Health inspection·November 16, 2023

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm Based on facility policy review, record reviews, interviews, and facility document review, the facility failed to ensure a resident's wheelchair was operable for 1 (Resident #7) of 1 sampled resident reviewed for accommodation of needs. Residents Affected - Few Findings included: Review of a facility policy tilted, Maintenance Service, revised in December 2009, revealed 3. The Maintenance Director is responsible for developing and maintaining a schedule of maintenance service to assure that the buildings, grounds, and equipment are maintained in a safe and operable manner. A review of Resident #7's admission Record revealed the facility readmitted the resident on 09/23/2022, with diagnoses that included morbid obesity, retention of urine, and chronic obstructive pulmonary disease. A review of Resident #7's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/21/2023, revealed Resident #7 had a Brief Interview for Mental Status (BIMS) score of 6, which indicated the resident had severe cognitive impairment. The MDS revealed Resident #7 was totally dependent on staff for transfers and toilet use. The MDS revealed the resident required extensive staff assistance with locomotion on and off their unit. The MDS revealed Resident #7 had impairments on their left and right lower extremities. The MDS revealed the resident used a wheelchair. Review of Resident #7's care plan initiated on 12/22/2017, revealed the resident had limited physical mobility and used a wheelchair that they could only propel themselves a few feet. The care plan revealed interventions that included instructions for staff to provide assistance with mobility as needed. During an interview on 11/14/2023 at 9:29 AM, Resident #7 said the left wheel on their wheelchair was broken and was not operable. The resident said they were forced to stay in bed. The resident said they needed to get out of bed. During an interview on 11/14/2023 at 9:21 AM, Licensed Vocational Nurse (LVN) #7 revealed Resident #7 needed a new wheel on the left side of their wheelchair. LVN #7 stated Resident #7 had not had an operable wheelchair in over a month. LVN #7 said the maintenance staff was aware the wheelchair needed repaired. LVN #7 said the resident was lying in bed because their wheelchair was inoperable but said even when the resident's chair was operable, the resident would not get out of bed. Review of the Maintenance Log, for the unit where Resident #7 resided, dated06/23/2023 to 11/03/2023, revealed no evidence Resident #7's wheelchair had been reported for repair. Page 1 of 22 555104 555104 11/16/2023 Concord Post Acute 1050 San Miguel Road Concord, CA 94518

F 0558 Level of Harm - Minimal harm or potential for actual harm During an interview on 11/14/2023 at 3:34 PM, the Maintenance Director stated each month the residents' wheelchairs were washed, and any repairs were made. He said requests for repairs for residents' equipment should be placed on the Maintenance Log. The Maintenance Director said a request had not been made to repair Resident #7's wheelchair and he was not aware of the wheelchair did not work until 11/14/2023. Residents Affected - Few During an interview on 11/15/2023 at 10:47 AM, Certified Nurse Assistant (CNA) #5 stated she had not placed Resident #7 in their wheelchair because the wheelchair was broken. She said when Resident #7's family member visited, Resident #7 requested to be placed in their wheelchair. She said LVN #7 informed the resident the wheelchair was still broken. CNA #5 said she did not know how long the wheelchair had been broken. CNA #5 said she assumed a nurse, or an assistant reported the broken wheelchair on the maintenance log. During an interview on 11/26/2023 at 10:21 AM, Maintenance Assistant (MA) #17 indicated he repaired the resident's wheelchair in October 2023 but was unaware of a current issue with the wheelchair. He said facility staff had been educated to report equipment issues on the Maintenance Log and said sometimes staff reported issues to him directly. During an interview on 11/16/2023 at 2:24 PM, the Director of Nursing indicated she expected the CNAs' involvement in ensuring residents' wheelchairs were operable. She stated if a wheelchair did not work, facility staff should complete a form in the Maintenance Log, then the maintenance staff should check the log and address the issue. During an interview on 11/16/2023 at 3:23 PM, the Administrator indicated he expected nursing staff to inform the maintenance staff of a residents' wheelchair that required a repair. The Administrator said they always had other wheelchairs available, and a broken wheelchair should not dictate the care being provided. 555104 Page 2 of 22 555104 11/16/2023 Concord Post Acute 1050 San Miguel Road Concord, CA 94518

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm Based on interviews, record review, and facility policy review, the facility failed to implement their abuse prohibition policy when staff failed to identify an allegation as abuse. This failure to identify an allegation of abuse resulted in the allegation not being reported to the state, investigated, and the accused staff not being removed from resident contact, as directed by the facility's abuse prohibition policy for 1 (Resident #327) of 2 sampled residents reviewed for abuse. Residents Affected - Few Findings included: Review of a facility policy titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, revised in September 2022, revealed All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, and theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Policy Interpretation and Implementation Reporting Allegations to the Administrator and Authorities 1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and other officials according to state law. 2. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility. The policy revealed '3. 'Immediately' is defined as: a. within two hours of an allegation involving abuse or result in serious bodily injury; or b. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. The policy revealed 6. Upon receiving any allegations of abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source, the administrator is responsible for determining what actions (if any) are needed for the protection of residents. The section of the policy titled, Investigating Allegations, revealed 5. The administrator ensures that the resident and the person(s) reporting the suspected violation are protected from retaliation or reprisal by the alleged perpetrator, or by anyone associated with the facility.6. Any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete. A review of Resident #327's admission Record revealed the facility admitted the resident on 10/25/2023 with diagnoses that included depression, anxiety disorder, insomnia, essential hypertension, and acute and chronic respiratory failure with hypoxia. A review Resident #327's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/01/2023, revealed Resident #327 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. During an interview on 11/13/2023 at 12:17 PM, Resident #327 said a certified nurse assistant (CNA) made them feel intimidated and thought the CNA would retaliate against them due to report the resident made to a night shift nurse. The resident said the CNA would sit in the hallway on her phone and eat loudly. The resident said they asked a nurse to ask the CNA to be quieter, then the CNA came back into their room and told the resident that they were the worst resident and said the resident could close their door because she was not going to lower her voice. Resident #327 stated nobody had come to speak to them after the incident was reported to the nurse. The resident said they did not know the CNA's name or the nurse they reported the incident to. A review of Resident #327's Progress Notes revealed a late entry note, dated 10/29/2023 at 7:34 AM, 555104 Page 3 of 22 555104 11/16/2023 Concord Post Acute 1050 San Miguel Road Concord, CA 94518

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few which revealed during the night shift the resident reported to a nurse they felt unsafe in the facility due to a CNA. The Progress Note revealed, the resident reported they had pressed their call light due to not being able to sleep related to the CNA's loud voice. Per the Progress Note, Resident #327 reported the CNA answered their call light and told the resident they could close their door but did not agree to lower their voice. The Progress Note revealed, Resident #327 reported they felt threatened by the CNA's response and could no longer sleep due to fear of t the CNA. According to the Progress Note, Resident #327 reported the CNA's tone was aggressive and rude and the resident considered calling 911. The Progress Note indicated the CNA was asked to keep their voice down and to avoid the resident's room. The Progress Note revealed, the Facility Manager (FM) was notified of the incident. During an interview on 11/14/2023 at 9:39 AM Administrator indicated he had no reportable incidents since August 2023. During an interview on 11/14/2023 at 9:48 AM, the Facility Manager (FM) stated he did not remember the incident. The FM stated if an incident was reported to him, he would have gotten the social worker to start an abuse investigation. In a follow-up interview on 11/14/2023 at 2:10 PM, Resident #327 said the Administrator had not interviewed them about the incident. Resident #327 reported the CNA was rude and intimidating. During a telephone interview on 11/14/2023 at 4:43 PM, CNA #3 stated she did not remember any incident with any resident who complained about her. Per CNA #3, no nurse or facility staff had spoken to her about her tone of voice or about being quieter when the residents slept. She said she did not remember being told not to go into certain residents' rooms. During a telephone interview on 11/14/2023 at 4:55 PM, Registered Nurse (RN) #1 said she did remember the night Resident #327 reported to her they felt fearful and did not feel comfortable around CNA #3. Per RN #1, Resident #327 did seem fearful. According to RN #1, Resident #327 reported that CNA #3 was in the hallway eating loudly and had a phone conversation on speaker and was very loud. She said the resident could not sleep and knew it was bothering other residents too. RN #1 stated she did speak to CNA #3 about lowering her voice, that the residents were trying to sleep and to not go back into Resident #327's room. RN #1 stated she would answer the call lights for the resident. She stated Resident #327 told her that they did not feel comfortable and felt threatened so she stayed with the resident and ensured the resident they were safe, and that CNA #3 would no longer take care of them. RN #1 stated the way Resident #327 acted and told them about what happened, she considered the incident potentially to be abuse so she reported it to the FM. RN #1 stated she had not heard anything more about this incident and was never asked to write a statement. In a follow-up interview on 11/15/2023 at 10:28 AM, the FM acknowledged he did receive a telephone call from RN #1 related to the incident and he did not feel like it was an abuse allegation because it was about a loud voice. He said the incident occurred on 10/28/2023.He stated when he was notified of the incident the word abuse was not used. He said he was told the resident felt unsafe and thought about calling 911, but he thought that since he had the nurse speak with the CNA and remove her from caring for Resident #327, the incident was resolved. He said that he did not remove the CNA from resident contact. He stated the facility staff did not do an investigation because he did not consider it to be abuse. He stated no other staff or residents were interviewed. During an interview on 11/15/2023 at 12:24 PM, the Director of Staff Develeopment stated she was 555104 Page 4 of 22 555104 11/16/2023 Concord Post Acute 1050 San Miguel Road Concord, CA 94518

F 0607 Level of Harm - Minimal harm or potential for actual harm told a resident had voiced concerns about CNA #3 being too loud. She stated the nurse on the shift had in-serviced the CNA and told her not to go back into the resident's room who had voiced the concern. She stated she had not read the progress note related to the incident until 11/14/2023 and she was shocked that it was not investigated. She stated that if she had read it before, she would agree that it could be abuse and needed to be investigated. She stated the facility staff failed to investigate the incident. Residents Affected - Few During an interview on 11/16/2023 at 2:28 PM, the Director of Nursing stated that she expected her staff to report any incident that could be abuse to the Administrator or herself. She stated that if it were staff-to-resident abuse, then the staff would be suspended (removed from resident contact), and they would start an investigation. She said if she had read the progress notes about this incident, she would have started an investigation. During an interview on 11/16/2023 at 3:30 PM, the Administrator stated he did not think the incident which involved Resident #327 and CNA #3 needed to be reported or investigated as it was not an abuse allegation. He said the words in the progress note were unclear and needed clarified. He said he read the progress notes, and he thought the wording was inaccurate after speaking to the resident, nurse, and CNA. He said he would always report any abuse as required. 555104 Page 5 of 22 555104 11/16/2023 Concord Post Acute 1050 San Miguel Road Concord, CA 94518

F 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. Based on record reviews, document review, and interviews, the facility failed to ensure timely completion of comprehensive Minimum Data Set (MDS) assessments for 2 (Resident #142 and Resident #113) of 7 sampled residents reviewed for resident assessments. Findings included: Instrument 3.0 User's Manual, dated October 2023, revealed The admission assessment is a comprehensive assessment for a new resident and, under some circumstances, a returning resident that must be completed by the end of day 14. The document indicated, The ARD must be set no later than day 14, counting the date of admission as day 1. The document revealed, The Annual assessment is a comprehensive assessment for a resident that must be completed on an annual basis unless an SCSA [significant change in status assessment] or an SCPA [significant correction to prior comprehensive assessment] has been completed since the most recent comprehensive assessment was completed. A review of Resident #142's admission Record revealed the facility admitted the resident #142 on 07/01/2022. A review of Resident #142's annual MDS, with an Assessment Reference Date (ARD) of 07/09/2023, revealed the MDS was signed as being completed on 08/15/2023 by the MDS Registered Nurse (RN). A review of the facility's MDS 3.0 Final Validation Report, with a submission date of 08/18/2023, revealed Resident #142's annual MDS was signed as being completed more than 14 days after the ARD. A review of Resident #113's admission Record revealed the facility admitted the resident on 07/01/2023. A review of Resident #113's admission MDS, with an ARD of 07/08/2023, revealed the MDS was signed as being completed on 07/25/2023 by the MDS RN. A review of the facility's MDS 3.0 Final Validation Report, with a submission date of 07/27/2023, revealed Resident #113's admission MDS was signed as being completed more than 14 days after the resident admission date. During an interview on 11/16/2023 at 11:28 AM, the MDS RN stated a MDS assessment should be signed as being completed 14 days after the admission date or the ARD. The MDS RN stated he was responsible to sign the MDS assessment as being accurate and complete. The MDS RN stated he did not recall any reason why the MDS assessments were late. During an interview on 11/16/2023 at 2:46 PM, the Director of Nursing (DON) stated she was not sure about the timing of MDS assessments but thought they had to be completed 14 days from the ARD. The DON stated she was not aware there were late MDS assessments. During an interview on 11/16/2023 at 3:25 PM, the Administrator stated MDS assessments should be completed within 14 days of the ARD. The Administrator stated he was not aware MDS assessments in July 2023 were late. 555104 Page 6 of 22 555104 11/16/2023 Concord Post Acute 1050 San Miguel Road Concord, CA 94518

F 0638 Assure that each resident’s assessment is updated at least once every 3 months. Level of Harm - Minimal harm or potential for actual harm Based on record reviews, document review, and interviews, the facility failed to ensure timely completion of quarterly Minimum Data Set (MDS) assessments for 3 (Residents #98, #85, and #110) of 7 sampled residents reviewed for resident assessments. Residents Affected - Few Findings included: Instrument 3.0 User's Manual, dated October 2023, revealed The Quarterly assessment is an OBRA non-comprehensive assessment for a resident that must be completed at least every 92 days following the previous OBRA [Omnibus Budget Reconciliation Act] assessment of any type. It is used to track a resident's status between comprehensive assessment to ensure critical indicators of gradual change in a resident's after the ARD. A review of Resident #98's admission Record revealed the facility admitted the resident on 10/15/2020. A review of Resident #98's quarterly MDS, with an Assessment Reference Date (ARD) of 07/07/2023, revealed the MDS assessment was signed as being completed on 07/26/2023 by the MDS Registered Nurse (RN). A review of Resident #85's admission Record revealed the facility admitted the resident on 12/22/2017. A review Resident #85's quarterly MDS, with an ARD of 07/07/2023, revealed the MDS assessment was signed as being completed on 07/26/2023 by the MDS RN. A review of Resident #110's admission Record revealed the facility admitted the resident on 12/27/2019. A review of Resident #110's quarterly MDS, with an ARD of 07/07/2023, revealed the MDS assessment was signed as being completed on 07/26/2023 by the MDS RN. A review of the facility's MDS 3.0 Final Validation Report, with a submission date of 07/27/2023, revealed Residents #85, #98, and #110's quarterly MDS assessments were signed as being completed more than 14 days after the ARD. During an interview on 11/16/2023 at 11:28 AM, the MDS RN stated a MDS assessment should be signed as being completed 14 days after the admission date or the ARD. The MDS RN stated he was responsible to sign the MDS assessment as being accurate and complete. The MDS RN stated he did not recall any reason why the MDS assessments were late. During an interview on 11/16/2023 at 2:46 PM, the Director of Nursing (DON) stated she was not sure about the timing of MDS assessments but thought they had to be completed 14 days from the ARD. The DON stated she was not aware there were late MDS assessments. During an interview on 11/16/2023 at 3:25 PM, the Administrator stated MDS assessments should be 555104 Page 7 of 22 555104 11/16/2023 Concord Post Acute 1050 San Miguel Road Concord, CA 94518

F 0638 completed within 14 days of the ARD. The Administrator stated he was not aware MDS assessments in July 2023 were late. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 555104 Page 8 of 22 555104 11/16/2023 Concord Post Acute 1050 San Miguel Road Concord, CA 94518

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure the discharge Minimum Data Set (MDS) assessment was accurate for 1 (Resident #176) of 3 sampled residents reviewed for closed record review. Residents Affected - Few Findings included: A review of Resident #176's admission Record revealed the facility admitted Resident #176 on 07/04/2023. Per the admission Record, the resident discharged home on [DATE]. A review of Resident #176's discharge MDS, with an Assessment Reference Date (ARD) of 08/31/2023, revealed the resident discharged to an acute hospital on [DATE]. A review of Resident #176's discharge summary Progress Notes, dated 08/31/2023, revealed the resident discharged home on [DATE] at 11:20 AM. During an interview on 11/16/2023 at 11:28 AM, the MDS Registered Nurse (RN) stated he was responsible for ensuring the accuracy and completeness of the MDS assessments. The MDS RN stated that according to the Progress Notes, Resident #176 discharged home, and he verified the MDS assessment was coded incorrectly to indicate the resident discharged to the hospital. During an interview on 11/16/2023 at 2:46 PM, the Director of Nursing stated the MDS RN was responsible for the accuracy and completion of the MDS assessments. During an interview on 11/16/2023 at 3:25 PM, the Administrator stated he expected the MDS assessments to be accurate. 555104 Page 9 of 22 555104 11/16/2023 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 record reviews, interviews, and policy review, the facility failed to refer a resident with a newly evident serious mental disorder for a Level II Preadmission Screening and Resident Review (PASARR) for 2 (Resident #48 and Resident #130) of 5 sampled residents reviewed for PASARR requirements. Findings included: A review of the facility policy titled, admission Criteria, revised in March 2023, revealed b. If the level I screen indicates that the individual may meet the criteria for a MD [mental disorder], ID [intellectual disorder], or RD [related disorder], he or she is referred to the state PASARR representative for the Level II (evaluation and determination) screening process. 1. Review of Resident #48's admission Record revealed the facility admitted the resident on 01/25/2022 with diagnoses that included bipolar disorder and unspecified psychosis. A review of Resident #48's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/15/2023, revealed the resident had active diagnoses that included bipolar disorder and psychotic disorder. Review of Resident #48's Preadmission Screening and Resident Review Level I Screening, dated 10/14/2022, revealed the resident had diagnoses of psychosis and bipolar disorder. Review of a document from the State of California-Health and Human [NAME] Agency Department of Health Care Services addressed to the resident, carbon copied to the facility, and dated 10/14/2022, revealed a Level II Mental Health Evaluation Referral was required for Resident #48. During an interview on 11/14/2023 at 2:38 PM, the MDS Registered Nurse (RN) stated Resident #48's result of the Level I PASARR was positive and that a Level II PASARR should have been completed. The MDS RN acknowledged he failed to contact the Department of Health Care Services to have the Level II completed. During an interview on 11/16/2023 at 2:10 PM, the Director of Nursing (DON) stated the facility was responsible for ensuring the Level II evaluation was completed. During an interview on 11/16/2023 at 3:16 PM, the Administrator stated the MDS staff, and the DON were responsible for ensuring Level II evaluations were completed. 2. A review of Resident #130's admission Record revealed the facility admitted the resident on 08/04/2022. Per the admission Record, Resident #130 received a diagnosis of anxiety disorder on 08/25/2022 and diagnoses of depression and mood disorder on 10/14/2022. A review of Resident #130's annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/12/2023, revealed Resident #130 had active diagnoses to include anxiety disorder, depression, and psychotic disorder. A review of Resident #130's Preadmission Screening and Resident Review Level I Screening, dated 555104 Page 10 of 22 555104 11/16/2023 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 08/05/2022, revealed the resident did not have a diagnosed mental disorder such as depression, anxiety, panic, schizophrenia/schizoaffective disorder, psychotic, delusional, and/or mood disorder. The was not able to provide evidence a new Level I PASARR screening was completed after the resident received new mental disorder diagnoses. During an interview on 11/14/2023 at 3:05 PM, the MDS Registered Nurse (RN) indicated the facility would only do another Level I if the resident displayed a behavior that warranted a review. During an interview on 11/16/2023 at 1:05 PM, the Director of Nursing (DON) confirmed the facility did not submit a new Level I when Resident #130 was diagnosed with anxiety disorder. In a follow-up interview on 11/16/2023 at 2:14 PM, the DON confirmed a new Level I should have been submitted for Resident #130 for the new mental disorder diagnoses of depression and mood disorder. During an interview on 11/16/2023 at 3:18 PM, the Administrator indicated he was not a clinician, so he would rely heavily on the judgement of the DON and the MDS RN to determine when the PASARR screenings should be done. 555104 Page 11 of 22 555104 11/16/2023 Concord Post Acute 1050 San Miguel Road Concord, CA 94518

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review, interviews, and policy review, the facility failed to ensure staff followed professional standards of practice by not leaving medications at the bedside of 1 (Resident #128) of 8 residents observed for medication administration. Residents Affected - Few Findings included: A review of Resident #128's admission Record revealed the facility admitted the resident on 08/26/2021, with diagnoses that included chronic obstructive pulmonary disease (COPD), diabetes mellitus, fibromyalgia (nerve pain), hypertension (high blood pressure), malignant neoplasm (cancer) of the right breast, and chronic kidney disease. A review of Resident #128's annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/04/2023, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. A review of Resident #128's care plan initiated on 10/11/2021, revealed the resident had an alteration in neurological mental status related to disease process. Interventions directed staff to give medications as ordered. During medication administration observation on 11/15/2023 at 8:27 AM, Licensed Vocational Nurse (LVN) #12 prepared medications for Resident #128. The surveyor noted as LVN #12 placed six tablets in a medication cup for the resident. LVN #12 placed the medication cup, along with a cup of water on the resident's over-bed table. After LVN #12 talked with the resident about their upcoming appointments, LVN #12 walked out of the resident's room and left the six tablets in the medication cup on the resident's over-bed table. During an interview on 11/15/2023 at 12:51 PM, LVN #12 stated medications should not be left at the bedside unless the resident had been assessed to self-administer. She stated Resident #128 would be capable of administering their own medications but had not been assessed. LVN #12 stated she got busy talking about the appointments and forgot about the medications. During an interview on 11/16/2023 at 2:46 PM, the Director of Nursing stated medications should not be left at the bedside. During an interview on 11/16/2023 at 3:25 PM, the Administrator stated medications should not be left at the bedside and he expected medications to be administered as ordered by the physician according to professional standards. 555104 Page 12 of 22 555104 11/16/2023 Concord Post Acute 1050 San Miguel Road Concord, CA 94518

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, record review, and policy review, the facility failed to ensure respiratory equipment was sanitized and properly stored for 1 (Resident #134) of 4 sampled residents reviewed for respiratory care. Residents Affected - Few Findings included: Review of a facility policy titled, CPAP [continuous positive airway pressure]/BiPAP [Bi-level positive airway pressure] Support, revised in March 2015, revealed 8. Headgear (strap): Wash with warm water and mild detergent as needed. Allow to air dry. A review of Resident #134's admission Record revealed the facility admitted the resident on 09/30/2023 with diagnoses that included asthma and encephalopathy. A review of Resident #134's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/07/2023, revealed Resident #134 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident used a non-invasive mechanical ventilator. A review of Resident #134's care plan, initiated on 10/01/2023, revealed the resident was at risk for complications with their respiratory system due to their diagnosis of asthma. Review of Resident #134's Order Summary Report with active orders as of 11/15/2023, revealed an order dated 10/06/2023, to replace the resident's CPAP mask, tubing, and accessories one time a day every Saturday. Review of Resident #134's Medication Administration Record and Treatment Administration Record for the time frame of 11/01/2023 through 11/30/2023, revealed no evidence of documentation staff documented the replacement of the resident's CPAP mask, tubing, and accessories weekly as ordered. On 11/13/2023 at 1:57 PM and 11/15/2023 at 2:32 PM, the surveyor observed as Resident #134's CPAP mask laid on top of the resident's dresser. The mask was dirty with a dried crusty white substance present. On 11/16/2023 at 9:26 AM, the surveyor observed Resident #134's CPAP mask was dirty with a dried crusty white substance present. During an interview on 11/15/2023 at 3:44 PM, Licensed Vocational Nurse #10 stated the CPAP machines were cleaned on Saturdays. During an interview on 11/15/2023 at 3:55 PM, Registered Nurse #11 stated that Resident #134's CPAP mask was cleaned on Saturdays and the masks and tubing were supposed to be stored in a bag. During an interview on 11/16/2023 at 2:28 PM, the Director of Nursing stated that the CPAP equipment should be cleaned every seven days. She said she expected the nurses to clean the mask with soap and water and air dry before placement in a plastic bag. She stated she expected the nurse to also monitor the mask and CPAP machine in the morning before they bagged it and expected the next shift to also check the equipment and make sure it was clean before placement on the resident. She expected 555104 Page 13 of 22 555104 11/16/2023 Concord Post Acute 1050 San Miguel Road Concord, CA 94518

F 0695 the staff to clean and store the CPAP machines according to the manufacturer guidelines. Level of Harm - Minimal harm or potential for actual harm During an interview on 11/16/2023 at 3:30 PM, the Administrator stated he expected the staff to follow the manufacturer guidelines to keep the equipment clean and sanitized. Residents Affected - Few 555104 Page 14 of 22 555104 11/16/2023 Concord Post Acute 1050 San Miguel Road Concord, CA 94518

F 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. Based on observations, record review, interviews, and facility policy review, the facility failed to ensure bed rails were used properly per assessment for 1 (Resident #152) of 5 sampled residents reviewed for accidents. Findings included: A review of the facility policy titled, Bed Safety and Bed Rails, revised in August 2022, revealed, 3. The use of bed rails or side rails (including temporarily raising the side rails for episodic use during care) is prohibited unless the criteria for use of bed rails have been met, including attempts to use alternatives, interdisciplinary evaluation, resident assessment, and informed consent. A review of Resident #152's admission Record revealed the facility admitted the resident on 07/08/2023 with diagnoses that included traumatic subdural hemorrhage (brain bleed) with loss of consciousness, encephalopathy (brain disorder), and cerebral edema (swelling of the brain). Review of Resident #152's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/29/2023, revealed Resident #152 had a Brief Interview for Mental Status (BIMS) score of 0, which indicated the resident had severe cognitive impairment. The MDS indicated the resident required extensive assistance with bed mobility and transfers and had impairment on both sides in their lower extremities. A review of Resident #152's care plan initiated on 07/08/2023, revealed the resident had an activities of daily living self-care performance deficit and limited mobility. A review of Resident #152's Bed Rail Observation/Assessment dated 08/20/2023, revealed bed rails were not recommended for the resident. A review of Resident #152's Bed Rail Observation/Assessment dated 09/22/2023, revealed bed rails were not in use for the resident. On 11/13/2023 at 11:30 AM, the surveyor observed as Resident #152 laid in their bed, with half bed rails raised on both sides of the upper bed. On 11/14/2023 at 12:17 PM and 11/15/2023 at 3:08 PM, the surveyor observed as Resident #152 laid in their bed, with the bed rail by the wall raised and the outside rail lowered. During an interview on 11/15/2023 at 1:13 PM, Licensed Vocational Nurse (LVN) #15 said she was not sure if Resident #152 used the bed rails or not but since the resident was at risk for falls, she thought they might be on the resident's bed for safety. LVN #15 stated a resident would need to be assessed before they used bed rails. After review of Resident #152's medical record, LVN #15 confirmed the last bed rail assessment for the resident indicated bed rails were not in use. During an interview on 11/15/2023 at 3:42 PM, Certified Nurse Assistant #16 stated Resident #152 should not have bed rails. 555104 Page 15 of 22 555104 11/16/2023 Concord Post Acute 1050 San Miguel Road Concord, CA 94518

F 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 11/16/2023 at 2:46 PM, the Director of Nursing (DON) stated when a resident admitted to the facility, the staff checked with the resident to see if they wanted bed rails, and if so, an assessment was completed to determine if the rail was used as an enabler or as a restraint. Per the DON, if the rails were to be used for safety, it would need to be an interdisciplinary team decision and the resident would have to use alternatives before the use of the bed rails. The DON stated if a resident had not been assessed for the use of bed rail, the bed rails should not be used. 555104 Page 16 of 22 555104 11/16/2023 Concord Post Acute 1050 San Miguel Road Concord, CA 94518

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based on the interviews, record review, document reviews, and policy review, the facility failed to act on a pharmacy recommendation to lower the dosage of medication for 1 (Resident #42) of 5 sampled residents reviewed for unnecessary medications, psychotropic medications, and medication regimen review. Findings included: Review of the facility's policy titled, Medication Monitoring Medication Regimen Review and Reporting, dated January 2023, revealed, 8. The nursing care center follows up on the recommendations to verify that appropriate action has been taken. Recommendations shall be acted upon within 30 calendar days. a. For those issues that require physician intervention, the attending physician either accepts and acts upon the report and recommendations or rejects all or some of the report and should document his or her rationale or why the recommendation is rejected in the resident's medical record. Review of Resident #42's admission Record revealed the facility admitted the resident on 08/14/2019 with diagnoses that included atrial fibrillation, Alzheimer's disease, and dementia. Review of Resident #42's Order Summary Report with active orders as of 11/01/2023, revealed an order dated 08/15/2019, for aspirin tablet 325 milligram (mg), give one tablet by mouth one time a day. Review of the Consultant Pharmacist report dated 07/31/2023, revealed Resident #42 received aspirin 325 mg daily for cerebrovascular prevention. Per the report, According to the STEMI [ST-elevation myocardial infarction] guidelines, 81 mg once daily is preferred. Please evaluate whether the dose of aspirin in this patient could be decreased to 81mg daily to continue the therapeutic benefit of the aspirin antiplatelet effect, and reduce the potential GI [gastrointestinal] side effects of the medication. The section of the document for the physician/prescriber response was blank. Review of the Consultant Pharmacist report dated 08/31/2023, revealed Resident #42 received aspirin 325 mg daily for cerebrovascular prevention. Per the report, According to the STEMI guidelines, 81 mg once daily is preferred. Please evaluate whether the dose of aspirin in this patient could be decreased to 81mg daily to continue the therapeutic benefit of the aspirin antiplatelet effect, and reduce the potential GI side effects of the medication. The section of the document for the physician/prescriber response was blank. Review of the Consultant Pharmacist report for outcomes entered between 09/01/2023 and 09/30/2023, revealed Resident #42 received aspirin 325 mg daily for cerebrovascular prevention. Per the report, According to the STEMI guidelines, 81 mg once daily is preferred. Please evaluate whether the dose of aspirin in this patient could be decreased to 81mg daily to continue the therapeutic benefit of the aspirin antiplatelet effect, and reduce the potential GI side effects of the medication. The section of the document for the recommendation status was blank. Review of the Consultant Pharmacist report for outcomes entered between 10/01/2023 and 10/31/2023, revealed Resident #42 received aspirin 325 mg daily for cerebrovascular prevention. Per the report, According to the STEMI guidelines, 81 mg once daily is preferred. Please evaluate whether the dose of aspirin in this patient could be decreased to 81mg daily to continue the therapeutic benefit of the aspirin antiplatelet effect, and reduce the potential GI side effects of the medication. The 555104 Page 17 of 22 555104 11/16/2023 Concord Post Acute 1050 San Miguel Road Concord, CA 94518

F 0756 section of the document for the recommendation status was blank. Level of Harm - Minimal harm or potential for actual harm During an interview on 11/15/2023 at 12:43 PM, the Director of Nursing (DON) stated medication regimen reviews were received by nurse management and then faxed to the physician for review. Residents Affected - Few During an interview on 11/16/2023 at 7:59 AM, Attending Physician #9 stated the facility staff would fax over the medication regimen reviews. She stated she would review the recommendations and send over a change order or provide a rationale for not following the recommendation of the Consultant Pharmacist. Attending Physician #9 stated she could not recall if she had previously reviewed the July 2023, August 2023, September 2023, or October 2023 Consultant Pharmacist recommendations for Resident #42. During an interview on 11/16/2023 at 8:07 AM, the Consultant Pharmacist stated the medication order of aspirin 325 mg for Resident #42 had been recommended to be reduced for four months. During an interview on 11/16/2023 at 3:11 PM, the Administrator said he relied on the clinical team to ensure medication reviews were completed timely. 555104 Page 18 of 22 555104 11/16/2023 Concord Post Acute 1050 San Miguel Road Concord, CA 94518

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observations, record reviews, interviews, document review, and policy review, the facility failed to have a medication error rate less than 5%. Specifically, there were two medication errors out of 25 opportunities, which yielded a medication error rate of 8% for 2 (Resident #89 and Resident #380) of 8 residents observed for medication administration. Residents Affected - Few Findings included: A review of the facility policy titled, Administering Medications, revised in April 2019, revealed, 10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. 1. During medication administration observation on 11/15/2023 at 8:41AM, Licensed Vocational Nurse (LVN) #13 prepared and administered medications for Resident #89 that included one senna (a laxative) 8.6 milligrams (mg) tablet. A review of Resident #89's Order Summary Report with active orders as of 08/01/2023, revealed an order dated 10/29/2022, for senna-docusate sodium 8.6-50 mg, give one table by mouth two times a day for constipation. During an interview on 11/15/2023 at 12:45 PM, LVN #13 stated that to ensure medications were administered according to physician orders, he would check the resident's name, room number, and photo and check the dosage on the Medication Administration Record (MAR) with the dosage on the label of the medication. LVN #13 stated he should have followed the five rights of medication administration, the right resident, right medication, right dose, right route, and right time. LVN #13 stated he realized after he had already given the senna to Resident #89, that he should have given the one with docusate sodium instead. 2. A review of a document provided by the facility titled, Oral Medications That Should Not Be Crushed or Altered, dated February 2023, revealed, Extended Release Products: The formulation of some tablets is specialized as to allow the medication within it to be slowly released into the body. The document specified, Crushing or breaking a tablet or opening a capsule of a potentially hazardous substance may increase the risk of exposure to the substance through skin contact, inhalation, or accidental ingestion. The document listed Depakote as delayed release, hazardous substance. During medication administration observation on 11/15/2023 at 12:03 PM, Licensed Vocational Nurse (LVN) #14 prepared and administered medications for Resident #380 that included two Depakote (an anticonvulsant medication) delayed release (DR) 125 milligrams (mg) tablets. LVN #14 crushed and mixed the two tablets of Depakote in applesauce and administered the medication to the resident. A review of Resident #380's Order Summary Report with active orders as of 10/12/2023, revealed an order dated 10/12/2023, for divalproex sodium (Depakote) delayed release 125 mg, two tablets by mouth one time a day for psychotic disturbance. During an interview on 11/15/2023 at 1:07 PM, LVN #14 stated she had a list on her medication cart of medications that could not be crushed but she said it usually indicated it on the order or the label of the medication if the medication could not be crushed. At this time, LVN #14 realized she had 555104 Page 19 of 22 555104 11/16/2023 Concord Post Acute 1050 San Miguel Road Concord, CA 94518

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few crushed delayed release Depakote for Resident #380. LVN #14 stated the delayed release Depakote should have been changed to liquid or sprinkle form since the delayed release medication should not be crushed. During an interview on 11/16/2023 at 2:46 PM, the Director of Nursing (DON) stated to ensure medications were administered according to physician orders, the nurse should compare the medication label with the electronic Medication Administration Record and follow the five rights of medications administration. The DON stated the nurses had a list of medications that could not be crushed in their binder on the medication cart. During an interview on 11/16/2023 at 3:25 PM, the Administrator stated medications should be administered as ordered by the physician and according to professional standards. 555104 Page 20 of 22 555104 11/16/2023 Concord Post Acute 1050 San Miguel Road Concord, CA 94518

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, record review, and policy review, the facility failed to ensure a resident's urinary catheter drainage bag was not on the floor for 1 (Resident #7) of 3 sampled residents reviewed for urinary catheters. Residents Affected - Few Finding included: A review of a facility policy tilted, Catheter Care, Urinary, revised in August 2022, revealed, Infection Control 1. Use aseptic technique when handling or manipulating the drainage system. 2. Be sure the catheter tubing and drainage bag are kept off the floor. A review of Resident #7's admission Record revealed the facility admitted the resident on 10/24/2017 with diagnoses that included dementia and retention of urine. A review of Resident #7's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/21/2023, revealed Resident #7 had a Brief Interview for Mental Status (BIMS) score of 6, which indicated the resident had severe cognitive impairment. The MDS indicated the resident was totally dependent on staff for toilet use and had an indwelling catheter. Review of Resident #7 s care plan initiated on 10/25/2017, revealed the resident had an indwelling catheter due to a diagnosis of urinary retention/neurogenic bladder. Interventions directed staff to ensure the catheter was anchored to prevent tugging. Review of Resident #7's Order Summary Report with active orders as of 11/01/2023, revealed an order dated 04/15/2023, for an indwelling urinary catheter. On 11/14/2023 at 9:09 AM and 12:14 PM, the surveyor observed Resident #7's urinary catheter drainage bag uncovered, lying on the floor on the right side of the resident's bed. During an interview on 11/15/2023 at 10:30 AM, Certified Nurse Assistant (CNA) #4 said a resident's catheter drainage bag should not lie on the floor because it could lead to the catheter being contaminated. During an interview on 11/15/2023 at 3:38 PM, the Infection Preventionist (IP) stated the catheter drainage bag should not be on the floor because bacteria and feces could be on the floor which could lead to infection for the resident. The IP stated nursing staff were expected to follow the catheter care policy and keep the bag off the floor. During an interview on 11/16/2023 at 8:09 AM, CNA #6 stated she had found Resident #7's catheter drainage bag on the floor on 11/14/2023 when she arrived that morning for her shift. CNA #6 said she notified Licensed Vocational Nurse (LVN) #7 that the catheter drainage bag was located on the floor. During an interview on 11/16/2023 at 9:17 AM, LVN #7 stated the aides were expected to inform the nurse if a resident's catheter drainage bag had been on the floor. Per LVN #7, the catheter drainage bag should not be on the floor because it could put weight on the catheter and the catheter become dirty which was an infection control issue. During an interview on 11/16/2023 at 2:18 PM, the Director of Nursing (DON) stated it was her 555104 Page 21 of 22 555104 11/16/2023 Concord Post Acute 1050 San Miguel Road Concord, CA 94518

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few expectation the aides would ensure the catheter drainage bags were inside the privacy bags for dignity. The DON stated the catheter drainage bag should hang on the resident's bed frame, below the bladder and the nurse should also monitor the placement of the catheter drainage bag. During an interview on 11/16/2023 at 3:28 PM, the Administrator stated residents with catheters should have proper sanitation and privacy with catheter care. Per the Administrator, if the nursing staff saw the catheter drainage bag on the floor, it should be reported and changed. 555104 Page 22 of 22