Health inspection·April 21, 2025

F 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure Resident 1 had privacy during care when staff transferred Resident 1, who was not wearing clothes and uncontrollably yelling fuck repeatedly, from a shower chair into his room without adequately covering his genitals. Residents Affected - Few This failure had the potential for psychosocial harm when Resident 1 ' s genitals were exposed and viewable to anyone in the hallway when Resident 1 was being transferred from the shower chair into the room and was yelling uncontrollably. Findings: A review of Resident 1 ' s admission record indicated Resident 1 was admitted with diagnoses for vascular dementia (loss of mental function due to loss of brain tissue from reduced blood supply), Tourette syndrome (disorder involving repetitive movements or unwanted sounds which a person has little or no control over), seizures (changes in brain electrical activity), intracranial injury (injury in the head) and need for assistance with personal care. During a record review of Resident 1 ' s minimum data set (MDS, an assessment tool to guide resident care), dated 3/31/25, the MDS indicated Resident 1 was unable to communicate with others and was dependent on staff for all aspects of care including eating, toileting, personal hygiene and transfers in and out of bed. During an observation on 3/21/25, at 10:00 a.m., Certified Nursing Assistant (CNA) 1, CNA 1 and Resident 1 were in the hallway outside Resident 1 ' s room. Resident 1 was sitting on a shower chair covered with linens but did not have clothes underneath. While CNA 1 and another CNA were lifting Resident 1 out of the chair with a mechanical lift, staff tried to cover Resident 1 with linens, but Resident 1 ' s scrotum remained visible. A privacy curtain was not utilized during the transfer. Resident 1 ' s genitals remained exposed and viewable from the hallway while they moved Resident 1 into his room. Though the entire transfer, Resident 1 repeatedly said fuck loudly and in an agitated tone which drew attention from staff and other individuals in the hallway. During a concurrent observation and interview on 3/21/25, at 10:15 a.m., with CNA 1, Resident 1 was in his bed with clothing on and covered with a blanket. CNA 1 stated Resident 1 could not be transferred from chair to bed inside his room because there was not enough room to transfer safely. CNA 1 stated the width of Resident 1 ' s bed prevented placement of the shower chair next to the bed. CNA 1 stated Resident 1 had to be taken out to the hallway on a mechanical lift for all transfers for as long as CNA 1 could remember. CNA 1 stated Resident 1 usually yelled out fuck during transfers in and out of bed. Page 1 of 2 056327 056327 04/21/2025 Walnut Creek Skilled Nursing & Rehabilitation Cent 1224 Rossmoor Parkway Walnut Creek, CA 94595

F 0583 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 4/24/25, at 1:00 p.m., with the Director of Nursing (DON), the DON stated residents have an expectation of privacy when receiving care and was not acceptable to have their genitals visible in the hallway. During a record review of Resident 1 ' s care plan titled, Care Plan Report, dated 4/24/25, the care plan indicated Resident 1 needed use of mechanical lift for transfer with 2 persons assist. During a review of facility policy and procedure (P&P) titled Resident Rights, dated 10/2017, the P&P indicated residents in long term care facilities have rights guaranteed to them .including those specified in this section. Employees shall treat residents with kindness, dignity and respect .the facility promotes the rights of each resident, including .privacy and confidentiality .the facility promotes the rights of all residents including any who face barriers (such as communication problems). 056327 Page 2 of 2