated cutting boards were replaced as needed. DS stated the scratched cutting boards were overused and two of the scratched cutting boards were dirty. Review of the P&P titled Cleaning Instructions: Cutting Boards dated 2023, showed cutting boards will be cleaned and sanitized after each use. Cutting boards should be replaced when the surface is deeply scored. According to the 2022 Federal Food Code, multiuse food-contact surfaces are to be clean be smooth and free from inclusions, pits, and similar imperfections. Food-contact surfaces of equipment are to be clean to sight and touch. Surfaces such as cutting boards that are subject to scratching and scoring are to be resurfaced if they can no longer be effectively cleaned and sanitized, or discarded if they are not capable of being resurfaced. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056260 If continuation sheet Page 9 of 11 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 06/28/2024 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 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure: 1. Family members could bring in food for residents. Residents Affected - Many 2. Residents had a location to safely store perishable food. 3. A policy described the safe storage of food brought in by family members. This failure had the potential to result in foodborne illness from unsafe food storage, decreased food intake, and did not create a homelike environment for 80 residents who took food by mouth out of a census of 80. Findings: During an interview on 6/24/24 at 11:21 a.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated that the facility did not have any refrigerators to store resident food in, and perishable foods were thrown away. During an interview on 6/24/24 at 11:25 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 confirmed that there was no refrigerator on the unit to store food in, and that perishable resident food was thrown away if the resident did not want to consume the food at the time it was provided. During an interview on 6/24/24 at 11:27 a.m., the Assistant Director of Nursing (ADON) stated typically perishable food brought in by family members was not stored for residents. ADON stated the family members were asked not to bring food in for residents. During an interview on 6/24/24 at 11:29 a.m. with the Director of Nursing (DON), the DON stated food is brought in for residents by family members was not stored and the facility let family members know there was not a refrigerator to store food. DON stated family was asked not to bring food in food to the facility. DON stated once food enters the Resident room it was contaminated. When DON was asked if food that did not enter the resident room could it be stored, DON stated the facility did not have a refrigerator. During a review of the facility's policy and procedure titled Food Brought by Family/Visitors, undated, the policy indicated family members should inform nursing staff of their desire to bring food into the facility. The Clinical Dietitian or a Nurse Supervisor should assure that the food is not in conflict with the resident's prescribed diet plan. Perishable foods must be discarded after an appropriate time (specific to food and temperature). It was noted this policy did not describe how to safely store food brought in by family and visitors. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056260 If continuation sheet Page 10 of 11 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 06/28/2024 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 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure all equipment was maintained in good working order when one of three freezers did not maintain food frozen solid. Residents Affected - Few This failure to improperly store food had the potential to result in decreased quality of food as well as foodborne illness to residents receiving food from the kitchen. Findings: During an observation on 6/24/24 at 9:29 a.m., the temperature of freezer 1 was 19 degrees Fahrenheit (F). Items inside the freezer, including individual cartons of supplement shakes and pie crusts were soft to the touch and not frozen solid. During a concurrent observation and interview on 6/24/24 at 10:05 a.m. with the Dietary Supervisor (DS), freezer 1 and its contents were observed again. Seven uncooked pie dough crusts labeled with a received date of 4/22/24 were all noted as being soft to the touch, along with 2 angel food cakes labeled with a received date of 5/24/24. The DS then opened two health shakes stored in the freezer, which were not frozen solid and had a gooey, pudding-like consistency and ice build-up on the surface. The DS stated the shakes should not be this consistency and should be frozen solid. During a concurrent observation and interview on 6/26/24 at 9:20 a.m. with the DS, freezer 1 was 20 degrees F. During a review of the facility's policy and procedure (P&P) titled Food Storage, dated 2017, the policy indicated All freezer units will . be kept in good working condition at all times . and Frozen foods must be maintained a temperature to keep the food frozen solid. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056260 If continuation sheet Page 11 of 11