Health inspection·June 20, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the Responsible Party (RP is the person designated as being responsible for another person's medical and financial decisions) of Resident 1 ' s change of condition (COC). This failure resulted in Resident 1 ' s RP being uninformed and unaware of Resident 1 ' s COC. Findings: During a review of Resident 1's admission Record, dated 5/21/25, indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included cognitive communication deficit (communication difficulties)and aphasia (a language disorder that affects the ability to communicate). Review of Resident 1 ' s Minimum Data Set (an assessment tool) dated 4/22/25, indicated he had a brief interview for mental status or BIMS of 0 (BIMS score of 0-7 indicates severe cognitive impairment). During a review of the clinical record for Resident 1, the progress notes documented by Registered Nurse (RN) 1 dated 2/19/25 at 8:46 a.m., indicated, Right foot big toe have a foul smell. Will be referred to Podiatry( Podiatry is a branch of medicine that focuses on the diagnosis, treatment, and prevention of disorders of the feet, ankles and lower legs). During a concurrent joint interview and record review with the Director of Nursing (DON) and RN 1 on 5/21/25 , at 1:16 p.m., RN 1 and DON could not find the documentation that Resident 1 ' s RP was informed of the resident ' s foul smelling right big toe. RN 1 acknowledged she could not recall that she informed Resident 1 ' s RP about the the resident's toe. During an interview with the DON on 5/21/25 at 1:36 p.m., DON stated the facility had to notify the physician and the RP if there was a COC. During a review of the facility's policy and procedure (P&P) titled, Change of Condition: Notification of, dated 8/25/21 the P&P indicated, I. Purpose: To ensure residents, family, legal representatives, and physicians are informed of changes in the resident ' s condition. II. Policy: A facility must immediately inform the resident, consult with the Resident ' s physician . and notify, consistent with his/her authority, Resident Representative where there is: . A significant change in the Resident ' s physical, mental or psychosocial status . A need to alter treatment significantly (that is, a need to discontinue or change an existing form of treatment .or to commence a new form of Page 1 of 2 056476 056476 06/20/2025 Rosewood Post Acute 1911 Oak Park Boulevard Pleasant Hill, CA 94523

F 0580 treatment) . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 056476 Page 2 of 2