Health inspection·September 28, 2023

F 0759 Ensure medication error rates are not 5 percent or greater. 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 administer medications below a five percent (5%) error rate when: Residents Affected - Some 1. A Licensed Vocational Nurse (LVN 1) did not administer sertraline (a drug used to treat depression; a mental health disorder associated with low mood) 100mg and lidocaine patch (a patch used for temporary pain relief) 4% to one (Resident 31) of 19 sampled residents. 2. A second Licensed Vocational Nurse (LVN 2) did not administer chlorhexidine mouthwash (a prescribed mouthwash that decreases bacteria in the mouth) to one (Resident 83) out of 19 sampled residents. These errors have resulted in Resident 31 and 83, not receiving medication as prescribed by their physicians. Findings: 1. During a concurrent observation and interview on 9/26/23 at 8:10 a.m. with Licensed Vocational Nurse (LVN 1), LVN 1 was observed preparing medications for Resident 31. LVN 1 stated there was no more lidocaine patch 4% and no sertraline 100mg in the medication cart so she is unable to give those medications. LVN 1 stated Resident 31's sertraline was reordered on 9/24/23, but was not available. During a concurrent interview and record review on 9/26/23 at 11:53 a.m., with LVN 1, Resident 31's physician orders were reviewed. The physician orders indicated sertraline 100mg, give 1 tablet by mouth daily for depression m/b (manifested by) sad facial expression. LVN 1 stated if Resident 31 did not receive sertraline, potential consequences include becoming more sad or anxious. 2. During a concurrent observation and interview on 9/26/23 at 11:43 a.m., Licensed Vocational Nurse (LVN 2) was observed preparing six medications for Resident 83. LVN 2 looked through Medication Cart 1, and stated she was unable to find Resident 83's Chlorhexadine mouthwash so she would not be able to give it. During a concurrent interview on 9/28/23 at 9:17 a.m., with Director of Nursing (DON), the DON stated resident medication lists are located in the Cubex (an automatic medication dispensing machine) and the Cubex has most routine medications. The DON stated there is no reason for residents not to get routine medications and that not giving a medication as ordered is considered a medication error. During a review of the facility's policy and procedure titled, Medication Errors, dated [DATE], indicated a medication error is defined as administration to a resident .omission of the prescribed medication . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056476 If continuation sheet Page 2 of 8 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 056476 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rosewood Post Acute 1911 Oak Park Boulevard Pleasant Hill, CA 94523 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 - Some 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that biologicals were labeled and stored according to professional standards when 1. Aluminum packages of 55 vials of ipratropium-albuterol inhalation solution were left open to air and light 2. A vial of timolol maleate ophthalmic solution was unlabeled and undated. This failure had the potential to result in administering ineffective medications to residents which could lead to residents health care needs being unmet and potential hospitalization. Findings 1 . During a concurrent medication storage observation and interview on 9/27/23 at 11:15 a.m., with Registered Nurse (RN 1), four aluminum packages were observed unrolled and left open and without open dates at Station 1's Medication Cart 2. Inside the four aluminum packages were a total of 55 vials of ipratropium-albuterol 0.5-2.5 (3) mg/3mL (a combination of two medications given through a mask to help open the airway in lungs) solution. RN 1 stated that this medication needs to be protected from light. RN 1 stated that if exposed to light, the medication could lose effectiveness and residents could have breathing issues since this medications helps open the airway. During an interview on 9/28/23 at 10:42 a.m., with Pharmacy Consultant (PC), PC stated the expectation is for Duoneb (the brand name for ipratropium-albuterol) to be preserved in foil packaging, following manufacturer guidelines. PC stated the foil packaging is to protect the integrity of the medication. During a review of the manufacturer's storage guidelines, dated [DATE], the guidelines indicated that vials should be protected from light before use, therefore, keep unused vials in the foil pouch or carton. During a review of facility's policy and procedure titled, Medication Storage in the Faciity, dated April 2008, indicated Medications and biologicals are stored .following manufacturer's recommendations . 2. During a concurrent medication storage observation and interview on 9/27/23 at 10:42 a.m., with Registered Nurse (RN 1), one vial of timolol maleate (a medication to decrease the pressure in the eye to prevent blindness) had no label and no open date at Station 1's Medication Cart 1. RN 1 stated that once opened, eye drops are good for 28 days so there should be an open date to let nurses know how long the bottle has been open. During an interview on 9/28/232 at 8:54 a.m., with Director of Nursing (DON), the DON stated eye drops need to have open dates. During a review of facility's policy and procedure titled Medication Ordering and Receiving from (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056476 If continuation sheet Page 3 of 8 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 056476 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rosewood Post Acute 1911 Oak Park Boulevard Pleasant Hill, CA 94523 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 Pharmacy (undated), indicated .e.g. eye drops .B. each prescription medication label includes: 1) resident name .5) prescriber's name, 6) date dispensed, 7) expiration date of medication . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056476 If continuation sheet Page 4 of 8 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 056476 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rosewood Post Acute 1911 Oak Park Boulevard Pleasant Hill, CA 94523 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 record review, the facility failed to ensure the dietary staff stored and prepared food under sanitary conditions for 89 of 97 residents whose food were prepared in the kitchen. Residents Affected - Many These deficient practices placed the residents at risk for foodborne illnesses (refers to illness caused by the ingestion of contaminated food or beverages). Findings: During an initial tour of the kitchen with the Dietary Supervisor (DS) on 9/25/23 at 9:40 A.M., the following were observed: A jar of Kikkoman soy sauce had a use by date of 9/24/23. A 4.5lb container of sweet and sour sauce did not have an open date and a use by date. A one-gallon jar of mayonnaise had no open date and use by date. Four dented cannisters of oats with ill-fitting lids were on the emergency supply shelf. There were hamburger patties in the freezer with an expiration date of 9/24/23. Enchiladas in the freezer had an expiration date of 8/27/23. Ten pounds of ground beef in the freezer had a use by date of 9/24/23. Five pieces of bell pepper and two containers of strawberries in the refrigerator were rotten. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056476 If continuation sheet Page 5 of 8 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 056476 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rosewood Post Acute 1911 Oak Park Boulevard Pleasant Hill, CA 94523 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 An open pack of American cheese did not have an open date and a use by date. Level of Harm - Minimal harm or potential for actual harm A pack of lemon bars had an expiration date of 8/6/23. Residents Affected - Many Farina Hot Meal Cereal had an expiration date of 5/24/23. - The following food items in the Unit 2 refrigerator did not have use by dates: ten pounds diced chicken, cooked turkey breast, a bag of meat balls, a bag of breaded fish. During an interview on 9/25/23 at 9:40 a.m., the DS stated expired food items and other food items that were not consumed before the use by date should be discarded because these could be a source of foodborne illness. A review of the facility's undated policy titled: Labeling and Dating of Food indicated: all food will be dated, labeled, and prepared for storage to prevent contamination, deterioration, and dehydration . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056476 If continuation sheet Page 6 of 8 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 056476 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rosewood Post Acute 1911 Oak Park Boulevard Pleasant Hill, CA 94523 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 0912 Level of Harm - Potential for minimal harm Residents Affected - Some Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. Based on observation, interview, and record review, the facility failed to provide no less than 80 square feet per resident for 18 of 51 rooms (Rooms 103, 105, 109, 111, 112, 114, 115, 118, 123, 124, 200, 201, 202, 203, 204, 206, 208, and 210). This failed practice had the potential to result in lack of sufficient space for staff to deliver care and provide storage space for resident belongings. Findings: During the initial tour on 9/28/23 at 9:30 a.m., the living space for Rooms 103, 105, 109, 111, 112, 114, 115, 118, 123, 124, 200, 201, 202, 203, 204, 206, 208, and 210 were observed as follows: Room [103] had 2 beds and measured 149.58 square feet, providing 74.79 square feet per resident. Room [105] had 2 beds and measured 145.12 square feet, providing 72.55 square feet per resident. Room [109] had 2 beds and measured 149.62 square feet, providing 74.79 square feet per resident. Room [111] had 2 beds and measured 151.77 square feet, providing 75.88 square feet per resident. Room [112] had 2 beds and measured 153.54 square feet, providing 76.77 square feet per resident. Room [114] had 2 beds and measured 151.39 square feet, providing 75.69 square feet per resident. Room [115] had 2 beds and measured 152.39 square feet, providing 76.19 square feet per resident. Room [118] had 2 beds and measured 149.62 square feet, providing 74.79 square feet per resident. Room [123] had 2 beds and measured 152.13 square feet, providing 76.06 square feet per resident. Room [124] had 2 beds and measured 156.74 square feet, providing 78.37 square feet per resident. Room [200] had 2 beds and measured 151.39 square feet, providing 75.69 square feet per resident. Room [201] had 2 beds and measured 151.39 square feet, providing 75.69 square feet per resident. Room [202] had 2 beds and measured 152.13 square feet, providing 76.06 square feet per resident. Room [203] had 2 beds and measured 154.68 square feet, providing 77.34 square feet per resident. Room [204] had 2 beds and measured 146.84 square feet, providing 73.42 square feet per resident. Room [206] had 2 beds and measured 150.26 square feet, providing 75.13 square feet per resident. Room [208] had 2 beds and measured 149.38 square feet, providing 74.69 square feet per resident. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056476 If continuation sheet Page 7 of 8 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 056476 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rosewood Post Acute 1911 Oak Park Boulevard Pleasant Hill, CA 94523 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 0912 Room [210] had 2 beds and measured 151.39 square feet, providing 75.69 square feet per resident. Level of Harm - Potential for minimal harm Residents in the affected rooms by observation, had privacy, storage space for personal belongings and there were no complaints received from those residents. The facility's staff were observed to be able to provide nursing services to meet the individual needs of each resident within those affected rooms. Residents Affected - Some During the group interview on 9/28/23 at 11:00 a.m., the residents stated they had no issues with their private space and had enough room for their personal items. There were no negative consequences attributable to the decreased space (less than 80 square feet) in Rooms 103, 105, 109, 111, 112, 114, 115, 118, 123, 124, 200, 201, 202, 203, 204, 206, 208, and 210. During the entrance conference on 9/25/23 at 09:40 a.m., the facility's administrator (ADM) stated the facility would be requesting room waivers for Rooms 103, 105, 109, 111, 112, 114, 115, 118, 123, 124, 200, 201, 202, 203, 204, 206, 208, and 210. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056476 If continuation sheet Page 8 of 8