Health inspection·August 9, 2024

F 0684 Level of Harm - Minimal harm or potential for actual harm During a review of Resident 's ED (Emergency Department) Provider Notes, dated 7/22/24, the ED Provider Notes indicated Resident 2 had diagnoses that included sepsis (life-threatening medical emergency that occurs when the body's immune system has an extreme response to an infection), gross hematuria (visible blood in urine), and urinary tract infection. Resident 2 received intravenous antibiotics to treat the urinary infection. Residents Affected - Few During a review of Resident 2's Order Summary Report, as of 7/22/24, the Order Summary Report indicated the following physician's orders: a. Monitor for change in urine character: document 0=none, C=cloudiness, S=Sediment, FS=Foul Smell, B=Blood in urine, DC=Deepening or Concentrating urine output. Notify MD for potential UTI every shift. b. Monitor for signs and symptoms of possible urinary infection and notify MD. Document 0= none, FP=Flank Pain, SP=Suprapubic Pain or T=Tenderness, CU=Change in character of urine (new bloody urine; foul smell of urine or change in urinary sediment, MC=Mental Change, FC=Functional change worsening of status. c. Perform Foley catheter care every shift and as needed. During an interview and concurrent record review on 8/8/24 at 2:07 p.m. with Director of Nursing (DON), Resident 2's Treatment Administration Record (TAR) for June 2024 and July 2024 were reviewed. Resident 2's June 2024 TAR indicated Resident 2 had blood in urine on 6/23/24. DON stated, on 6/23/24, there was a physician's order to hold heparin (a blood thinner) for one day and re-evaluate. The June 2024 TAR indicated blood in urine continued until 6/25/24, with missing documentation of Resident 2's urine character monitoring five out of 24 times from 6/23/24 until 6/30/24. Resident 2's July 2024 TAR indicated from 7/1/24 to 7/22/24, Resident 2's urine appeared cloudy and with sediment. DON stated the clinical record indicated the attending physician was not notified of these observations. During a telephone interview on 8/12/24 at 3:45 p.m. with RN 1, RN 1 stated she flushed Resident 2's catheter with 60 ml NS after Resident 2's Foley catheter was observed leaking. RN 1 stated most residents who have a Foley catheter, that included Resident 2, have a written physician order to flush with 60 ml NS. During a review of Resident 2's Order Summary Report, as of 7/22/24, the Order Summary Report did not indicate a written order to flush Resident 2's Foley catheter. During a review of Resident 2's TAR for July 2024, the TAR did not indicate that flushing of the foley catheter was done. During a review of Resident 2's Foley Catheter Care Plan, initiated on 6/18/24, the care plan indicated the goal for Resident 2 was to not to have signs and symptoms of a urinary tract infection for 90 days. The care plan indicated the following interventions: a. Monitor for signs and symptoms of infection and report to the physician. b. Monitor urine output for odor, color, consistency, and amount. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056476 If continuation sheet Page 2 of 6 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 08/09/2024 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 0684 c. Monitor urine for sediment, cloudy, odor, blood, and amount. Level of Harm - Minimal harm or potential for actual harm d. Report to physician promptly if the urine contains any sediment, or blood, is cloudy, or odorous, or if the resident has a fever. Residents Affected - Few 2. During a review of Resident 3's admission Record, dated 8/8/24, the admission Record indicated Resident 3 was admitted to the facility in May 2024 with diagnoses that included chronic kidney disease (a long-term condition where the kidneys do not work as well as they should), urinary retention (a condition that occurs when someone is unable to fully empty their bladder), and severe sepsis with septic shock (a life-threatening condition that occurs when sepsis, a severe reaction to an infection, causes dangerously low blood pressure). During a review of Resident 3's MDS, dated 5/21/24, the MDS indicated Resident 3 had an indwelling urinary catheter. During a review of Resident 3's Order Summary Report, as of 8/9/24, the Order Summary Report indicated the following physician's orders: a. Monitor for change in urine character: document 0=none, C=cloudiness, S=Sediment, FS=Foul Smell, B=Blood in urine, DC=Deepening or Concentrating urine output. Notify MD for potential UTI every shift. b. Monitor for signs and symptoms of possible urinary infection and notify MD. Document 0= none, FP=Flank Pain, SP=Suprapubic Pain or T=Tenderness, CU=Change in character of urine (new bloody urine; foul smell of urine or change in urinary sediment, MC=Mental Change, FC=Functional change worsening of status. c. Perform Foley catheter care every shift and as needed. During a review of Resident 3's Foley Catheter Care Plan, initiated on 5/1/24, the care plan indicated the goal for Resident 3 was to not to have signs and symptoms of a urinary tract infection for 90 days. The care plan indicated the following interventions: a. Monitor for signs and symptoms of infection and report to the physician. b. Monitor urine output for odor, color, consistency, and amount. c. Monitor urine for sediment, cloudy, odor, blood, and amount. d. Report to physician promptly if the urine contains any sediment, or blood, is cloudy, or odorous, or if the resident has a fever. During a review of Resident 3's TAR for July 2024, the TAR indicated Resident 3's urine was observed to have sediment from 7/1/24 to 7/23/24 with cloudiness on 7/18/24. The TAR also indicated a foul smell was observed every shift from 7/24/24 to 7/29/24. During an interview and concurrent review of Resident 3's clinical record on 8/8/24 at 2:52 p.m. with DON, DON stated Resident 3's Situation, Background, Appearance, Review/Notify (SBAR, a structured communication framework that can help teams share information about the condition of a patient) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056476 If continuation sheet Page 3 of 6 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 08/09/2024 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 0684 dated 7/19/24, 7/22/24, and 7126/24 did not address Resident 3's change in urine character. Level of Harm - Minimal harm or potential for actual harm During an interview on 8/8/24 at 3:08 p.m. with Sub-Acute Manager (SAM), SAM stated presence of sediments and bloody urine are not considered normal and therefore warrant physician notification so that appropriate diagnostic procedures like obtaining laboratory examinations, like urine analysis, could be done. Residents Affected - Few During an interview on 8/8/24 at 3:12 p.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated Foley catheter care for Resident 3 included watching out for signs and symptoms of infection like presence of cloudy urine output and sediment, and report to MD. LVN 2 also stated to flush the Foley catheter every shift and change the drainage bag every week and as needed. During a review of Resident 3's Order Summary Report, as of 8/9/24, the Order Summary Report did not indicate an order to flush Resident 3's Foley catheter. During a review of Resident 3's TAR for July 2024, the TAR did not indicate that flushing of the foley catheter was done. During an interview on 8/8/24 at 2:40 p.m. with LVN 1, LVN 1 stated if a resident's urine output is cloudy and has evidence of bleeding, one must check if there is an existing physician order to flush the catheter, if there is an order, flush the catheter following the written physician's order. LVN 1 stated, if there is no written order, one must call the MD to obtain a flush order and discuss with the MD if urine analysis is indicated. During a telephone interview on 8/16/24 at 9:38 a.m. with Attending Physician (AP) 1, AP 1 stated for cloudy urine with sediment, AP would order flushing of the catheter with 50 ml of NS, which is a standard protocol for most residents with Foley catheter. The amount of the flush would depend on the residents' situation. During a review of the facility's policy and procedure (P&P) titled Catheter Irrigation, Open System, last revised October 2010, the P&P indicated steps in the procedure that included instilling 30 ml of the prescribed solution into the catheter and allow the catheter to drain into a sterile collection basin via gravity. The resident's clinical record should indicate the date and time the procedure was performed, name and title of the individual who performed the procedure, the amount of solution used to irrigate, amount returned as drainage and the amount of urine drained, and the signature and title of the person recording the data. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056476 If continuation sheet Page 4 of 6 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 08/09/2024 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, interview, and record review, for one of three sampled residents (Resident 1), the facility failed to provide assistive device and adequate supervision to prevent accidents when a two-person assist during Activities of Daily Living (ADLs, activities needed for self-care and mobility and include activities such as bathing, dressing, grooming, oral care, ambulation, toileting, eating, transferring, and communicating) for bed mobility (moving from one bed position to another like rolling from side to side in bed) care was not provided. This failure resulted in Resident 1 falling out of bed and sustaining a nasal bone fracture and facial bruising. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility in April 2020 with diagnoses that included hemiplegia (paralysis of one side of the body) and hemiparesis (weakness of one side of the body) affecting the right dominant side, morbid obesity, and weakness. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan), dated 5/12/24, the MDS indicated a Brief Interview for Mental Status (BIMS, a scoring system used to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information) score of 13. A BIMS score of 13-15 is an indication of intact cognitive status. During an observation and concurrent interview on 8/8/24 at 11:40 a.m. with Resident 1, Resident 1 stated she fell out of the right side of the bed during ADL care. Resident 1 stated, I fell on my face! There was profuse bleeding from the nose, left eye was swollen shut and had severe pain on the face. Resident 1 stated, when Certified Nursing Assistant (CNA) 1 had Resident 1 turn to the right side, there was no bed rail that Resident 1 could hold onto. Resident 1's entire left side of the face, including around the left eye, was purplish with visible swelling on the left cheek. There were two quarter side rails on each side of the bed. Resident 1 stated the facility provided a bigger bed after the fall incident. During an interview on 8/8/24 at 11:48 a.m. with CNA 1, CNA 1 stated being inside Resident 1's room with a student CNA to provide ADL care when Resident 1 told the student CNA to leave the room. CNA 1 stated, after student CNA left the room, CNA 1 proceeded with ADL care by having Resident 1 turn to a right side-lying position, facing the window. CNA 1 stated being on Resident 1's left side of the bed, facing and cleaning Resident 1's back. CNA 1 stated she turned away to grab a towel, when Resident 1 rolled over and fell on the right side of the bed. CNA 1 stated she went to call Licensed Vocational Nurse (LVN) 1 for help. CNA 1 stated Resident 1 had always needed a two-person assist with ADLs. CNA 1 stated she should have told LVN 1 when student CNA left the room, in order to get another staff to assist. CNA 1 also stated not knowing Resident 1 did not have side rails on the right side of the bed to aid with turning and repositioning. During a review of Resident 1's Progress Notes dated 7/21/24, the Progress Notes indicated CNA 1 called LVN 1 after Resident 1 rolled over the right side of the bed and fell on the floor. The notes indicated Resident 1 was found on the floor, face down, and lying on the left side. The notes also (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056476 If continuation sheet Page 5 of 6 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 08/09/2024 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few indicated a Large amount of blood was on the floor with more blood coming out from Resident 1's nose. Resident 1 was transferred to the hospital via 911. During a review of the Interdisciplinary Fall (IDT, a team that includes staff members from multiple disciplines such as nursing, therapy, physicians, and other advanced practitioners), dated 7/21/24, the Interdisciplinary Fall indicated, under Safety review, several safety issues were identified that included, Resident is obese and needs at least 2 person assist/max [maximum] assist for all ADLs. During an interview on 8/8/24 at 2:48 p.m. with LVN 1, LVN 1 stated on 7/21/24, CNA 1 approached LVN 1 and said Resident 1 had rolled out of bed. LVN 1 stated she went to the room and saw Resident 1's face was planted on the floor on a left side-lying position. LVN 1 stated there was a large amount of blood already on the floor while Resident 1's nose was still bleeding profusely. LVN 1 stated she did not know the student CNA had left the room, leaving CNA 1 to do ADL care by herself. LVN 1 stated had she known, LVN 1 stated she would have helped CNA 1 with ADL care. LVN 1 also stated Resident 1 had always required a two-person assist, and it was again discussed in an in-service few weeks ago that residents with bigger frame, like Resident 1, needed to have two-person assist for ADL care. During an interview and concurrent review on 8/9/24 at 12:50 p.m. with Director of Staff Development (DSD), Inservice Attendance Record Sign-In Sheet, dated 5/29/24, with a subject, Assisting with Positioning a Patient in Bed was reviewed. DSD stated it was an in-service education given for CNAs to provide two-person assist during ADL care to residents like Resident 1. The sign-in sheet indicated CNA 1 attended the in-service education. During a review of Resident 1's Weekly Summary Documentation, the documents indicated the following: 1. Effective date 6/18/24, Resident 1 was totally dependent and needed two-person assist with bed mobility. 2. Effective date 6/25/24, Resident 1 was totally dependent and needed two-person assist with bed mobility. 3. Effective date 7/9/24, Resident 1 was totally dependent and needed two-person assist with bed mobility. 4. Effective date 7/16/24, Resident 1 needed extensive assistance, with two-person assist with bed mobility. During a review of Resident 1's ADL Care Plan, last revised 1/28/24, the care plan indicated to provide Resident 1 a positioning bar/rail in bed as an enabler, upper bilateral quarter rails. The care plan did not indicate the need to provide two-person assist with bed mobility as documented in the Weekly Summary Documentation. During a review of Resident 1's Hospitalist Discharge Summary, dated 8/5/24, the Hospitalist Discharge Summary indicated Resident 1 had a closed fracture of the nasal bone and traumatic ecchymosis (medical term for bruises, which form when blood pools under your skin, caused by a blood vessel break) of face. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056476 If continuation sheet Page 6 of 6