Health inspection·September 5, 2024

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. Based on interviews and record review, the facility failed to ensure Resident's right to choose health care and providers of health care services was honored for one of three sampled residents (Resident 3), when Registered Nurse (RN) 1 proceeded to administer medications to Resident 3, after Resident 3 had already refused to receive care from RN 1. This failure resulted in emotional distress for Resident 3. Findings: During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was initially admitted to facility during 11/23, and had multiple diagnoses that included, dependence on ventilator (breathing machine), chronic respiratory failure with hypoxia (a long-term condition that makes it difficult for the body to exchange oxygen and carbon dioxide), amyotrophic lateral sclerosis (nervous system disease that weakens muscles and impacts physical function, causes nerve cells in the brain and spinal cord to die, eventually causes the brain to lose ability to control voluntary movements and breathing), anxiety disorder (persistent and excessive worry that interferes with daily activities), and major depressive disorder (persistent feeling of sadness and loss of interest and can interfere with your daily life). During a review of Resident 3's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 8/16/24, the MDS indicated a Brief Interview for Mental Status (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information.) score of 15. A BIMS score of 13-15 indicated intact cognitive status. During an interview on 9/5/24 at 10:59 a.m., with Sub-Acute Manager (SAM), SAM stated, Resident 3 had a history of refusing new staff to provide care. SAM also stated Resident 3, having multiple medical issues that included ALS and anxiety, felt new staff were not familiar with Resident 3's daily routine. During an interview on 9/5/24 at 11:12 a.m., with RN1, RN1 stated being assigned to Resident 3 on three separate occasions. RN1 stated, the first time, Resident 3 refused RN1, so RN1 switched assignment with another nurse. RN 1 stated, 8/21/24 was the third time RN1 was assigned to Resident 3. RN1 stated, RN1 entered the room and told Resident 3 she was the assigned nurse for the morning shift. RN 1 stated telling Resident 3 she will be preparing Resident 3's scheduled morning medications and will be right back. RN1 stated Resident 3 said, I don't like you; I want another nurse. RN1 stated she told Resident 3 that she will be back to administer Resident 3's medications. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 056327 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 056327 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Walnut Creek Skilled Nursing & Rehabilitation Cent 1224 Rossmoor Parkway Walnut Creek, CA 94595 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)