Health inspection·September 20, 2023

F 0559 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure one of three sampled residents (Resident 1) received a written notification prior to being moved to another room within the facility. This failure placed Resident 1 at risk to experience increased anxiety and confusion related to spontaneous/unplanned change of environment. Findings: During a review of Resident 1's admission Record dated 7/25/23, the record showed Resident 1 was admitted to the facility on [DATE] with diagnosis of Anxiety (worry that interferes with daily activities), Depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), Psychosis (loss of contact with reality), Mood disorder (inconsistent emotions leading to inability to function). During a review of Resident 1's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 5/23/23, the MDS assessment showed Resident 1's Brief Interview for Mental Status (BIMS- a mental status exam) was 12 of 15, indicating mildly impaired mental status. During a record review of facility's document with Resident Census dated 5/9/23 showed residents and their assigned room numbers. The document showed Resident 1 was in a room in Station 1, that day. During a record review of Resident 1's nursing progress notes dated 5/10/23, Licensed Vocational Nurse 3 (LVN 3) documented Resident 1 got moved to Station 3 . During a concurrent observation and interview on 7/25/23 at 9:35 a.m., Resident 1 was lying in bed, awake, in her room located in facility's Memory Care unit (a unit where facility placed residents with memory issues and behaviors) in Station 3. Resident 1 stated she was placed in that unit a few months back, did not like it there and began to cry. During an interview with Social Worker 1 (SW1) on 7/25/23 at 12:05 a.m., SW 1 stated she was involved in resident room changes and only gave verbal notification to the residents and/or the resident's responsible parties when room changes were done. During a concurrent interview and record review with Licensed Vocational Nurse 1 (LVN 1) on 7/25/23 at 1:50 p.m., at nursing station 3, Resident 1's electronic health record and paper chart were reviewed. LVN 1 stated she was the assigned charge nurse for Resident 1 that day. LVN 1 stated she was Page 1 of 3 555104 555104 09/20/2023 Concord Post Acute 1050 San Miguel Road Concord, CA 94518

F 0559 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few unable to find a written documentation of prior notification for room change given to Resident 1 and/or her responsible party. During an interview on 9/20/23 at 10:00 a.m., with Certified Nursing Assistant 2 (CNA2), in the Memory Care Unit, CNA 2 stated she physically helped move residents and their belongings during room changes but did not complete any paperwork for residents' room changes. During an interview on 9/20/23 at 10:05 a.m., with Licensed Vocational Nurse 2 (LVN 2) on the Memory Care Unit, LVN 2 stated he has worked at facility for five (5) years. LVN 2 stated facility didn't provide any notice of room changes to the residents. LVN 2 stated nurses just verbally notified the residents about room changes. During an interview with Director of Nursing (DON) on 9/20/23 at 11:00 a.m., the DON stated she was not aware of any written notice requirement for facility initiated resident room changes. 555104 Page 2 of 3 555104 09/20/2023 Concord Post Acute 1050 San Miguel Road Concord, CA 94518

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on an interview and record review the facility failed to ensure the Preadmission Screening and Resident Review (PASARR- an assessment of necessity for special services relating to psychiatric and/or intellectual disability) assessment for one of three sampled residents (Resident 1) was completed accurately. Resident 1's PASARR assessment did not reflect current diagnoses of Anxiety (a feeling of fear, dread, and uneasiness). This failure placed Resident 1 at risk to not receive care and services appropriate to her needs. Findings: During a review of Resident 1's admission record titled admission Record dated 7/25/23, the record showed Resident 1 was admitted to the facility on [DATE]. The record showed Resident 1 had diagnoses of Depression (loss of pleasure or interest in daily activities), Adult Failure to Thrive (physical decline, inactivity and depression), Mood Disorder (inconsistent emotions leading to inability to function), Anxiety Disorder, Psychosis (loss of contact with reality) and Cognitive Communicative Deficit (difficulty with thinking and language usage). During a review of Resident 1's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 5/23/23, showed Resident 1's Brief Interview for Mental Status (BIMS- a mental status exam) was 12 of 15, indicating mildly impaired mental status. During an interview on 9/20/23 at 11:00 a.m., the Director of Nursing (DON) stated the Admitting Nurse or the MDS Nurse completed the PASARR assessment for residents. During a concurrent interview and record review on 9/20/23 at 11:11 a.m., with the MDS Coordinator (MDSC 1), Resident 1's PASARR assessment dated [DATE] and Hospital Discharge notes dated 8/3/22 were reviewed. MDSC 1 stated he reviewed hospital discharge/transfer documentation to complete the PASARR assessment. MDSC 1 stated he did not always physically observe the residents to complete the PASARR assessment. MDSC 1 stated the hospital notes showed Resident 1 was admitted to the facility with a diagnosis of Anxiety Disorder. The PASARR assessment, under Section III-Serious Mental Illness Screen, 10. Does the individual have diagnosed mental disorder such as Depression, Anxiety, Panic, Schizophrenia/ Schizoaffective disorder, Psychotic, Delusional, and/or Mood Disorder? was marked as No . During an interview on 9/20/23 at 11:20 p.m., the MDSC 2 stated completing the PASARR assessment accurately was significant because it alerted the facilities if residents required additional behavioral services. MDSC 2 stated if assessment was not coded correctly, it placed the resident at risk to not receive necessary/additional behavioral services. 555104 Page 3 of 3