Other·May 14, 2019

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE THIS FORM CMS-2567 HAS BEEN AMENDED TO CORRECT F 600 WHICH HAD BEEN REPLACED BY F 584, AND THE SCOPE AND SEVERITY WAS CHANGED TO "D." ALL OTHER ITEMS OF THIS FORM CMS-2567 REMAIN UNCHANGED AND EFFECTIVE. The following reflects the findings of the California Department of Public Health during the Annual Re-certification Survey conducted from 2/04/19 to 2/7/19. Representing the Department: Health Facilities Evaluator Nurses: 33155, 39512, 39948, 38533, 36891,40747 and 16684. The resident census at the time of survey was 150.

F580 SS=D Notify of Changes (Injury/Decline/Room, etc.) CFR(s): 483.10(g)(14)(i)-(iv)(15)

F580 04/04/2019 §483.10(g)(14) Notification of Changes. (i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention; (B) A significant change in the resident's physical, mental, or psychosocial status (that LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1U1711 Facility ID: CA020000083 If continuation sheet 1 of 31 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056327 (X3) DATE SURVEY COMPLETED 02/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WALNUT CREEK SKILLED NURSING & REHABILITATION CENTER 1224 Rossmoor Parkway Walnut Creek, CA 94595 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); (C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or (D) A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii). (ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request to the physician. (iii) The facility must also promptly notify the resident and the resident representative, if any, when there is(A) A change in room or roommate assignment as specified in §483.10(e)(6); or (B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section. (iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident representative(s). §483.10(g)(15) Admission to a composite distinct part. A facility that is a composite distinct part (as defined in §483.5) must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations under §483.15(c) (9). This REQUIREMENT is not met as evidenced by: Based on an interview and record review, the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1U1711 Facility ID: CA020000083 If continuation sheet 2 of 31 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056327 (X3) DATE SURVEY COMPLETED 02/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WALNUT CREEK SKILLED NURSING & REHABILITATION CENTER 1224 Rossmoor Parkway Walnut Creek, CA 94595 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE facility failed to notify the physician when medications were not administered as ordered during dialysis days for one (Resident 37) of 34 sampled residents. This failure resulted in Resident 37's continued missed medications during dialysis days, placing the resident at increased risk of complications. Findings: Review of the Admission Record indicated Resident 37 was admitted to the facility with multiple medical diagnoses that included end stage renal disease (ESRD: a condition in which the kidneys lose the ability to remove waste and balance fluids) and was being treated with hemodialysis (a procedure that removes waste material and extra fluids from the blood) outside of the facility, three times a week every Monday, Wednesday and Friday. Review of the Physician Orders dated 10/25/18, indicated: "Cranberry Tablet 450 mg - give one tablet, by mouth, in the morning (supplement), Docusate Sodium (DSS) 100 mg - two times a day, for constipation and Cholecarciferol Tablets - by mouth, in the morning." Review of the Medication Administration Record (MAR) for the month of November 2018, December 2018 and January and February 2019 indicated Cholecarciferol, Cranberry Tablets and Docusate Sodium to be taken by mouth at 9:00 a.m., were not administered for the following days. For the month of November 2018, Cranberry Tablet, DSS and Cholecarciferol were not administered on the following days: November FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1U1711 Facility ID: CA020000083 If continuation sheet 3 of 31 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056327 (X3) DATE SURVEY COMPLETED 02/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WALNUT CREEK SKILLED NURSING & REHABILITATION CENTER 1224 Rossmoor Parkway Walnut Creek, CA 94595 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 2, 5, 7, 9, 12, 14, 16, 19, 23, 26, 30. For the month of December 2018, Cranberry Tablets, DSS and Cholecarciferol were not administered on the following days: December 1,5, 7, 10, 12, 14, 17, 19, 24, 26, 28, 31. For the month of January 2019, Cranberry Tablets, DSS and Cholecarciferol were not administered on the following days: January 4, 7, 9, 11, 14, 16, 18, 21, 23, 25, 30. For the month of February 2019, Cranberry Tablets, DSS, Cholecarciferol and Sensipar 60 mg were not administered on the following days: February 2, and 4. During an interview with Resident 37 on 2/7/19 at 8:05 a.m., Resident 37 stated, "I'm not receiving my morning medications during dialysis days on Monday, Wednesday and Friday because I leave between 6:00 - 6:30 in the morning to go to my scheduled dialysis." During an interview and concurrent record review with Licensed Vocational Nurse 4 (LVN 4) on 2/7/19 at 8:15 a.m., LVN 4 stated Resident 37 was out of the facility for her scheduled dialysis so the medications were not administered as ordered. LVN 4 added, "We should be notifying the physician promptly so they can change the time of administration of medications." During an interview and concurrent record review with the Director of Nursing (DON) on 2/7/19 at 8:45 a.m., the DON stated, she would notify the physician right away and give an in-service with the nursing staff as soon as possible. Review of the facility's Policy and Procedure titled "Change in Resident's Condition or Status" indicated "facility staff shall promptly notify the resident, his /her attending physician, and representative of changes in the resident's medical/mental condition and/or status (e.g. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1U1711 Facility ID: CA020000083 If continuation sheet 4 of 31 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056327 (X3) DATE SURVEY COMPLETED 02/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WALNUT CREEK SKILLED NURSING & REHABILITATION CENTER 1224 Rossmoor Parkway Walnut Creek, CA 94595 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE change in level of care, billing/payments, resident's rights, etc.)."

F584 SS=D Safe/Clean/Comfortable/Homelike Environment F584 CFR(s): 483.10(i)(1)-(7) 04/04/2019 §483.10(i) Safe Environment. The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. The facility must provide§483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. (i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. (ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft. §483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior; §483.10(i)(3) Clean bed and bath linens that are in good condition; §483.10(i)(4) Private closet space in each resident room, as specified in §483.90 (e)(2) (iv); §483.10(i)(5) Adequate and comfortable lighting levels in all areas; FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1U1711 Facility ID: CA020000083 If continuation sheet 5 of 31 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056327 (X3) DATE SURVEY COMPLETED 02/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WALNUT CREEK SKILLED NURSING & REHABILITATION CENTER 1224 Rossmoor Parkway Walnut Creek, CA 94595 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81°F; and §483.10(i)(7) For the maintenance of comfortable sound levels. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to remove or deep clean (thoroughly clean) carpet from one room shared by two (Resident 54 and Resident 35) of 34 sampled residents when the facility was aware of urine-stained and strong urinesmelling carpet. This deficiency resulted in Resident 54 and Resident 35 to reside in a room that was not maintained in a home-like environment. Findings: A review of Resident 54's FaceSheet showed Resident was admitted to the facility on 9/1/03. A review of Resident 35's FaceSheet showed Resident was admitted to the facility on 8/5/11. During an interview with Resident 54 on 2/6/19 at 8:54 a.m., Resident 54 stated his room "stinks of urine". Resident 54 stated his roommate "urinates, then some spills and gets dumped on the floor." Resident 54 stated he had talked to the facility about the smell, the facility stated they were going to do something about it, "but nothing gets done." During an observation and concurrent interview FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1U1711 Facility ID: CA020000083 If continuation sheet 6 of 31 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056327 (X3) DATE SURVEY COMPLETED 02/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WALNUT CREEK SKILLED NURSING & REHABILITATION CENTER 1224 Rossmoor Parkway Walnut Creek, CA 94595 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE with the Director or Nurses (DON) on 2/6/19 at 8:57 a.m., the DON confirmed room 704 had a strong, foul-smelling urine odor. The DON stated the 700 wing had a sewer problem underneath the carpet in the hallway, but confirmed the odor from room 704 was not a "sewer" smell, but instead a strong urine odor. During a concurrent interview and record review with Housekeeping Supervisor (HSS) on 2/6/19 at 9:44 a.m., the HSS stated there was a schedule for deep cleaning of the nine rooms with carpet in the facility once a month. Record review showed deep clean of room 704 by janitor was scheduled on January 24th, 2019. The HSS stated he did not keep a log regarding deep cleans, but relied on a verbal communication of completion of the rooms by the janitor. During an interview with Resident 35 on 2/6/19 at 12:08 p.m., Resident 35 stated he did know there was a "urine smell" in his room, and stated, "It is probably my fault because I have two urinals and sometimes they spill." Resident 35 stated he had been in his room "a long time", and had grown accustomed to the smell. During an interview with the DON on 2/7/19 at 10:54 a.m., the DON stated she had worked at the facility since July, 2018, and had been aware since she had been here that room 704 had a strong urine smell. The DON stated the issue regarding room 704 and the strong urine smell had been addressed in meetings and huddles, but stated housekeeping stated it was in the carpets, which went into the concrete, and there was nothing they could do. During an interview with the HSS on 2/7/19 at 11:03 a.m., the HSS stated he had been aware of the carpet smell in room 704, for a while. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1U1711 Facility ID: CA020000083 If continuation sheet 7 of 31 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056327 (X3) DATE SURVEY COMPLETED 02/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WALNUT CREEK SKILLED NURSING & REHABILITATION CENTER 1224 Rossmoor Parkway Walnut Creek, CA 94595 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The HSS stated, "today is the first time an outside company has come in to professional treat/clean the carpet in room 704." During an interview with Housekeeping (HS) on 2/7/19 at 11:06 a.m., the HS stated she has worked at the facility for three or four months. HS stated she cleaned the rooms in 700's, and had been aware of the smell in room 704. The HS stated she cleaned and vacuumed in room 704 every day, but the odor was "really bad" and "could not clean enough to get the odor out." During an interview with Licensed Vocational Nurse 3 (LVN 3) on 2/7/19 at 11:32 a.m., the LVN 3 stated she was the Nurse Manager on Unit 3 by the 700's hallway. The LVN 3 stated the facility had known about the problem of foul-smelling odor in room 704 for over a year.

F644 SS=D Coordination of PASARR and Assessments CFR(s): 483.20(e)(1)(2)

F644 04/04/2019 §483.20(e) Coordination. A facility must coordinate assessments with the pre-admission screening and resident review (PASARR) program under Medicaid in subpart C of this part to the maximum extent practicable to avoid duplicative testing and effort. Coordination includes: §483.20(e)(1)Incorporating the recommendations from the PASARR level II determination and the PASARR evaluation report into a resident's assessment, care planning, and transitions of care. §483.20(e)(2) Referring all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1U1711 Facility ID: CA020000083 If continuation sheet 8 of 31 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056327 (X3) DATE SURVEY COMPLETED 02/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WALNUT CREEK SKILLED NURSING & REHABILITATION CENTER 1224 Rossmoor Parkway Walnut Creek, CA 94595 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE upon a significant change in status assessment. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure a Level 1 Pre-admission screening and resident review (PASARR-a mental health assessment tool) form was accurately coded for one (Resident 97) of 34 sampled residents when question 16 of the form indicated Resident 97 had a current (less than 18 months) PASARR in her chart. This deficient practice had the potential to result in Resident 97 not receiving appropriate mental health referrals and care. Findings: Review of Resident 97's face sheet, dated 12/18/18, indicated Resident 97 was admitted to the facility on 12/20/16 and was re-admitted on 10/24/18 with multiple diagnoses that included depressive (feeling sad) episodes and anxiety (feeling worried or nervous) disorder. Review of Resident 97's medical record, indicated Resident 97's initial PASARR was completed on 12/21/16. Review of Resident 97's record a PASARR form, dated 12/19/18, indicated the diagnoses of depressive disorder and anxiety disorder were not listed under question 13. Further review of this document, indicated question 16 ,"Is there a current (less than 18 months) PASRR on file for this resident with no significant change in condition? If no, go to the next section", was marked "Yes". Further review of Resident 97's PASARR forms, dated 11/30/18, 9/10/18 and 7/24/18, indicated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1U1711 Facility ID: CA020000083 If continuation sheet 9 of 31 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056327 (X3) DATE SURVEY COMPLETED 02/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WALNUT CREEK SKILLED NURSING & REHABILITATION CENTER 1224 Rossmoor Parkway Walnut Creek, CA 94595 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE question 16 was marked "Yes." During an interview with the Medical Records Assistant (MRA) on 02/06/19 at 9:45 a.m., MRA stated when a PASARR was done online and question 16 was answered "yes", the rest of the PASARR sections would close. MRA stated he was instructed to only put the first three to four medical diagnoses that were listed on the residents' face sheets on the PASARR. During an interview with MRA on 2/06/19 at 10:40 a.m., MRA stated he was trained to always answer question 16 "yes" by his former supervisor. During an interview with MRA on 2/06/19 at 11:23 a.m., MRA stated Resident 97's original admit PASARR was done on 12/21/2016, and the PASARRs dated 7/24/18, 9/10/18, 11/30/18 and 12/19/18 were incorrectly completed because question 16 was answered "yes". MRA stated question 16 should have been answered "no" because all those PASARRs were done after the 18 month time frame. MRA stated resident's medical diagnoses of depressive episodes and anxiety disorder should have been listed on the 12/19/18 PASARR. During an interview with the Medical Records Director (MRD) on 2/06/19 11:26 a.m., MRD stated PASARRs should be done on residents upon admission and for every readmission. MRD stated Resident 97's PASARR, dated 12/19/18, was inaccurately completed because question 16 should have been answered "No" because the 18 month timeframe had ended. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1U1711 Facility ID: CA020000083 If continuation sheet 10 of 31 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056327 (X3) DATE SURVEY COMPLETED 02/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WALNUT CREEK SKILLED NURSING & REHABILITATION CENTER 1224 Rossmoor Parkway Walnut Creek, CA 94595 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

F684 Quality of Care CFR(s): 483.25

F684 SS=E PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 04/04/2019 § 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive personcentered care plan, and the residents' choices. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, for two (Resident 5 and 86) of 34 sampled residents, the facility failed to provide professional nursing care when: 1. the physician's order to change the foley catheter for Resident 5 was not done; 2. the physician's order to ensure that emergency supplies were readily available for Resident 86 was not carried out. These practices had exposed Resident 5 to risk for urinary infection and Resident 86 for lifethreatening airway compromise. Findings: 1. Review of the Admission Record showed Resident 5 was admitted on 11/16/11 with multiple diagnosis including Urinary Tract Infections. During an observation on 2/4/19 at 8 a.m., FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1U1711 Facility ID: CA020000083 If continuation sheet 11 of 31 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056327 (X3) DATE SURVEY COMPLETED 02/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WALNUT CREEK SKILLED NURSING & REHABILITATION CENTER 1224 Rossmoor Parkway Walnut Creek, CA 94595 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Resident 5 was asleep in bed. A foley catheter (a thin, sterile tube inserted into the bladder to drain urine) was hanging on the right side of the bed. The foley tubing had cloudy urine with white sediments. In an interview with the Registered Nurse (RN 5) on 2/4/19 at 10:00 a.m., RN 5 acknowledged that the foley tubing was cloudy with sediments and the urine in the bag was cloudy. RN 5 added that the last foley catheter change was when Resident 5 was in the hospital. Review of the Hospitalist Discharge Summary from Resident 5's recent hospitalization on 1/6/19 to 1/16/19 showed, "Discharge Diagnoses: Severe Sepsis... UTI..." Review of the physician's order dated, 1/16/19 indicated, "Change Foley Catheter Q (every) 2 weeks, FF14 (FF - French Gauge, a standard set of diameters for catheters) one time a day every 14 days..." In a separate interview with the RN 2 on 2/6/17 at 9:30 a.m., RN 2 stated that the foley bag was changed yesterday but not the foley catheter. Review of the care plan dated 1/16/19, indicated, Resident 5 "has foley catheter d/t (due/to) Neurogenic Bladder and obstructive uropathy... Intervention include change catheter per policy/physician order." 2. Review of the Admission Record showed Resident 86 was admitted on 4/25/18 with multiple diagnosis including, Chronic Respiratory Failure and Dependence on Respirator (Ventilator) Status." In an observation on 2/5/19 at 9:30 a.m., Resident 86 was sitting in a recliner in the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1U1711 Facility ID: CA020000083 If continuation sheet 12 of 31 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056327 (X3) DATE SURVEY COMPLETED 02/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WALNUT CREEK SKILLED NURSING & REHABILITATION CENTER 1224 Rossmoor Parkway Walnut Creek, CA 94595 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE hallway in front of the subacute nursing station. Resident 86 had a tracheostomy tube (a curved tube that was surgically inserted into the neck and windpipe to facilitate breathing) was connected to the ventilator. Resident 86's emergency setup bag was empty. RN 3 went to Resident 86's room and found that the emergency setup was not at the bedside. RN 3 went to the supply room to get a new emergency set up to include an ambu bag (a bag mask set up used to help patient breath in an emergency) for Resident 86. In an interview with RN 3 on 2/5/19 at 9:50 a.m., RN 3 acknowledged that the emergency setup bag was empty and he was not able to find an emergency setup in Resident 86's room. RN 3 stated that he was not aware that there was no emergency setup for Resident 86. Review of the physician's order dated 10/4/18, indicated, "Emergency setup: 1 same size trach box, 1 smaller size trach box, obturator, lubrication kit, 10 cc empty syringe, trach gauge and normal saline... every shift."

F686 Treatment/Svcs to Prevent/Heal Pressure Ulcer F686 04/04/2019 SS=G CFR(s): 483.25(b)(1)(i)(ii) §483.25(b) Skin Integrity §483.25(b)(1) Pressure ulcers. Based on the comprehensive assessment of a resident, the facility must ensure that(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and (ii) A resident with pressure ulcers receives necessary treatment and services, consistent FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1U1711 Facility ID: CA020000083 If continuation sheet 13 of 31 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056327 (X3) DATE SURVEY COMPLETED 02/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WALNUT CREEK SKILLED NURSING & REHABILITATION CENTER 1224 Rossmoor Parkway Walnut Creek, CA 94595 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to monitor and revise the interventions developed for potential skin breakdown for one of three residents (Resident 41) who was at risk for skin breakdown. Resident 41 developed redness/discoloration over the coccyx/sacrum (large triangular bone at the base of the spine also know as the tailbone) which was not acted upon until two months later when the reddened area progressed into an unstageable pressure ulcer (obscured full thickness skin and tissue loss) containing seventy-five percent slough (soft, moist, dead tissue). Findings: A review of Resident 41's Admission Minimum Data Set (MDS- an assessment tool) dated 2/19/18 showed Resident 41 was admitted to the facility on 2/12/18, required two persons physical assist to position body while in bed, move to and from a lying position, and turn side to side, and was always incontinent of bladder and bowel. The MDS showed Resident 41 had no healed or unhealed pressure ulcers upon admission, but was at risk for developing a pressure ulcer. A review of Resident 41's Quarterly MDS dated 11/16/18 showed Resident 41 had no pressure ulcers but was at risk for developing a pressure ulcer. During a review of Resident 41's quarterly Braden scale (a tool for assessing a patient's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1U1711 Facility ID: CA020000083 If continuation sheet 14 of 31 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056327 (X3) DATE SURVEY COMPLETED 02/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WALNUT CREEK SKILLED NURSING & REHABILITATION CENTER 1224 Rossmoor Parkway Walnut Creek, CA 94595 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE risk for developing a pressure ulcer) indicated, on 6/1/18 a score of fifteen (at risk), 10/8/18 a score of thirteen (moderate risk), and 11/22/18 a score of fourteen (moderate risk). Review of Resident 41's care plan initiated on 2/16/18 indicated, "Monitor/document/report to MD (Medical Doctor) PRN (as needed) changes in skin status: appearance, color, wound healing, signs and symptoms of infection, wound size (length X width X depth), stage. Resident has pressure relieving mattress and chair cushion. Resident needs assistance to turn/reposition at least every two hours, more often as needed or requested." A review of Resident 41's skin/wound note dated 11/30/18 at 12:01 p.m., indicated an unstageable pressure ulcer to coccyx was observed by the wound treatment registered nurse (WTRN), and measured 1.2 centimeters by 0.9 centimeters with seventy-five percent slough and twenty-five percent granulation (new tissue). During an observation and concurrent interview on 2/6/19 at 9:36 a.m., Resident 41 was given wound care to sacral pressure ulcer by WTRN. An approximate four centimeter by one and one half centimeter open area was observed on sacrum. WTRN stated the pressure ulcer was unstageable with fifty percent slough and fifty percent granulation and tunneling (a passageway underneath the skin through soft tissue with potential for abscess formation) from seven o'clock to five o'clock. Resident 41 was given routine Tylenol for pain but was yelling at times during procedure. WTRN stated the sacral pressure ulcer was discovered on 11/30/18. During a review of the Certified Nursing Assistant's (CNA) documented skin FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1U1711 Facility ID: CA020000083 If continuation sheet 15 of 31 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056327 (X3) DATE SURVEY COMPLETED 02/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WALNUT CREEK SKILLED NURSING & REHABILITATION CENTER 1224 Rossmoor Parkway Walnut Creek, CA 94595 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE observations for Resident 41 for October 2018 and November 2018, "discoloration" was documented on 10/5/18 and 11/22/18; and "red area" was documented on the following dates: 10/8/18, 10/11/18, 10/16/18, 10/17/18, 10/18/18, 10/27/18, 11/3/18, 11/4/18, 11/19/18, 11/26/18, 11/28/18, and 11/29/18. During a phone interview with CNA 4 on 2/11/19 at 10:15 a.m., he stated he documented redness of the skin on Resident 41's buttocks area on 10/16/18, 10/27/18, 11/3/18, 11/4/18, 11/19/18, and 11/26/18, and reported it to the charge nurse every time. During a phone interview with CNA 5 on 2/7/19 at 1:35 p.m., she stated on 11/4/18 she documented redness of the skin on Resident 41's buttocks area and notified the charge nurse. During an interview and concurrent record review with licensed vocational nurse (LVN) 3 on 2/7/19 at 8:45 a.m., LVN 3 stated she was unable to locate the weekly skin integrity forms, progress notes or any report to the physician regarding a change in Resident 41's skin condition in the medical record for Resident 41. LVN 3 stated that weekly skin checks were to be completed by the licensed nurses every week on all residents. LVN 3 stated she was unable to locate any notification of changes of Resident 41's skin until 11/30/18 when an unstageable pressure ulcer was discovered. LVN 3 stated she had to discipline licensed nurses on 11/30/18 for not reporting the CNA's findings when the licensed nurses were notified by the CNAs of the reddened area on Resident 41's skin on 10/16/18, 10/27/18, 11/3/18, 11/4/18, 11/19/18, and 11/26/18. During a review of Resident 41's weekly licensed nurse progress notes on 10/10/18, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1U1711 Facility ID: CA020000083 If continuation sheet 16 of 31 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056327 (X3) DATE SURVEY COMPLETED 02/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WALNUT CREEK SKILLED NURSING & REHABILITATION CENTER 1224 Rossmoor Parkway Walnut Creek, CA 94595 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 10/17/18, 10/24/18, 11/7/18, 11/14/18 and 11/21/18 indicated, "Resident has no new skin issues." Review of the facility's policy and procedure titled, "Prevention of Pressure Ulcers," revised September 2013 indicated, "Routinely assess and document the condition of the resident's skin per Weekly Skin Integrity form for any signs and symptoms of irritation or breakdown. Report any signs of a developing pressure ulcer to the physician."

F698 SS=E Dialysis CFR(s): 483.25(l)

F698 04/04/2019 §483.25(l) Dialysis. The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. This REQUIREMENT is not met as evidenced by: Based on observation, interviews and record review the facility failed to provide hemodialysis [(HD), a process treatment where excess fluid and waste are removed from the body via the blood] services consistent with the professional standards of practice for two (Residents 37 and 88) of 34 sampled residents when: 1. the staff were not knowledgeable in the care and management of HD residents. 2. there were no consistent communication between the physician, facility and the dialysis FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1U1711 Facility ID: CA020000083 If continuation sheet 17 of 31 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056327 (X3) DATE SURVEY COMPLETED 02/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WALNUT CREEK SKILLED NURSING & REHABILITATION CENTER 1224 Rossmoor Parkway Walnut Creek, CA 94595 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE center for Resident 37 and 88. 3. facility failed to train staff on how to assess, document and manage HD residents. 4. the staff failed to follow physician's order to administer medication to Residents 37 on the dialysis days. These failures had the potential to result in staff not recognizing early preventable complications associated with dysfunctional access site between hemodialysis treatments and consequently lead to delayed medical intervention. Findings: 1. Review of the Record of Admission showed Resident 88 was admitted to the facility with multiple diagnosis including End Stage Renal Disease [(ESRD) - kidney disease] on HD. In an observation and concurrent interview on 2/4/19 at 8:30 a.m., Resident 88 was awake lying in bed watching television. Resident 88 stated that her HD days "are Monday, Wednesdays, and Fridays." Resident 88 added that she just had surgery on her right arm for future HD access and that the center used her right chest central line to do her dialysis. In an interview with the Licensed Vocational Nurse (LVN 1) on 2/5/19 at 9:00 a.m., LVN 1 stated that Resident 88's HD site was on the right forearm. LVN 1 added that she listened to the Thrill and feel the Bruit on Resident 88's right forearm (a bruit is an audible vascular sound associated with turbulent blood flow usually heard with the stethoscope, thrill is the turbulence of blood flow that can be palpated/felt). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1U1711 Facility ID: CA020000083 If continuation sheet 18 of 31 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056327 (X3) DATE SURVEY COMPLETED 02/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WALNUT CREEK SKILLED NURSING & REHABILITATION CENTER 1224 Rossmoor Parkway Walnut Creek, CA 94595 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 2. Review of the Dialysis Communication Record between the facility and the dialysis center showed, on Resident 88's HD days on 1/18/19, 1/21/19, 1/23/19, 1/25/19, 1/30/19 staff documented that Bruit and Thrill were not present. On 2/1/19 facility staff did not complete Resident 88's vascular access assessment. In an interview with the Director of Staff Development (DSD) on 2/5/19 at 11:00 a.m., DSD was not able to show that the physician was notified that the Bruit and Thrill on Resident 88's RA fistula was absent on the dates indicated. Review of the facility's policy titled, "Dialysis Management", dated 2016 indicted, "The facility employs qualified nursing staff to care for residents receiving dialysis treatment; including assessment and communication of dialysis related concerns." "Facility personnel shall notify the physician and designated dialysis representative of weight loss... Licensed Nurses assess, manage and report changes in bruit or thrill, bleeding, infections, hypertension or hypotension, ..." 3. In an interview with LVN 4 on 2/7/19 at 10:15 a.m., LVN 4 was not able to answer how she would assess the HD site except for bleeding complications. LVN 4 stated that she was not trained on the care of residents with ESRD on HD. Review of the "Inservice ComplianceTraining Record", attendance roster dated 10/10/18 showed LVN 1 and LVN 4 did not attend the training. 4. Review of the Admission Record indicated Resident 37 was admitted to the facility with multiple medical diagnoses that included end stage renal disease (ESRD: a condition in FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1U1711 Facility ID: CA020000083 If continuation sheet 19 of 31 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056327 (X3) DATE SURVEY COMPLETED 02/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WALNUT CREEK SKILLED NURSING & REHABILITATION CENTER 1224 Rossmoor Parkway Walnut Creek, CA 94595 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE which the kidneys lose the ability to remove waste and balance fluids) and was treated with hemodialysis outside the facility, three times a week on Monday, Wednesday and Friday. Review of the Physician Orders dated 10/30/18, indicated: "Renvela Packet: 0.8 mg, one packet, by mouth, three times a day." Review of the Medication Administration Record (MAR) for the month of November 2018 indicated: "Renvela 0.8 mg, one packet, to be given at 8:00 a.m." was not administered on the following days: November 2, 5, 7, 9, 12, 14, 16, and 19. Further review of November 2018 MAR indicated: "Renvela Packet 2.4 mg, three packets, to be given at 8:00 a.m." was not administered on the following days: November 23, 26 and 27. For the month of December 2018: "Renvela 2.4 mg, one packet, to be taken at 8:00 a.m." was not administered on December 1st. For the month of January 2019: "Renvela Tablet 1600 mg, to be taken at 7:00 a,m." was not administered on January 23. During an interview and concurrent record review with LVN 3 on 2/5/19 at 11:20 a.m., LVN 3 stated, Staff were not administering Renvela because Resident 37 "leaves early morning at 6:00 a.m. for her dialysis and comes back around 10:30 a.m." During an interview and concurrent record review with the Director of Nursing (DON) on 2/7/19 at 8:45 a.m., the DON stated she would give an in-service with the nursing staff as soon as possible.

F760 SS=E Residents are Free of Significant Med Errors CFR(s): 483.45(f)(2) FORM CMS-2567(02-99) Previous Versions Obsolete

F760 Event ID: 1U1711 04/04/2019 Facility ID: CA020000083 If continuation sheet 20 of 31 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056327 (X3) DATE SURVEY COMPLETED 02/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WALNUT CREEK SKILLED NURSING & REHABILITATION CENTER 1224 Rossmoor Parkway Walnut Creek, CA 94595 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The facility must ensure that its§483.45(f)(2) Residents are free of any significant medication errors. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to ensure that two (Resident 37 and 88) of 34 sampled residents were free from significant medication errors when: 1. Renagel [a phosphate binder drug used to lower high blood phosphorus (phosphate) levels in patients who are on hemodialysis (HD) - a process in cleaning toxins in the blood due to severe kidney disease] were administered to Residents 37 and 88 without meals. 2. the physician was not notified that the phosphate binder medication for Resident 37 was not given during HD days. These failures had the potential to result in significant electrolyte imbalance for Resident 37 and 88 that could lead to life threatening complications. Findings: 1. Review of the Record of Admission showed Resident 88, was admitted to the facility on 4/21/18 with multiple diagnosis including Acute Kidney Failure, Dependent on Renal Dialysis. In an observation and concurrent interview on 2/4/19 at 8:05 a.m., Resident 88 was awake lying in her bed in her room. Resident 88 stated that she had finished her breakfast but had not received her medications for this morning. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1U1711 Facility ID: CA020000083 If continuation sheet 21 of 31 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056327 (X3) DATE SURVEY COMPLETED 02/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WALNUT CREEK SKILLED NURSING & REHABILITATION CENTER 1224 Rossmoor Parkway Walnut Creek, CA 94595 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE In an interview with the Licensed Vocational Nurse (LVN 1) on 2/4/19 at 8:25 a.m., LVN 1 stated that she had not given Resident 88 her morning medications and that she would prepare them now. In a separate observation and concurrent interview on 2/5/19 at 12:05 a.m., Resident 37 was in the dining room on the other side of the building eating lunch. Resident 88 stated that she had not received her noon medications. In an interview with LVN 1 on 2/15/19 at 1:15 a.m., LVN 1 acknowledged that she had not given Resident 88's noon medications including the phosphate binder because Resident 88 was in the dining room. LVN 1 stated that she would give Resident 88's medication when she returned from the dining room. When asked about how the medication should be administered to the resident, LVN 1 was not able to answer that a phosphate binder medication should be given with meals. Review of the physician's order dated, 11/8/18, "Renagel Tablet 800 mg, Give 800 mg by mouth three times a day for chronic kidney disease take with meals". According to the National Institute of Health publication "Daily Med", dated, 10/19/18, "Renagel is a phosphate binder indicated for the control of serum phosphorus in patients with chronic kidney disease on dialysis. Take Renagel with meals based on serum phosphorus level. [Ref: https://dailymed.nlm.nih.gov/dailymed/drugInfo. cfm?setid=5e30120b-f2bf-43a0-86b244ae996dc681] 2. Review of the Admission Record indicated Resident 37 was admitted to the facility with multiple medical diagnoses that included End Stage Renal Disease (ESRD: a condition in FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1U1711 Facility ID: CA020000083 If continuation sheet 22 of 31 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056327 (X3) DATE SURVEY COMPLETED 02/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WALNUT CREEK SKILLED NURSING & REHABILITATION CENTER 1224 Rossmoor Parkway Walnut Creek, CA 94595 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE which the kidneys lose the ability to remove waste and balance fluids) and was being treated with hemodialysis outside the facility, three times a week on Monday, Wednesday and Friday. During an interview with Resident 37 on 2/7/19 at 8:05 a.m., Resident 37 stated, "The staff usually gives me Renvela without food before I leave around 6:00 - 6:30 a.m., for my dialysis appoinment." Review of the Physician Orders dated 10/30/18, indicated "Renvela Packet: 0.8 mg, one packet, by mouth, three times a day." Review of the Medication Administration Record (MAR) for the month of November 2018 indicated: "Renvela 0.8 mg, one packet to be given at 8:00 a.m." was not administered on the following days: November 2, 5, 7, 9, 12, 14, 16, and 19. Further review of the November 2018 MAR indicated: "Renvela Packet 2.4 mg, three packets to be given at 8:00 a.m." was not administered on the following days: November 23, 26 and 27. For the month of December 2018: "Renvela 2.4 mg, one packet to be taken at 8:00 a.m." was not administered on December 1st. For the month of January 2019: "Renvela Tablet 1600 mg to be taken at 7:00 a,m." was not administered on January 23. During a telephone interview with Physician 1 on 2/7/19 at 9:32 a.m., Physician 1 stated she was not notified of the Renvela not being given during dialysis days and Renvela should be given with meals to help control the phosphorus level in the body.

F812 Food Procurement,Store/Prepare/Serve- FORM CMS-2567(02-99) Previous Versions Obsolete

F812 Event ID: 1U1711 04/04/2019 Facility ID: CA020000083 If continuation sheet 23 of 31 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056327 (X3) DATE SURVEY COMPLETED 02/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WALNUT CREEK SKILLED NURSING & REHABILITATION CENTER 1224 Rossmoor Parkway Walnut Creek, CA 94595 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) SS=E Sanitary CFR(s): 483.60(i)(1)(2) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.60(i) Food safety requirements. The facility must §483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities. (i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations. (ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. (iii) This provision does not preclude residents from consuming foods not procured by the facility. §483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure food and canned goods were stored under sanitary conditions. This deficient practice placed residents at risk for developing food borne illnesses. Findings: During an initial observation of the dietary department on 1/14/19 at 8:21 a.m. the following were observed: 1. one dented 6 pound 8 ounce can of sliced apples was on the shelf in the dry storage area; and, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1U1711 Facility ID: CA020000083 If continuation sheet 24 of 31 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056327 (X3) DATE SURVEY COMPLETED 02/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WALNUT CREEK SKILLED NURSING & REHABILITATION CENTER 1224 Rossmoor Parkway Walnut Creek, CA 94595 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 2. five dented three pound two ounce cans of cream of chicken soup were on the shelf in the dry storage area. During an interview with RD on 1/14/19 at 8: 21 a.m., RD stated cans were inspected for dents when they were delivered and before the cans were put on the storage shelves for use in facility. RD stated all staff, including herself, were to spot check for dented cans. RD stated the facility's procedure was to place all dented cans together in dented can storage to be returned. RD acknowledged one six pound eight ounce can of sliced apples was dented and five three pound 2 ounce cans of creamed chicken soup were dented; these cans were on the shelves, and were not placed in dented can storage. 2. During an observation on 2/4/19 at 8:42 a.m., there were opened, unlabeled, undated bottles of Ketchup, soy sauce, mustard, pickled peppers, olives, jalapenos, a bag of potatoes chips, coffee creamer, jelly, peanut butter and syrup that were stored together with facial cream, lotion and briefs on Resident 99's bedside table. During an interview with Certified Nursing Assistant 1 (CNA 1) on 2/4/19 at 8:45 a.m., CNA 1 stated Resident 99's "family brings a lot of food when they come and visit". CNA 1 was unable to answer when asked about the facility's practice about family members bringing food into the facility. Review of Policy and Procedure titled, "Use and Storage of Food Brought to Residents by Family-Others" dated 10/2017 indicated: "Foods brought into the facility by family members should be in re-sealable containers with tight-fitting lids when retained in residents room. Perishable foods must be stored in the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1U1711 Facility ID: CA020000083 If continuation sheet 25 of 31 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056327 (X3) DATE SURVEY COMPLETED 02/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WALNUT CREEK SKILLED NURSING & REHABILITATION CENTER 1224 Rossmoor Parkway Walnut Creek, CA 94595 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE refrigerator, in re-sealable containers with tightly fitting lids. Containers will be labeled with the resident's names, and the manufacturer "use by date" as applicable."

F880 SS=D Infection Prevention & Control CFR(s): 483.80(a)(1)(2)(4)(e)(f)

F880 04/04/2019 §483.80 Infection Control The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. §483.80(a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: §483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards; §483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to: (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1U1711 Facility ID: CA020000083 If continuation sheet 26 of 31 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056327 (X3) DATE SURVEY COMPLETED 02/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WALNUT CREEK SKILLED NURSING & REHABILITATION CENTER 1224 Rossmoor Parkway Walnut Creek, CA 94595 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; (iv)When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and (vi)The hand hygiene procedures to be followed by staff involved in direct resident contact. §483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility. §483.80(e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. §483.80(f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary. This REQUIREMENT is not met as evidenced by: Based on an observation, interview and record review the facility failed to follow its established practice of removing gloves from the dispensing box and performing hand hygiene FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1U1711 Facility ID: CA020000083 If continuation sheet 27 of 31 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056327 (X3) DATE SURVEY COMPLETED 02/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WALNUT CREEK SKILLED NURSING & REHABILITATION CENTER 1224 Rossmoor Parkway Walnut Creek, CA 94595 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE with glove changes during wound dressing changes for one (Resident 75) of 34 sampled residents. This failure increased the potential for cross contamination. Findings: During an observation of a wound dressing change with Licensed Vocational Nurse 1 (LVN 1) and LVN 2 on 2/5/19 at 12:30 p.m. for Resident 75, LVN 1 removed multiple gloves from the dispensing box and placed them on top of the over bed table with no barrier. LVN 1 used the gloves from the over bed table leaving the gloves on from the beginning to the end without washing their hands during the entire course of the wound dressing change. During an interview with LVN 2 on 2/5/19 at 12:35 p.m., LVN 2 stated they should be changing their gloves and wash hands after taking off the old dressing. The gloves should be removed from the dispensing box when ready to use. During an interview with the Director of Staff Development 1 (DSD 1) on 2/6/19 at 2:12 p.m., the DSD stated, "During wound dressing treatments, nurses are supposed to take off gloves, wash their hands after taking off the dressing and do hand hygiene in between glove changes during wound care". The DSD added, "And remove one pair of gloves from the dispensing box at a time." Review of the Policy and Procedure, titled, "Handwashing/Hand Hygiene" dated August 2015 indicated, "All personnel shall follow the hand washing hand hygiene procedures to help prevent the spread of infections to other personnel, residents and visitor. Use an FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1U1711 Facility ID: CA020000083 If continuation sheet 28 of 31 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056327 (X3) DATE SURVEY COMPLETED 02/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WALNUT CREEK SKILLED NURSING & REHABILITATION CENTER 1224 Rossmoor Parkway Walnut Creek, CA 94595 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE alcohol- based hand rub containing at least 62% alcohol: or alternatively, soap (antimicrobial or non- handling antimicrobial) and water for the following situations: After handling used dressings, contaminated equipment, etc., after contact with objects (e.g., medical equipment) in the immediate vicinity of the resident, perform hand hygiene before applying non-sterile gloves. remove one glove from the dispensing box at a time, touching only the top of the cuff."

F921 SS=E Safe/Functional/Sanitary/Comfortable Environ CFR(s): 483.90(i)

F921 04/04/2019 §483.90(i) Other Environmental Conditions The facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public. This REQUIREMENT is not met as evidenced by: Based on an observation and interview, the facility failed to provide maintenance services for a sanitary and comfortable environment for residents and staff when the floors of multiple rooms were sticky and dirty and the privacy curtain were dusty and worn, along with missing window blinds and broken baseboards with holes in the wall. These failures resulted in an environment that was unclean and in disrepair. Findings: During an observation on 2/4/19 between 8:10 a.m., and 8:40 a.m., the following was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1U1711 Facility ID: CA020000083 If continuation sheet 29 of 31 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056327 (X3) DATE SURVEY COMPLETED 02/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WALNUT CREEK SKILLED NURSING & REHABILITATION CENTER 1224 Rossmoor Parkway Walnut Creek, CA 94595 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE observed: 1. In Room 108, the floor was sticky with brown colored liquid and small pieces of white paper on the floor; and there were a broken baseboard and two large holes in the wall. 2. In Room 304, the privacy curtain was torn with a brown colored stain. 3. In Room 310, the floor was dusty and sticky with multiple pieces of papers on the floor and there were three pieces of blinds missing from the window. During an interview with Resident 194 on 2/5/19 at 9:46 a.m., Resident 194 stated, "I thought it was cleaned because I told the cleaning lady of the dirty floor yesterday." Resident 194 added, "I was admitted to the facility a week ago and I noticed the hole in the wall." Resident 194 stated, "The Supervisor came and told me they will fix it." During a follow up observation and concurrent interview with Maintenance Supervisor (MS) on 2/6/19 at 7:30 a.m., MS acknowledged the wall had two large holes and a broken baseboard as well as the floor was dirty in Room 108. MS also acknowledged the privacy curtain in Room 304 was torn and the floor was dirty and sticky and that there were three blinds missing from the window in Room 310. MS stated, "I will ask the housekeeper to clean the dirty rooms, and will fix the broken wall and baseboard as soon as possible." During an interview with Certified Nursing Assistant 3 (CNA 3) on 2/7/19 at 8:38 a.m., CNA 3 stated, "We reported the dirty rooms to the housekeeper, but the housekeeper told us, 'It's not your job to report the dirty rooms to the janitor.'" FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1U1711 Facility ID: CA020000083 If continuation sheet 30 of 31 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056327 (X3) DATE SURVEY COMPLETED 02/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WALNUT CREEK SKILLED NURSING & REHABILITATION CENTER 1224 Rossmoor Parkway Walnut Creek, CA 94595 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) FORM CMS-2567(02-99) Previous Versions Obsolete ID PREFIX TAG Event ID: 1U1711 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) Facility ID: CA020000083 (X5) COMPLETE DATE If continuation sheet 31 of 31