Health inspection·January 8, 2026

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, for one of two sampled residents (Resident 6) who were reviewed for accidents, the facility failed to ensure two staff were present and bed rails were provided during incontinent care (providing support for individuals who cannot control their bladder or bowels) when Certified Nursing Assistant (CNA) 2 let go of Resident 6, with no bed rail to hold onto. Resident 6 fell out of bed and sustained fracture of the surgical neck of the left humerus with fracture line extension to the greater tuberosity (left shoulder fracture).During a review of Resident 6's admission Record (AR) dated 1/5/26, the AR indicated Resident 6 was admitted to the facility in November 2025 with multiple diagnoses that included hemiplegia (paralysis that affects only one side of the body) affecting right dominant side, and morbid obesity (severe obesity, excessive fat stores and a body mass index of 40 or higher (BMI, a measure of body fat based on height and weight, normal BMI 18.5-24.9).During review of Resident 6's Minimum Data Set (MDS, an assessment tool used to direct resident care) assessment dated [DATE], the MDS indicated a Brief Interview for Mental Status (BIMS, a scoring system used to determine the resident's cognitive [mental processes involved in gaining knowledge and comprehension] status regarding attention, orientation, and ability to register and recall information) score of 15. A BIMS score of 13-15 is an indication of intact cognitive response.During a concurrent observation and interview on 1/5/26 at 10:38 a.m. with Resident 6, in the hallway close to Resident 6's room, Resident 6 wore a sling on the left arm. Resident 6 stated she had to wear it after falling two weeks after admission to the facility. Resident 6 stated falling out of bed when CNA 2 placed her in a right-side lying position but did not instruct her to hold onto anything. Resident 6 was unsure if there was a bed rail. Resident 6 stated she rolled out of bed, landing on her left side, and experienced immediate significant pain in the left shoulder after the fall. Resident 6 stated she was then sent to the hospital for treatment.During a review of Resident 6's Progress Notes dated 12/2/25, the Progress Notes indicated, on 12/2/25, at 5:20 a.m., CNA 2 Noticed that the resident had fallen. The Progress Notes further indicated, Resident 6 was turned on her side near the edge of the bed and slid off, resulting in the fall. Resident 6 was transferred to the hospital for further evaluation due to concern of possible injury or fracture.During a review of Resident 6's Emergency Department (ED) Provider Notes dated 12/2/25, the ED Notes indicated Resident 6 sustained an impacted (bone pieces are jammed together) fracture of the surgical neck with extension to the greater tuberosity (fracture of the left shoulder) and had been placed in a sling.During a telephone interview on 1/6/26 at 11:21 a.m. with CNA 2, CNA 2 stated, on 12/2/25, around 5-5:30 a.m., CNA 2 went to Resident 6's bedside to provide incontinent care. CNA 2 stated he informed Resident 6 of his intention to change her, to which Resident 6 responded with a faint mumble. CNA 2 stated he proceeded to change Resident 6 and her bed linen, which were soaked with urine. CNA 2 described himself as a tall person. CNA 2 stated he raised the bed height to his waist level and positioned himself on Resident 6's left side. CNA 2 then requested Resident 6 to turn to her right side (CNA 2 faced Resident 6's back) while he applied the fitted sheet to the foot of the bed. During this process, CNA 2 stated he observed Resident 6's legs began to slide towards the edge of the bed before she turned completely to her right and rolled out of bed. CNA 2 stated he reached over the bed to prevent Resident 6 from falling but found it difficult due to Resident 6's weight and her deep sleep state, Like she was in a deep coma. CNA 2 stated he was not familiar with Resident 6's care as it was his first assignment with her and that he did not receive any report or instructions from the charge nurse at the start of the shift. CNA 2 also stated he tried to ask assistance from other staff, but none (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056260 If continuation sheet Page 2 of 17 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 01/08/2026 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 0689 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete were available as they were all occupied. CNA 2 stated there were no rails attached to Resident 6's bed.During a review of Resident 6's bed mobility care plan, undated, the care plan indicated interventions that included providing quarter rails on both sides of the bed to enable positioning and increase mobility. During a telephone interview on 1/7/26 at 9:18 a.m. with Licensed Vocational Nurse (LVN) 3, LVN 3 stated CNA 2 did not ask for help and only informed her after Resident 6 had fallen out of bed.During a review of Resident 6's IDT (Interdisciplinary Team, a group of individuals representing different departments of the facility): Post Accident/Fall (IDTPA), undated, the IDTPA indicated, improper positioning during care, specifically placing the resident too close to the mattress edge while turning, likely contributed to the fall. To prevent re-occurrence, the follow-up measures included reinforcing proper bedside positioning techniques and re-educating CNAs on continuous physical support during turns.During a review of the facility's policy and procedure (P&P), titled Repositioning, undated, the P&P indicated, to reposition a resident in bed, check the care plan for resident's specific positioning needs and the resident's level of participation, lower the side rails (if applicable) on the side where you are standing, use two people and a draw sheet to avoid shearing (when layers of skin tissue slide in opposite directions, damaging blood vessels and deep tissue, like sliding down in a chair or bed) while turning resident in bed, encourage the resident to participate if able, and encourage the resident to hold the side rail with the top arm in the direction of the turn.During an interview on 1/8/26 at 11:10 a.m. with Director of Staff Development (DSD), DSD stated, CNA 2 should have called for help, communicated with the charge nurse of his inability to get help from another staff, and ensured Resident 6 was fully awake before providing care. DSD stated, following the fall incident, CNA 2 was removed from the schedule and not allowed to return to work Event ID: Facility ID: 056260 If continuation sheet Page 3 of 17 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 01/08/2026 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview and record review, the facility failed to ensure safe pharmaceutical services with census of 82 residents when:Non-narcotic prescription drugs destruction was not witnessed by two licensed staff from April 2025 to August 2025.Hazardous drugs (or HD, medication that can cause harm posing risks to healthcare workers and patients through exposure during handling) were not stored and handled safely in the medication carts and during medication administration.These failed practices had the potential to result in drug diversion (unauthorized drug use) and unsafe drug handling for both staff and residents.Findings1. During an interview and record review, with Licensed Nurse (LVN 9), on 1/5/26 at 10:29 a.m., in Med Room on Station 2, LVN 9 stated non-narcotic prescription medications were disposed every 2 weeks and logged in the non-narcotic drug logbook. LVN 9 stated the disposal of non-narcotic drug form required only a one-person signature. LVN 9 confirmed there was only one signature on the non-narcotic drug disposal for April 2025 through August 2025.During a review of the facility's logbook, titled Non-Narcotic Destruction, with date range of April 2025 through August 2025, the Non-Narcotic logbook indicated the medication destruction were not witnessed by two-person signatures for the stated dates.During an interview, on 1/6/26 at 3:30 p.m., with Director of Nursing (DON), the DON confirmed non-narcotic drug destruction occurred monthly, every other Sunday, and the form required two - person signatures as witness. The DON confirmed the Non-Narcotic Destruction Logbook dated April 2025 through August 2025, had only one signature.2. During concurrent medication cart inspection and interview, on 1/5/26 at 10:00 a.m., on station 2, with Licensed Psychiatric Technician (LPT), the medication cart stored multiple liquid bottles of a hazardous medication called valproic acid (drug used to treat mood disorder and seizure). The valproic acid bottles were labeled with NIOSH-2 warning (National Institute for Occupational Safety and Health, a federal agency that ensures safety of handling hazardous material for health care workers) and one bottle had red color medication dripping on the outer surface of the product and the label. Further observation indicated that none of the bottles were stored in a Ziplock bag to prevent contamination. LPT stated she did not know what the label NIOSH-2 was for and was not aware of safe handling.During a concurrent medication administration observation and interview with Licensed Nurse (LVN 1), on 1/6/25 at 9:17 a.m., LVN 1 was observed administering a hazardous medication called spironolactone (blood pressure drug) that was labeled as NIOSH to Resident 33 without use of protective gloves. LVN 1 stated she did not know what NIOSH label meant and did not recall having an in-service on how to handle hazardous medications.During an interview, on 1/6/26 at 3:30 p.m., with Director of Nursing (DON), the DON stated that the needed to look into how to address handling hazardous drugs commonly used in the facility. The [NAME] stated it was safe to use gloves when handling any hazardous drugs. During a review of the facility's policy and procedure, titled Hazardous Drugs, dated April 2019, the policy indicated Any staff member who comes in contact with hazardous drugs are trained and exhibit competency in handling these drugs according to current safety and practice standards (according to manufacture guidance and drug package inserts). Hazardous drug handling areas are clearly marked with signs designating the hazard. Hazardous drugs are labeled, stored and transported in accordance with current USP (the United States Pharmacopeia) standards. Staff are trained on and required to wear personal protective equipment (PPE, includes gloves, mask, or gown) specific to the risk of exposure and activities preformed.During a review of the facility's policy and procedure, titled Pharmacy Services Overview, dated April 2019 the policy and procedure indicated Pharmaceutical services consist of the provision of medication related information to health care professionals. Medications are received, labeled, stored, administered and disposed of according to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056260 If continuation sheet Page 4 of 17 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 01/08/2026 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete all applicable state and federal law and consistent with standard of practice. The consultant pharmacist in collaboration with the dispensing pharmacy and facility oversees the development of procedures related to pharmacy services, including labeling and storage of medications and training and competency of personnel.Review of the Center for Disease Control's National Institute for Occupational Safety and Health (CDC, and NIOSH, a federal agency sets standard of safety in health care) document, titled Managing Hazardous Drug Exposures: Information for Healthcare Settings, dated 4/2023, the document indicated Many . drugs intended for individual use can be hazardous to healthcare workers with potential occupational exposure to those who handle, prepare, dispense, administer, or dispose of these drugs. Workplace exposure to hazardous drugs can result in negative acute and chronic health effects in healthcare workers including adverse reproductive outcomes. PPE (or Personal Protective Equipment, items like glove or mask) provides worker protection to reduce exposure to hazardous drugs. Efforts should be made to reduce all worker exposures to hazardous drugs. Occupational exposure to hazardous drugs merits serious consideration, as workers may be exposed daily to multiple hazardous drugs over many years. Further review of the document indicated to use single glove for handling intact tablet form and double glove for handling oral liquid form of the hazardous medications as directed. Event ID: Facility ID: 056260 If continuation sheet Page 5 of 17 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 01/08/2026 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm Based on interviews and record reviews, the facility failed to ensure medication use parameters ordered by the doctor were followed in 3 out of 30 sampled residents (Resident 4, Resident 6, and Resident 9) when:Resident 4's blood sugar parameters for insulin (drug in shot form to treat blood sugar disease) were not followed as ordered by medical doctor.Resident 6's opioid medication use did not follow the pain level ordered by the medical doctor.Resident 9's blood pressure drug parameter was not followed.These failed practices could contribute to unsafe medication use and residents not benefiting from prescribed medication and/or experience side effects.1. During a record review of the Resident 4's Order Summary Report, dated 1/8/26, the record indicated the following orders: NovoLOG Flex Pen Subcutaneous (or SC, inject under the skin) solution Pen-Injector (or Flex Pen, a pen shaped insulin container) . (insulin Aspart, a short acting insulin): Inject 3 units subcutaneously with meals . hold if patient doesn't eat meal; Start date: 10/21/25 (Novolog is a type on insulin, unit is a measure of insulin dose). Hypoglycemia protocol (low blood sugar guide)- Able to take PO (orally): follow 15/15 rule: Give 15 gm ( gm is gram, a unit of measure) fast acting carbohydrate as needed for hypoglycemia; blood sugar less than 70 mg/dL (normal blood sugar is 80-120, mg/dL is milligram per deciliter, a measure of blood sugar level); may repeat in 15 minutes.The orders did not specify any parameter for hyperglycemia or when the nursing staff should call the doctor for further guidance.During a record review of the Resident 4's Medication Administration Record (or MAR), dated 12/2025, the MAR record indicated insulin was held and noted as No Med Required-Outside Parameters as follow:12/4/25 at 5 PM for BG (Blood Sugar) of 97 (Thursday)12/5/25 at 5 PM for BG of 111(Friday)12/6/25 at 7 AM for BG 89 (Saturday)12/16/26 at 5 PM for BG of 108 (Tuesday)12/19/25 at 5PM for BG of 92 (Friday)12/21/25 at 12 noon for BG 99 (Sunday)12/24/25 at 12 noon for BG 87 (Wednesday)12/25/25 at 5 PM for BG 107 (Thursday)12/28/25 at 5 PM for BG 99 (Sunday)The nursing notes did not reflect on why the doses were held or if the medical doctor was contacted. 2. During a record review of the Resident 6's Medication Administration Record (or MAR), dated 1/2026, the MAR record indicated patient was receiving a pain medication called Norco (an opioid pain killer) as follow: Hydrocodone-Acetaminophen oral tablet 5-325 MG (same as Norco, a combination of opioid and plain Tylenol in one pill; MG is milligram, a unit of measure); Give 1 tablet by mouth every 6 hours as needed for Moderate pain 4-7, severe pain 8-10 ( pain level intensity is from 1 to 10, and 10 being the most painful) .; start date 12/3/25Further review of the MAR record indicated the pain medication was administered to Resident 6 when pain level was documented as zero (no pain) on the following days:1/3/26 at 8:25 PM, 1/4/26 at 7:59 PM, 1/5/26 at 8:48 PM, and 1/6/25 at 8:34 PM. 3. During a record review of the Resident 9's Medication Administration Record (or MAR), dated 1/2026, the MAR record indicated patient was receiving a medication with safety parameters called midodrine (help raise the blood pressure due to the disease process causing low blood pressure that could contribute to fall or other risks) as follow: Midodrine (drug help raise blood pressure) oral tablet 5 MG; Give 1 tablet by mouth every 8 hours for hypotension (low blood pressure); hold if SBP > (more than) 130 mmHg ( mmHg a measure blood pressure); start date:9/9/25Further review of MAR record indicated the midodrine hold parameters were not followed on 1//1/26 at 11 PM for BP of 139/84 mmHg, and on 1/2/26 a 3 PM for BP of 146/89 mmHg. In an interview with Licensed Nurse 4 (LVN 4), on 1/8/26, at Nurse Station number 1 , LVN 4 stated she followed the hold parameters for insulin when written in MAR and it was easier to address the parameters at the point of administration rather than going back and forth to other areas of the patient's record. LVN 4 stated she measured the blood pressure prior to giving any medication affecting blood pressure with parameters. LVN 4 stated pain level was documented in the MAR every time a pain medication was given, and they Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056260 If continuation sheet Page 6 of 17 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 01/08/2026 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 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete needed to do a follow up to see if resident was pain free or comfortable. In a concurrent record review and interview with Director of Nursing (DON), in his office, on 1/8/26, at 1:20 PM, the DON reviewed the nursing hold parameters documentation for Resident 4, Resident 6, and Resident 9. The DON stated the nursing staff should have clarified the orders with medical provider and followed the order if parameters were in place.A review of facility policy, titled Administering Medications, dated 2001, the policy indicated Medications are administered in a safe and timely manner, and as prescribed. The policy on section 4 indicated Medications are administered in accordance with prescriber order, including any required time frame. Event ID: Facility ID: 056260 If continuation sheet Page 7 of 17 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 01/08/2026 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview and record review, the facility failed to ensure safe storage of medications and supplies with expired, unlabeled and comingled drugs in the medication's rooms and medication carts with resident census of 82.These unsafe practices had the potential for residents to receive medications with reduced potency and may contribute to medication errors.During an observation and concurrent interview, on 1/5/26 at 10:35 a.m., with License Vocational Nurse (LVN 9), in medication room on Station 2 , the following were observed:i. Comingled medications with different routes of administration were stored on the same shelf with no dividers. Medication included liquid prescription drugs, non-prescription pills were stored side by side with topical product such as topical head lice drug along with enema and rectal suppositories.ii. Expired medications and supplements were stored in the cabinets included: packages of Beneprotein (instant protein powder) with expiration date of 5/2025, Ingress (drug for movement disorder) with expiration date of 12/06/25, Nicotine gum (used to quit smoking) box with expiration date of 12/31/25, and opened single use sterile bottles of normal saline irrigation bottles when the label indicated to discard after opening.LVN 9 acknowledged the findings and removed the outdated products.During an observation and interview, on 1/5/26 at 11:27 a.m., with LVN 10, in medication room on Station 1, there were 3 bottles of hand sanitizer with an expiration date of 2022. LVN 10 confirmed the findings and stated that the expired items should have been thrown out.During an observation and concurrent interview, on 1/5/26 at 10:35 a.m., with License Vocational Nurse (LVN 9), in medication room on Station 2, the following were observed:i. Comingled medications with different routes of administration were stored on the same shelf with no dividers. Medication included liquid prescription drugs, non-prescription pills were stored side by side with topical product such as topical head lice drug along with enema and rectal suppositories.ii. Expired medications and supplements were stored in the cabinets included: packages of Beneprotein (instant protein powder) with expiration date of 5/2025, Ingress (drug for movement disorder) with expiration date of 12/06/25, Nicotine gum (used to quit smoking) box with expiration date of 12/31/25, and opened single use sterile bottles of normal saline irrigation bottles when the label indicated to discard after opening.LVN 9 acknowledged the findings and removed the outdated products.During an observation and interview, on 1/5/26 at 11:27 a.m., with LVN 10, in medication room on Station 1, there were 3 bottles of hand sanitizer with an expiration date of 2022. LVN 10 confirmed the findings and stated that the expired items should have been thrown out.During an inspection of Medication cart 1C, and interview with LVN 10, on 1/5/26 at 11:4 a.m., the medication cart stored the following:i. Opened and undated bottle of test strip used to measure blood sugar when the product label indicated to discard the bottle 90 days after first opening it.ii. Duoneb (inhalation medication brand name) packaging was open, and outer wrap was exposed and had an open date of 12/22/25. The drug label instructions on the box indicated to discard 2 weeks after opening.LVN 10 confirmed the findings and stated the medication should have been thrown out and reordered.During an inspection of treatment cart (cart stored medication and supplies for wound care) and interview with Registered Nurse (RN 2), on 1/5/25 at 12:15 p.m., at station 1 hallway, the treatment cart stored an opened packet of ‘Aquacel advantage sterile dressing package (supply used to treat wound), and an expired box of Adaptic non adhesive dressing ( wound care product) expired on 10/ 31/2024. RN 2 confirmed the findings and stated that the open sterile dressing and the expired items should have been thrown out.During an interview, on 1/6/26 at 3:30 p.m., with Director of Nursing (DON), in his office, the DON stated the expectation was for the nurses to follow the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056260 If continuation sheet Page 8 of 17 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 01/08/2026 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete medication storage room and medication cart cleaning schedule and procedure. The medication room and cart cleaning/audit schedule indicated what aspects of the medication room and cart should have been addressed. The night shift was responsible for ensuring medication were not comingled, expired medications were removed, the medication area were cleaned and organized, and the medication carts were audited for expired and unlabeled drugs or products. DON stated the expectation was for the wound treatment nurses to clean their carts and dispose of open and expired items.During review of the facility policy and procedure, titled Administering Medications, dated 2001, the policy indicated when opening a multi-dose container, the date opened is recorded on the container. Vials labeled as single dose, or single use' are not used on multiple residents. Such vials are used only for one resident in a single procedure.During review facility policy titled Medication, Labeling and Storage dated 2007, the policy indicated multi dose vials that have been opened or accessed are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial. Medications for external use, as well as hazardous drugs and biologicals, are clearly marked as such, and are stored separately from other medications.During an inspection of Medication cart 1C, and interview with LVN 10, on 1/5/26 at 11:4 a.m., the medication cart stored the following:i. Opened and undated bottle of test strip used to measure blood sugar when the product label indicated to discard the bottle 90 days after first opening it.ii. Duoneb (inhalation medication brand name) packaging was open, and outer wrap was exposed and had an open date of 12/22/25. The drug label instructions on the box indicated to discard 2 weeks after opening.LVN 10 confirmed the findings and stated the medication should have been thrown out and reordered.During an inspection of treatment cart (cart stored medication and supplies for wound care) and interview with Registered Nurse (RN 2), on 1/5/25 at 12:15 p.m., at station 1 hallway, the treatment cart stored an opened packet of ‘Aquacel advantage sterile dressing package (supply used to treat wound), and an expired box of Adaptic non adhesive dressing ( wound care product) expired on 10/ 31/2024. RN 2 confirmed the findings and stated that the open sterile dressing and the expired items should have been thrown out.During an interview, on 1/6/26 at 3:30 p.m., with Director of Nursing (DON), in his office, the DON stated the expectation was for the nurses to follow the medication storage room and medication cart cleaning schedule and procedure. The medication room and cart cleaning/audit schedule indicated what aspects of the medication room and cart should have been addressed. The night shift was responsible for ensuring medication were not comingled, expired medications were removed, the medication area were cleaned and organized, and the medication carts were audited for expired and unlabeled drugs or products. DON stated the expectation was for the wound treatment nurses to clean their carts and dispose of open and expired items.During review of the facility policy and procedure, titled Administering Medications, dated 2001, the policy indicated when opening a multi-dose container , the date opened is recorded on the container. Vials labeled as single dose, or single use' are not used on multiple residents. Such vials are used only for one resident in a single procedure.During review facility policy titled Medication, Labeling and Storage dated 2007, the policy indicated multi dose vials that have been opened or accessed are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial. Medications for external use, as well as hazardous drugs and biologicals, are clearly marked as such , and are stored separately from other medications. Event ID: Facility ID: 056260 If continuation sheet Page 9 of 17 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 01/08/2026 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 0800 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. Based on observation, interview, and facility document review, the facility failed to provide an accurate and complete diet manual reference for all diets provided in the facility.This failure had the potential to result in residents receiving diets that do not match physicians' orders. Findings:During a concurrent observation and interview on 1/06/2026 at 11:28 a.m. with Restorative Nursing Assistant/ Certified Nursing Assistant 1 (RNA/CNA 1) at the nursing station, RNA/CNA 1 could not locate the diet manual. Once RNA/CNA 1 received assistance, she was able to locate the manual. RNA/CNA 1 stated that she could not locate the information for the soft and bite size (SB6) diet in the diet manual. RNA/CNA 1 stated that she would not know where to find the information if she had questions about the diet.During a review of the facility's Generations Diet Manual for Bayberry Community, dated 10/20/25, the diet manual did not include information on the puree, soft and bite size (SB6) and minced and moist diets.During a review of the facility's Diet Spreadsheet (a sheet containing the kind and amount of food each diet would receive) dated Tuesday Week 2 Day 11, the diet spreadsheet indicated puree, SB6 and minced and moist diets.During an interview on 1/06/2026 at 11:35 a.m. with Registered Dietitian (RD 1), RD 1 stated, that he approved the diet manual 10/20/25 and acknowledged that the diet manual does not include information regarding the puree, SB6 and minced and moist diets. RD 1 stated, the mechanically altered diet information should be included so that the nurses have a reference. RD 1 was not aware of who provided the diet manual or the diet spreadsheets. Event ID: Facility ID: 056260 If continuation sheet Page 10 of 17 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 01/08/2026 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete 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 mechanically altered foods according to the menu for SB6 diets (a therapeutic, texture-modified eating plan for individuals with swallowing difficulties, weak chewing muscles, or high choking risks).This failure had the potential to result in decreased satisfaction with food and/or decreased nutrient intake for one out of six (Resident 26) residents receiving SB6 diets.Findings:During a review of Diet Spreadsheet, dated Tuesday Week 2 Day 11, the diet spreadsheet indicated the SB6 diet served for lunch was beef stroganoff (minced), egg noodles (chopped), spinach (chopped), white bread (slurry), cookie (chopped).During a concurrent observation and interview on 1/06/2026 at 12 p.m. with DC in the kitchen during trayline, Resident 26's tray contained chopped pieces 1/2 inch in length of beef stroganoff, chopped macaroni noodles, chopped spinach, slurry bread and a regular cookie. DC stated that the items on the tray do not match the diet spreadsheet for SB6 diet.During a review of the facility's policy and procedure (P&P) titled, Menus, dated March 2023, the P&P indicated, menus are planned to meet the nutritional needs of the residents in accordance with the physician's diet order, the approved diet manual, federal/ state regulations.On 1/07/2026 11:00 am, the Registered Dietitian 2 (RD 2) was informed and acknowledged the above findings. Event ID: Facility ID: 056260 If continuation sheet Page 11 of 17 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 01/08/2026 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 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. Based on observation, interview, and facility document review, the facility failed to prepare foods in a form designed to meet individual needs, as hard candy was found on resident's meal tray with a physician's order for SB6 diet (a therapeutic, texture-modified eating plan for individuals with swallowing difficulties, weak chewing muscles, or high choking risks). These failures had the potential to result in difficulty swallowing, chewing, and a decrease in food and nutrient intake in one out of six (Resident 26) residents receiving SB6 diets.Findings:During a concurrent observation and interview on 1/5/2026 at 12:24 p.m. with Resident 26 in her room, the lunch meal tray was on the bedside table in front of the resident. The meal tray contained all appropriate items in addition to two pieces of wrapped hard candy. Resident 26 stated The people who brought me the tray brought me the candy.During an observation on 1/5/2026 at 12:26 p.m. in Resident 26's room, Licensed Vocational Nurse 8 (LVN 8) walked in the room, delivered a container of Ensure (oral nutritional drink to help people meet their daily nutritional needs with regular food intake is insufficient) on the resident's meal tray and walked out of the room without acknowledging the hard candy on the meal tray.During an interview on 1/5/2026 at 12:28 p.m. with Certified Nursing Assistant 3 (CNA 3), CNA 3 who delivered the tray stated, the candy shouldn't be on the tray and she didn't know how it got there.During an interview on 1/5/2026 at 12:30 p.m. with LVN 8, LVN 8 confirmed that Resident 26 had a diet order of SB6 and that residents on a SB6 diet shouldn't receive candy.During a review of Resident 26's Order Summary Report, dated 1/7/26, the Order Summary Report indicated, Resident 26 had an order for Regular Diet Soft and Bite-Sized texture, Thin Liquids consistency, Aspiration (the act of breathing in or drawing fluid into the lungs) precautions; Extra sauce or gravy on the side, straw ok, chopped meat for diet.During a review of the facility's diet spreadsheet titled Generations Health Care Menu Week 2 Day 10 Monday Lunch, dated 1/5/2026, the diet spreadsheet indicated residents on a SB6 diet would include the following foods on the meal tray:-V8 juice-Chicken thigh chopped-Mashed potatoes-Green peas-Apricot halves chopped-Poultry gravy-2% MilkDuring a review of the facility's P&P titled, Menus, dated March 2023, the P&P indicated, menus are planned to meet the nutritional needs of the residents in accordance with the physician's diet order, the approved diet manual, federal/ state regulations.During a review of the IDDSI guideline website titled IDDSI, dated 1/2019, the IDSSI guideline indicated, Level 6 Soft and Bite Sized should avoid foods with chewy characteristics such as lollies/ candies/ sweets. Event ID: Facility ID: 056260 If continuation sheet Page 12 of 17 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 01/08/2026 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 - Some FORM CMS-2567 (02/99) Previous Versions Obsolete 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:1. Gloves were not used appropriately;2. Food preparation equipment and utensils were not clean or in good working condition;3. Ice machine bin was dirty and not cleaned per manufacturer instructions;These failures had the potential to result in contamination of food, food preparation equipment, and utensils used for food and/or leading to food borne illness for 78 residents who received food from the kitchen with a total census of 78.1.During an observation on 1/06/2026 at 12 p.m. in the kitchen during meal tray line, Dietary Aide (DA) used his gloved hands to touch a container of oil, handles on refrigerator, dial on stove and then touched ready to eat hamburger buns and cheese.During a review of the facility's P&P titled, Food Preparation, dated 2023, the P&P indicated, plastic gloves should be worn to avoid direct contact with food.Hands must be washed prior to putting on gloves and any glove changes.During a review of the facility's P&P titled, Sanitation and Infection Control, dated 2023, the P&P indicated, use tongs and utensils for handling and preparing food instead of hands.According to the 2022 Federal Food Code, if used, single-use gloves shall be used for only one task such as working with ready-to-eat food or with raw animal food, used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation.2. During a concurrent observation and interview on 1/05/2026 at 10:00 a.m. with DC in the kitchen, the following was observed and confirmed by DC:- Refrigerator 1 with rusty shelves sheet pans with grime and black residue.- Two sheet pans with grime and black residue.- Two large frying pans with thick black residue.- Three cutting boards were heavily marred.During a review of the facility's P&P titled, Sanitation and Infection Control, dated 2023, the P&P indicated, the facility follow procedures to ensure sanitized utensils and equipment are being used.During a review of the facility's P&P titled, Food Preparation, dated 2023, the P&P indicated, the sinks, cutting boards, utensils and equipment will be cleaned and sanitized after each use and cutting boards may be nonporous acrylic and in good condition without deep cuts.3. During a concurrent observation and interview on 1/5/2026 at 2:07 p.m., with Maintenance Supervisor (MS) in the kitchen near the ice machine. MS stated that he cleans the ice machine weekly and monthly. MS explained the process used to clean the ice machine. MS opened up the machine's front panel, and the contents were visibly clean. MS stated that the vendor cleans the ice machine, including the bin, every six months. MS stated that ice removal and bin cleaning occur only during the vendor's 6-month service. MS stated he does not remove the ice or clean the bin when he does the weekly and monthly cleaning of the ice machine. MS put on gloves and wiped the ice bin with a clean white towel. The white towel had black particles from the bin of the ice machine. The MS acknowledged the white towel had dirt from wiping the bin.During a review of the Scotsman Ice Systems User's Manual, dated October 2014, the manual indicated it is the user's responsibility to keep the ice machine and ice storage bin in a sanitary condition. Without human intervention, sanitation will not be maintained.Sanitize the ice storage bin as frequently as local health codes require, and every time the ice machine is cleaned and sanitized.During a review of the Smart Care Planned Maintenance of Ice Machine report, dated 11/4/2025, the report indicated the ice bin was found to be dirty with biofilm present.A review of the USDA Food Code 2022, Section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, indicated .(A) Equipment Food-Contact Surfaces and utensils shall be clean to sight and touch . Event ID: Facility ID: 056260 If continuation sheet Page 13 of 17 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 01/08/2026 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 facility document review, the facility failed to ensure:Residents had a location to safely store perishable foods.Residents' food was separated from facility food.This failure had the potential to cause foodborne illnesses from unsafe food storage, decreased food intake and did not provide a homelike environment for 78 residents who consumed food out of a total census of 78.Findings:During a concurrent observation and interview on 1/05/2026 at 10:00 a.m. with DC in the kitchen, it was observed that a resident's popsicles were stored in the reach in freezer in the kitchen with facility food. DC stated that Nancy's popsicles are stored in the freezer for her to eat any time.During an interview on 1/05/2026 at 1:45 p.m. with Certified Nursing Assistant 4 (CNA 4), CNA 4 stated, the facility does not have a refrigerator, so perishable food must be consumed immediately. During an interview on 1/05/2026 at 1:55 p.m. with Registered Nurse Supervisor 2 (RNS 2), RNS 2 stated, there isn't a way to store perishable food. RNS 2 stated residents must consume their food from the outside right away.Review of CMS S&C-09-39 dated 5/29/09, showed the residents have the right to choose to accept food from visitors, family, friends, or other guests according to their rights to make choices. The CMS guideline further showed the facility has the responsibility under the food safety regulation to help the visitors to understand safe food handling practices such as not holding or transporting foods containing perishable ingredients at temperatures above 41 degrees Fahrenheit.Review of the facility's P&P titled, Foods Brought by Family/Visitors, dated March 2022, the P&P indicated, perishable foods cannot be stored in the facility and should be consumed within two hours to ensure patient safety.On 01/07/2026 11:00 am, RD 2 was informed and acknowledged the above findings. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056260 If continuation sheet Page 14 of 17 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 01/08/2026 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 0880 Provide and implement an infection prevention and control program. 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 safe infection prevention practices with census of 82 when: 1. Shared glucometer (device measuring blood sugar) was not cleaned and sanitized in-between resident care. 2. Licensed Nurse did not put on gloves before assessing Resident 14's swelling and redness to the Right eye. These unsafe practices could result in spread of infection among vulnerable elderly residents in the facility. Findings: Residents Affected - Some 1. During a medication administration observation with Licensed Nurse (LVN 6), on 1/5/26, at 4:06 PM, at the Station 1 hallway, LVN 6 was observed placing a glucometer and supplies in a small tray and was taken into Resident 6's room to measure blood sugar (or BG). LVN 6 placed the tray on top of bedside table, then with gloved hand poked Resident 6's right index finger with lancet (a pricking device) to get drops of blood and then soaked the test strip (a small strip transmits blood content to glucometer machine) attached to the glucometer with blood to get the BG measurement. LVN 6 when exited the room, removed her gloves without using hand sanitizer and then placed the glucometer back into the cart without cleaning or sanitizing. LVN 6 did not clean the small tray taken inside Resident 6's room. LVN 6 then moved on to next resident in another room to administer the evening shift medications. During an interview with LVN 6 on January 5, 2026, at 4:20 PM, LVN 6 stated that the glucometer did not need to be cleaned and sanitized after each use. LVN 6 explained that the glucometer was cleaned and sanitized three times during the work shift: at the beginning, in the middle, and toward the end. Additionally, LVN 6 acknowledged that she did not clean or sanitize the glucometer and the small tray taken inside the room. During an interview with facility's Infection Prevention Nurse (IP), on 1/8/26, at 11:20 AM, the IP stated the nursing staff had been trained to clean hands with sanitizer before and after using gloves during resident care. IP stated blood pressure cuff and pulse-ox devices were considered non-critical equipment (health care equipment that touch intact skin acting as a low-risk barrier for infection) and cleaned when visibly soiled. IP stated cleaning in-between resident care was not required. IP stated the facility was using CDC guidelines with [NAME] classification (Instruments are categorized as critical, semi-critical, or non-critical) and the facility followed manufacturer instructions for use (MIFU) on cleaning. IP did not provide any document on MIFU for BP and pulse-ox devices. IP stated the nursing staff should have cleaned and sanitized glucometer with Sani-cloth (sanitizing wipe) wipes in-between resident use and it needed to remain wet for 2 minutes. During an interview with Director of Nursing (DON), in his office, on 1/8/26, at 12:20 PM, the DON stated the facility was following the CDC guidelines and manufacturer specification for care and cleaning. DON stated he relied on IP nurses to educate the staff to follow infection prevention workflow to prevent spread of infections. During a review of the facility's policy, titled Cleaning and Disinfecting of Resident-Care items and Equipment, last revised on 9/2022, the policy indicated Resident -care equipment, including reusable items . will be cleaned and disinfected according to current CDC recommendations for disinfection . The policy further indicated The [NAME] Classification System is used to distinguish the levels of sterilization/disinfection necessary for items used in resident care. The policy indicated that glucometer was a critical item that carried high risk of infection. The policy considered blood pressure cuff a non-critical (items that came in contact with intact skin). The policy further indicated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056260 If continuation sheet Page 15 of 17 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 01/08/2026 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 0880 Level of Harm - Minimal harm or potential for actual harm non-critical items required cleaning followed by either low or intermittent level disinfection following manufacture's instruction. The policy indicated Reusable items are cleaned and disinfected or sterilized when visibly soiled, after use on a contact precautions or enteric contact precaution and periodically (e.g., stethoscopes, durable medical equipment). They policy referenced CDC guidelines for disinfection and sterilization in healthcare facilities 2008 Residents Affected - Some During a review of Association for Professionals in Infection Control (APIC) document titled Strategies to mitigate cross contamination of non-critical medical devices, dated 2021, the document indicated Non-invasive portable clinical items shared among patients are part of the patient's immediate surroundings and may pose a threat of pathogen transmission. These items are not typically assigned to a specific patient and may be overlooked when establishing routine disinfection practices. Micro-organisms can live on these items' surfaces for long periods, with the micro-organisms' life spans depending in part on the material of the surface, the ambient air temperature and humidity, and the presence of organic material. The occurrence of infection from contaminated environmental surfaces and non-critical medical devices has been documented in the literature . inappropriate disinfection practices increase the risk of HAIs transmitted from such items . non-critical patient care items still frequently serve as reservoirs for multi-drug-resistant organisms (MDROs, bugs that antibiotic can't kill) . as well as other pathogens . healthcare providers seem to have a false sense of security that materials are microbiologically clean when they are visually clean. They urge healthcare providers to presume that surfaces are unclean rather than clean. During a review of CDC' s document, titled Recommendations for Disinfection and Sterilization in Healthcare Facilities, dated 2008 and 2023, the document indicated 3C. Remove visible organic residue (e.g., residue of blood and tissue) and inorganic salts with cleaning. Use cleaning agents that are capable of removing visible organic and inorganic residues. 4c. Ensure that, at a minimum, noncritical patient-care devices are disinfected when visibly soiled and on a regular basis (such as after use on each patient or once daily or once weekly). 5g. uncertainty exists about the presence of multidrug resistant organisms on such surfaces. See recommendation 5n for recommendations requiring cleaning and disinfecting blood-contaminated surfaces. During a review of instruction sheet by manufacturer of Assure Platinum glucometer (a brand name by ARKRAY, the manufacturer of glucometer used by the facility), titled ARKRAY Technical Brief: Cleaning and Disinfecting the Assure Platinum Blood Glucose Monitoring System , dated 9/2024, the documents under Cleaning and Disinfecting FAQ (Frequently Asked Questions) indicated Each time the cleaning and disinfecting procedure is performed, two wipes are needed. One wipe to clean the meter and the second wipe to disinfect the meter. What will happen if a blood glucose meter is not clean and disinfected after use? . It is important that long term care facility establish a program for infection control . Program include addressing the cleaning and disinfecting of blood glucose meters along with other equipment and environmental surfaces . It is also important to provide education on infection control and the proper use of products. During a review of the Center for Disease Control (A federal agency responsible for the health and safety of people) guideline, titled Considerations for Blood Glucose Monitoring and Insulin Administration, last accessed on 1/15/26 via https://www.cdc.gov/injection-safety/hcp/infection-control/index.html, the guideline indicated Blood glucose meters can easily become contaminated during use. When used in healthcare or other group settings, germs and infections can spread if preventive measures are not in place. The guideline further indicated Dedicated meters should be cleaned and disinfected per the manufacturer's instructions and, at a minimum, anytime the device is reassigned to a different person . If blood glucose meters must be shared, the device should be cleaned and disinfected (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056260 If continuation sheet Page 16 of 17 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 01/08/2026 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some after every use, per the manufacturer's instructions, to prevent the spread of blood and infectious agents. If the manufacturer does not specify how the device should be cleaned and disinfected, it should not be shared. 2. During a review of Resident 14's admission Record, printed on 1/6/26, indicated resident was admitted to the facility on [DATE] with diagnoses that included hemiplegia (muscle weakness on one side of the body, complete paralysis) and hemiparesis (partial weakness), and a need for assistance in personal care. During a review of Resident 14's Minimum Data Set (MDS, a resident assessment tool used to provide care), dated 11/6/25, indicated resident only spoke his native language, had clear speech, was able to make himself understood, and was able to understand others. During a concurrent observation and interview on 1/5/26, at 11:38 a.m., with Rehabilitation Assistant 1 (RA 1), in Resident 14's room, resident's right upper eyelid appeared red, swollen, and with slight watery discharge. Resident stated his right eye/eyelid hurt a little but does not know what was going on with it. Resident denied receiving any nursing care related to his right upper eyelid condition. During a concurrent observation, interview, and record review on 1/6/26, at 10:35 a.m., with Registered Nurse Supervisor 1 (RNS 1), Resident 14's medical records and Weekly Evaluations did not show documentation that resident had any recently reported change of condition to his right upper eyelid. Upon interview and assessment of Resident 14, in his room, resident's right upper eyelid was noted with redness, swelling, and with slight clear, watery discharge. Resident denied itchiness to the right eye/eyelid yet stated the right eye area was crusty in the morning when he woke up. Resident 14 stated this condition of his right upper eyelid has been going on for a week with a pain level of 2 (based on a pain scale, Numeric Rating Scale, 0=no pain, 10=worst. RNS 1, after performing hand hygiene and without donning gloves, assessed and touched the resident's right upper eyelid. RNS 1 stated since Resident 14's skin area to the right eye was intact, it was okay not to wear gloves during skin assessment. During an interview on 1/7/26, at 11:07 a.m., with the Infection Preventionist (IP), IP stated when assessing a resident's eye area with visible signs and symptoms of inflammation, license nurse should perform hand hygiene then wear gloves before touching the resident to reduce the risk of transmission of bacteria or cross-contamination. A review of the facility's policy and procedure (P&P) titled, Personal Protective Equipment – Gloves, dated 2001, indicated, Gloves must be worn when handling blood, body fluids, secretions, excretions, mucous membranes and or non-intact skin. A review of the facility's P&P titled, Policies and Procedures – Infection Prevention and Control, dated 2001, indicated, The facility adopted infection prevention and control policies and procedures are intended to help maintain safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections.All personnel are trained on infection prevention and control policies and procedures upon hire and periodically thereafter including where and how to find and use pertinent procedures and equipment related to infection control. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056260 If continuation sheet Page 17 of 17