Other·August 25, 2017

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following represents the findings of the California Department of Public Health during the investigation of a complaint. Complaint number: CA00499461 Representing the Department: Health Facilities Evaluator Nurse: 35388 The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. Two deficiencies were issued for the complaint number CA00499461

F157 SS=D NOTIFY OF CHANGES (INJURY/DECLINE/ROOM, ETC) CFR(s): 483.10(b)(11)

F157 11/29/2016 A facility must immediately inform the resident; consult with the resident's physician; and if known, notify the resident's legal representative or an interested family member when there is an accident involving the resident which results in injury and has the potential for requiring physician intervention; a significant change in the resident's physical, mental, or psychosocial status (i.e., a deterioration in health, mental, or psychosocial status in either life threatening conditions or clinical complications); a need to alter treatment significantly (i.e., a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or a decision to transfer or discharge the resident from the facility as specified in §483.12(a). The facility must also promptly notify the 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: 9QFC11 Facility ID: CA020000105 If continuation sheet 1 of 7 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: _______________ 056021 (X3) DATE SURVEY COMPLETED 10/31/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LONE TREE POST ACUTE 4001 Lone Tree Way Antioch, CA 94509 (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 and, if known, the resident's legal representative or interested family member when there is a change in room or roommate assignment as specified in §483.15(e)(2); or a change in resident rights under Federal or State law or regulations as specified in paragraph (b)(1) of this section. The facility must record and periodically update the address and phone number of the resident's legal representative or interested family member. This REQUIREMENT is not met as evidenced by: Based on interview and record review the facility failed to notify the Responsible Party (RP) for one (1) of three sampled residents when Resident 1 had a fall. This failure resulted in the resident's RP not having the option to make decisions about treatment. Findings: During a review of the medical record for Resident 1, the admission record showed she was admitted 8/1/15. A review of Resident 1's Minimum Data Set Assessment (MDSassessment tool), dated 5/5/16, indicated severe memory impairmen, which prevented her from making her own health care decisions. A review of the Licensed Vocational Nurse (LVN) 1's progress note for 8/11/16 at 2:26 p.m., showed Resident 1 had a fall when she was transferred to the wheelchair. LVN 1 attempted to call Resident 1's Responsible Party on 8/11/16, but the line was busy. No further calls were documented. The Post Fall Observations form, dated 8/11/16 at 2:30 p.m., showed Resident 1 received a skin tear of her left thumb due to the fall. There were no more nursing progress notes written until 8/13/16. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9QFC11 Facility ID: CA020000105 If continuation sheet 2 of 7 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: _______________ 056021 (X3) DATE SURVEY COMPLETED 10/31/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LONE TREE POST ACUTE 4001 Lone Tree Way Antioch, CA 94509 (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 Progress notes on 8/13/16 at 6:58 a.m. indicted ,"Skin discoloration, inflammation, deformity to right knee. Resident cries out in pain with movement and gentle touch. Also noted with skin discoloration/inflammation to right ankle, skin discoloration to right hand/arm." Nursing progress notes, dated 8/13/16 at 7:00 a.m., indicated Resident 1 had severe pain (eight out of ten), swelling of her right thigh and bruising of right knee and ankle. Resident 1 was transferred to the hospital. Hospital x-ray records showed she had fractures of both thigh bones. During a telephone interview on 9/7/16 at 1:20 p.m., Resident 1's RP, stated he was not notified of Resident 1's fall on 8/11/16, until Resident 1 was transferred to the hospital on 8/13/16. RP stated because he was not notified of the fall, he was unable to request additional follow up information after it occurred. The facility policy and procedure titled, "Assessing Falls, Their Causes, Definition" indicated after a fall the nursing staff will notify the resident's family in an appropriate time frame.

F323 SS=G FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES CFR(s): 483.25(h)

F323 11/29/2016 The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9QFC11 Facility ID: CA020000105 If continuation sheet 3 of 7 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: _______________ 056021 (X3) DATE SURVEY COMPLETED 10/31/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LONE TREE POST ACUTE 4001 Lone Tree Way Antioch, CA 94509 (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 devices to prevent accidents. This REQUIREMENT is not met as evidenced by: Based on interview, and record review, the facility failed to prevent a fall with fractures for one of three sampled residents (Resident 1), when Certified Nurse Assistant (CNA) 1 transferred Resident to the wheelchair without assistance. This failure resulted in Resident 1 sustaining severe injuries, including fractures of both thigh bones. Findings: A review of the clinical record on 8/19/16 showed Resident 1 was admitted on 8/1/15 with diagnoses including dementia (problems with memory, thinking and behavior). The Minimum Data Set Assessment (MDS, an assessment tool), dated 5/5/16, showed Resident 1 required extensive assistance of two or more persons to transfer to and from the bed and the wheelchair. Resident 1's care plan, updated on 8/5/16, showed a risk for falls due to a heart condition, arthritis, receiving a medication (Metropol) with risks for side effects, such as dizziness, a history of falls, attempted unsafe self transfers, poor vision and resistance to care at times. The facility's approach to decrease the risk for falls included transfers with extensive assistance. Resident 1's care plan also indicated she had previous falls on 8/27/15 and 12/15/15. A Post Fall Observation (nurse assessment form completed after a fall), dated 8/11/16 at 2:30 p.m., indicated Resident 1 started to fall during a transfer to the wheelchair and was assisted to the floor by CNA 1. Facility progress notes, dated 8/13/16 at 7:00 a.m., almost two days FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9QFC11 Facility ID: CA020000105 If continuation sheet 4 of 7 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: _______________ 056021 (X3) DATE SURVEY COMPLETED 10/31/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LONE TREE POST ACUTE 4001 Lone Tree Way Antioch, CA 94509 (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 after the fall, indicated Resident 1 had pain in her right leg with swelling of the thigh and knee. Resident 1 was transferred to the hospital on 8/13/16. During an interview on 8/19/16 at 11:15 a.m., CNA 1 stated she was assisting Resident 1 to the wheelchair at 2:10 p.m. on 8/11/16. CNA 1 stated she sat Resident 1 up on the side of the bed and lifted her by holding her around the waist. CNA 1 told Resident 1 to hold onto her. Resident 1 reached to grab the arm of the wheelchair. The wheelchair tilted and CNA 1 and Resident 1 went to the floor. CNA 1 further stated most staff do not want to put Resident 1 in the wheelchair because it is not easy. CNA 1 stated, "She puts up a fuss." During an interview on 9/7/16 at 11:27 a.m., CNA 2 stated she cared for Resident 1 on 8/11/16. CNA 2 stated she placed Resident 1 back in bed from the wheelchair with the assistance of another CNA 3 at about 3:10 p.m. CNA 2 stated Resident 1 was yelling and holding her right side when she put her back in bed. CNA 2 stated she always used two people to transfer Resident 1 from the wheelchair, because she was not comfortable moving Resident 1 by herself. During an interview on 9/7/16 at 11:35 a.m., Licensed Vocational Nurse 1 (LVN 1) stated she cared for Resident 1 on the night shift on 8/11/16. LVN 1 stated she was told that Resident 1 had almost fallen, but had been caught by the CNA 1. LVN 1 did not document any after-fall assessment, nor observations of Resident 1 that night. A review of the facility's policy and procedure titled, Assessing Falls, Their Causes, Definition, dated 10/2010, indicated, "The definition of a fall is an unintentional change in FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9QFC11 Facility ID: CA020000105 If continuation sheet 5 of 7 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: _______________ 056021 (X3) DATE SURVEY COMPLETED 10/31/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LONE TREE POST ACUTE 4001 Lone Tree Way Antioch, CA 94509 (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 position coming to rest on the ground or floor. Nursing staff will observe for delayed complications of a fall for approximately seventy-two hours after an observed or suspected fall, and will document findings in the medical record." The policy and procedure also indicated, "Documentation will include any observed signs of pain, swelling, bruising, deformity and/or decreased mobility; and any change in level of responsiveness/consciousness and overall function. It will note the presence or absence of significant findings." During an interview on 8/19/16 at 9:40 a.m., Registered Nurse 1 (RN 1) stated she provided care for Resident 1 on 8/13/16. RN 1 stated CNA 3 told her Resident 1 had bruising and swelling of her right leg. RN 1 stated she examined Resident 1 and noted a sharp piece of bone just under the skin of her right thigh, her right knee was rotated inwardly, and her right knee and ankle were bruised. RN 1 stated she was not aware of the fall Resident 1 had on 8/11/16. During an interview on 9/22/16 at 3:04 p.m. the facility's Director of Nursing, stated Resident 1 did not get out of bed again after the fall on 8/11/16. A review of the hospital discharge summary dated 8/19/16, showed Resident 1 was treated at the hospital for a right femoral shaft stress fracture (break in the thigh bone caused by a twisting force) and a left femur comminuted fracture (break in the thigh bone when the bone has broken into three or more pieces). Resident 1 had surgery to repair the right femur fracture and a cast was placed on the right leg. Resident 1 was discharged from the hospital to have hospice care (end of life care). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9QFC11 Facility ID: CA020000105 If continuation sheet 6 of 7 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: _______________ 056021 (X3) DATE SURVEY COMPLETED 10/31/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LONE TREE POST ACUTE 4001 Lone Tree Way Antioch, CA 94509 (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 During a telephone interview on 9/27/16 at 9:46 a.m., the physician who treated Resident 1 in the emergency room (MD 1), stated he would not expect the types of fractures Resident 1 sustained to occur in an assisted fall. MD 1 stated the fracture to Resident 1's right leg was a high energy fracture, meaning a direct fall onto her right knee. MD 1 reviewed Resident 1's x-rays and stated he did not see any osteoporosis of her bones (condition in which bones become weak and brittle). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9QFC11 Facility ID: CA020000105 If continuation sheet 7 of 7