Health inspection·April 17, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on interview, record review, facility document review, and facility policy review, the facility failed to report an allegation of abuse to the state survey agency within two hours that involved 1 (Resident #18) of 1 sampled resident reviewed for abuse. Findings included: A facility policy titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, with a copyright date of 2001, indicated, All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or 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 to 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, which included a. The state licensing/certification agency responsible for surveying/licensing the facility. The policy revealed, 3. 'Immediately' is defined as, including a. within two hours of an allegation involving abuse or result in serious bodily injury. An admission Record revealed the facility admitted Resident #18 on 02/14/2009. According to the admission Record, the resident had a medical history that included diagnoses of unspecified dementia, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/19/2025, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. An untitled, undated typed facility document indicated that on 03/27/2025 at 9:30 AM, a resident stated that their bed bath water was cold. The document indicated that a certified nursing assistant (CNA) told the resident to shut up or they would pour water on the resident. Per the document, the resident stated, I will be quiet, please don't hurt me. The document indicated that the resident removed a bed sheet, and the CNA hit the resident on the knee and shoulder with an open hand with medium strength. A Facsimile Transmittal Cover Sheet, dated 03/27/2025, indicated the facility reported Alleged Staff to resident abuse to the state survey agency. The document had a handwritten note, initialed by Page 1 of 9 555104 555104 04/17/2025 Concord Post Acute 1050 San Miguel Road Concord, CA 94518

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the Assistant Director of Nursing (ADON), that indicated the report was submitted on 03/27/2025 at 5:00 PM. During an interview on 04/17/2025 at 11:25 AM, the ADON stated he was notified about 10 minutes after the incident allegedly occurred around 9:30 AM. He stated he reported the allegation to the state via telephone at 1:05 PM. During an interview on 04/17/2025 at 1:05 PM, the Administrator stated he was notified on 03/27/2025, and he did not know the exact time he was notified. He stated the initial report was sent to the state survey agency at 5:00 PM on 03/27/2025. 555104 Page 2 of 9 555104 04/17/2025 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 Based on interview, record review, and facility policy review, the facility failed to ensure the accuracy of the Minimum Data Set (MDS) for 2 (Resident #7 and Resident #108) of 35 sampled residents. Residents Affected - Few Findings included: A facility policy titled, Resident Assessments with a copyright date of 2001, revealed, 10. Assessments are completed by staff members who have the skills and qualifications to assess relevant care areas and who are knowledgeable about the resident's strengths and areas of decline. 11. All persons who have completed any portion of the MDS resident assessment form must sign the document attesting to the accuracy of such information. 12. Information in the MDS assessments will consistently reflect information in the progress notes, plans of care and resident observation/interviews. 1. An admission Record revealed the facility admitted Resident #108 on 07/10/2024. According to the admission Record, the resident had a medical history that included diagnoses of obstructive uropathy and non-pressure chronic ulcer of the lower leg. Resident #108's Care Plan Report included a focus area initiated 09/12/2022, that indicated the resident had non-compliance with nursing care interventions. Resident #108's Progress Notes, dated 12/17/2024 at 2:54 PM, revealed, the resident refused treatment three times. A quarterly MDS, with an Assessment Reference Date (ARD) of 12/19/2024, revealed Resident #108 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident did not reject care. Resident #108's Progress Notes, dated 03/17/2025 at 3:21 PM, revealed, the resident was on charting related to refusal of care. According to the Progress Notes, the resident refused wound care three times. A quarterly MDS, with an ARD of 03/21/2025, revealed Resident #108 had a BIMS score of 10, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident did not reject care. During an interview on 04/15/2025 at 2:09 PM, Licensed Vocational Nurse (LVN) #4 stated Resident #108 refused all wound care. During an interview on 04/16/2025 at 10:31 AM, LVN #5 stated Resident #108 refused nearly all care, to include showers, incontinence brief changes, and wound care. Per LVN #5, Resident #108 had refused care for several years. During an interview on 04/16/2025 at 10:36 AM, Certified Nursing Assistant (CNA) #6 confirmed she was assigned to Resident #108. CNA #6 stated Resident #108 refused showers and care in general. CNA #6 stated the resident would rarely consent to care, but she would offer. During an interview on 04/16/2025 at 2:47 PM, the MDS Registered Nurse (RN) stated accuracy of the 555104 Page 3 of 9 555104 04/17/2025 Concord Post Acute 1050 San Miguel Road Concord, CA 94518

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few MDS was delegated to the person who completed the MDS. Per the MD RN, Social Services Director (SSD) #8 completed the behavior section of Resident #108's MDSs. The MDS RN stated there was a seven-day look back period for the completion of the behavior section related to rejection of care. Per the MDS RN, if a resident refused care within seven days of the assessment (look back) period, the MDS should indicate the resident rejected care. The MDS RN confirmed Resident #108's MDSs with an ARD of 12/19/2024 and 03/21/2025 were inaccurate because the resident refused care during those times. During an interview on 04/16/2025 at 3:39 PM, SSD #8 confirmed she was responsible for the behavior section of the MDS assessment. SSD #8 stated she talked with the resident and knew the resident did not reject care, as the resident always asked for their incontinence brief to be changed. SSD #8 stated she did not review the resident's progress notes or other parts of the clinical record when she completed the behavior section of the MDS assessment. During an interview on 04/17/2025 at 11:25 AM, the Assistant Director of Nursing (ADON) stated the process for the MDS was to collect and enter data based on documentation within a resident's clinical record. The ADON stated he was familiar with Resident #108 and was aware the resident refused care intermittently since admission to the facility, to include wound care, showers, and incontinence brief changes. The ADON stated it was his expectation that the MDS accurately reflected resident care. During an interview on 04/17/2025 at 12:49 PM, the Administrator stated it was his expectation that the MDS was accurate and reflected actual resident care activities. The Administrator stated he was aware of Resident #108 but was not aware the resident refused care as frequently. The Administrator stated if a resident refused care, his expectation would be the refusal was accurately reflected on the MDS. 2. An admission Record revealed the facility admitted Resident #7 on 09/23/2022. According to the admission Record, the resident had a medical history that included a diagnosis of dementia. Resident #7's Care Plan Report included a focus area initiated 10/17/2024, that indicated the resident had a hearing impairment as evidenced by decreased hearing acuity in both ears. Interventions directed staff to apply the resident's hearing aid to both ears (initiated 10/17/2024). An annual MDS, with an Assessment Reference Date (ARD) of 12/20/2024, revealed Resident #7 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. The MDS indicated Resident #7's hearing was adequate, and no hearing aid or other hearing appliance was used. A quarterly MDS, with an ARD of 03/22/2025, revealed Resident #7 had a BIMS score of 3, which indicated the resident had severe cognitive impairment. The MDS indicated Resident #7's hearing was adequate, and no hearing aid or other hearing appliance was used. During an interview on 04/14/2025 at 11:04 AM, Resident #7 was hard of hearing and acknowledged they wore hearing aids. During an interview on 04/15/2025 at 1:40 PM, Certified Nursing Assistant #10 stated Resident #7 had hearing aids. During an observation on 04/15/2025 at 1:44 PM, Resident #7 was in bed and hearing aids were noted in both of the resident's ears. 555104 Page 4 of 9 555104 04/17/2025 Concord Post Acute 1050 San Miguel Road Concord, CA 94518

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 04/16/2025 at 9:25 AM, the MDS Registered Nurse stated social services completed the hearing section of a resident's MDS. During an interview on 04/16/2025 at 11:51 AM, Social Services Director (SSD) #32 stated she and SSD #8 completed the hearing section of the MDS. SSD #32 stated she was aware Resident #7 had hearing aids. Per SSD #32, SSD #8 completed the hearing section of Resident #7's MDS with an ARD of 12/20/2024 and 03/22/2025. SSD #32 stated Resident 7's MDS with an ARD of 12/20/2024 and 03/22/2025 were not accurate as the resident wore hearing aids and had difficulty hearing. During an interview on 04/16/2025 at 12:01 PM, SSD #8 stated that when she did the MDS for Resident #7, she did not think the resident had hearing aids in. SSD #8 confirmed the resident used a hearing aid and both MDSs were inaccurate. During an interview on 04/17/2025 at 11:39 AM, the Assistant Director of Nursing (ADON) stated his expectation was the data in the MDS assessments should be accurate. The ADON acknowledged Resident #7's MDS with an ARD of 12/20/2024 and 03/22/2025 were inaccurate. During an interview on 04/17/2025 at 1:03 PM, the Administrator stated his expectation was that the MDS assessment were accurate. 555104 Page 5 of 9 555104 04/17/2025 Concord Post Acute 1050 San Miguel Road Concord, CA 94518

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm Based on interview, record review, and facility policy review, the facility failed to ensure a Level I preadmission screening and resident review (PASARR) was timely resubmitted after a resident remained in the facility longer than 30 days for 1 (Resident #145) of 4 sampled residents reviewed for PASARR. Residents Affected - Few Findings included: A facility policy titled Pre-admission Screening and Resident Review, with a copyright date of 2001, revealed, All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review process. An admission Record revealed the facility admitted Resident #145 on 12/02/2024. According to the admission Record, the resident had a medical history that included diagnoses of depression and bipolar disorder. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/09/2024, revealed Resident #145 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. According to the MDS, Resident #145 had active diagnoses to include depression and bipolar disorder. Resident #145's Care Plan Report included a focus area initiated 12/12/2024, that indicated the resident was at risk for nutritional risk related to bipolar disorder, depression, and the use of psychotropic medications. A letter from the California Department of Health Care Services dated 03/11/2025, indicated If the individual remains in the NF [nursing facility] longer than 30 days, the facility must resubmit a new Level I Screening as a Resident Review on the 31st day, Resident #145's medical record revealed a Preadmission Screening and Resident Review Level I Screening with a start date of 04/15/2025. During an interview on 04/16/2025 at 3:13 PM, the MDS Registered Nurse (RN) stated he was responsible for ensuring the PASARRs were complete. The MDS RN stated if a resident remained in the facility after 30 days, a new PASARR was required. The MDS RN acknowledged another Level I PASARR was resubmitted for Resident #145 on 04/15/2025. During an interview on 04/16/2025 at 3:40 PM, the MDS Assistant stated Resident #145's Level I PASARR was due on 04/11/2025; however, it was not resubmitted until 04/15/2025. The MDS Assistant stated it was on his list to do on 04/11/2025, but he forgot to get it done. During an interview on 04/17/2025 at 12:50 PM, the Administrator stated he expected the PASARRs to be completed timely. 555104 Page 6 of 9 555104 04/17/2025 Concord Post Acute 1050 San Miguel Road Concord, CA 94518

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on interview, record review, and facility policy review, the facility failed to develop and implement a person-centered care plan to address the use of antidepressant medication, antipsychotic medication, and address a diagnosis of post-traumatic stress disorder (PTSD) for 1 (Resident #162) of 5 sampled residents reviewed for unnecessary medications. Findings included: A facility policy titled, Care Plans, Comprehensive Person-Centered, with a copyright date of 2001, revealed, A comprehensive, person-centered care plan should include measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs. The policy revealed, 2. The Comprehensive person-centered care plan should be developed within the seven (7) days of the completion of the required MDS [Minimum Data Set] assessment. (Admission, Annual, or significant change in status), and should be completed within 21 days of admission. The policy revealed, 3. The care plan interventions should be derived from information obtained from the resident and his/her family/responsible party, with possible discretionary modifications resulting from the comprehensive assessment. An admission MDS, with an Assessment Reference Date (ARD) of 02/28/2025, revealed the facility admitted Resident #162 on 02/21/2025. The MDS revealed Resident #162 had a Brief Interview for Mental Status (BIMS) score of 6, which indicated the resident had severe cognitive impairment. The MDS indicated the resident had active diagnoses that included dementia, depression, and PTSD. Per the MDS, the resident received antidepressant and antipsychotic medication during the assessment timeframe. The MDS revealed the resident received antipsychotic medication on a routine basis. Resident #162's Psychiatric Progress Notes, dated 02/16/2025, revealed Resident #162 had diagnoses of PTSD and major neurocognitive disorder with behavioral disturbance related to superimposed delirium. The Psychiatric Progress Notes revealed the resident was a war veteran and recently had aggressive outbursts with staff. The record revealed the Assessment/Plan indicated the resident was receiving sertraline (a selective serotonin reuptake inhibitor [SSRI]) 25 milligram (mg) daily and olanzapine (an antipsychotic) 3.75 mg every night. Resident #162's Hospitalist Progress Note, dated 02/17/2025, revealed the resident had a diagnosis of PTSD on 08/31/2024. The Hospitalist Progress Note listed the chief complaint as confusion and abnormal behavior. The Case Management Progress Note revealed the resident's spouse no longer slept next to the resident as the resident often had dreams that they was in the country in war and had given their spouse a concussion. Resident #162's IDT [Interdisciplinary Team] Conference Notes, dated 02/25/2025, indicated Resident #162 ambulated with problems, had decreased safety awareness, and received antidepressant medications. The IDT Conference Notes revealed no evidence that the IDT reviewed the resident's diagnosis of PTSD or potential triggers. Resident #162's Social History Assessment, dated 02/27/2025 and completed by Social Services Director (SSD) #8, indicated that combat or exposure to a warzone (in the military or as a civilian) or any other stressful event or experience did not apply to the resident. The Social History Assessment indicated Resident #162 received psychotropic medications including olanzapine and sertraline, 555104 Page 7 of 9 555104 04/17/2025 Concord Post Acute 1050 San Miguel Road Concord, CA 94518

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few initiated on 02/21/2025. The Social History Assessment indicated Resident #162 was a veteran and indicated the resident was in the facility for long term and would eventually transition into the behavioral health unit. Resident #162's Order Summary Report, with active orders as of 04/16/2025, revealed an order for olanzapine 7.5 mg, one-half tablet at bedtime for dementia with behavioral disturbance for 30 days, with a start date of 03/23/2025 and end date of 04/22/2025. The Order Summary Report indicated the targeted behavior for olanzapine was agitation, with an order date of 02/23/2025. The Order Summary Report revealed an order to observe the resident for side effects of antipsychotic medication use of olanzapine, with an order date of 02/23/2025. The Order Summary Report revealed an order for sertraline hydrochloride (HCl), one tablet once a day for depression related to PTSD, with a start date of 02/22/2025. The Order Summary Report also revealed the targeted behavior for sertraline was verbalization of sadness/crying, with an order date of 02/23/2025. The Order Summary Report included an order to observe the resident for side effects of antidepressant medication use of sertraline. Resident #162's Care Plan Report, initiated 02/21/2025, revealed the resident had a diagnosis of PTSD but there was no focus statement or interventions for the diagnosis of PTSD or triggers associated with this diagnosis. The Care Plan Report revealed it did not include a focus statement or interventions regarding the use of antidepressant medication or antipsychotic medication. During an interview on 04/14/2025 at 10:44 AM, Resident #162 stated they had PTSD. Resident #162 stated they could use some psychological care. Resident #162 stated the PTSD symptoms came and went. Resident #162 stated they were a war veteran. During an interview on 04/16/2025 at 9:27 AM, the MDS Registered Nurse (RN) stated the normal process for a resident who had PTSD was to make sure all active diagnoses were being care planned. In review of the current care plan for Resident #162, the MDS RN stated that based on the care plan in the electronic medical record, the diagnosis was PTSD was not addressed. He stated nursing staff determined what the PTSD triggers were. He stated if the resident received psychotropic medications and exhibited behaviors, then they triggered for assessment. He stated Resident #162's psychotropic medication started on 02/21/2025. He stated the resident was on olanzapine for dementia with behavioral disturbance and had a psychiatric consultation scheduled that month. He stated that there was nothing in the care plan that addressed the resident's diagnosis of PTSD other than indicating that the resident had the diagnosis. During an interview on 04/16/2025 at 10:28 AM, the MDS RN stated they reviewed a resident's social history assessment for PTSD, and Resident #162 did not show triggers on admission. He stated that they looked at olanzapine use, which was why the resident was going to have a psychiatric evaluation. The MDS RN stated he thought they missed a focus area for PTSD on the care plan and they would add it. During an interview on 04/16/2025 at 12:07 PM, SSD #8 stated that Resident #162's spouse told her that Resident #162 had PTSD, and that the resident had been in a war. She stated that when Resident #162 was admitted to the facility, the resident was hard to assess. She stated Resident #162 answered no to all the assessment questions. SSD #8 stated they did not identify the PTSD triggers for Resident #162. She stated that she did not see that the resident had PTSD, and the resident did not verbalize any triggers. SSD #8 stated PTSD did not trigger on the social history assessment for Resident #162 based on the questions about trauma. She stated that the resident's spouse was not able to tell her anything other than the resident was a pilot. She stated the resident tried to go home with the 555104 Page 8 of 9 555104 04/17/2025 Concord Post Acute 1050 San Miguel Road Concord, CA 94518

F 0656 Level of Harm - Minimal harm or potential for actual harm spouse and was aggressive with the spouse. SSD #8 stated if there was a diagnosis, then a care plan focus should have been in place. During an interview on 04/17/2025 at 9:03 AM, SSD #32 reviewed Resident #162's care plan and stated focus areas were added on 04/16/2025 on the care plan for antidepressant and antipsychotic use. Residents Affected - Few During an interview on 04/17/2025 at 12:53 PM, RN #12 stated nurses input the medications, physician orders, and care plans, to include the diagnosis of PTSD. She stated they also got help from management staff. She stated she was aware that Resident #162 had PTSD but was not aware of the resident's triggers. She stated the use of antidepressant and antipsychotic medications, and the diagnosis of PTSD should have been on the care plan. During a telephone interview on 04/17/2025 at 3:35 PM, Licensed Vocational Nurse (LVN) #13 stated she was the admitting nurse for Resident #162. She stated she might have missed entering the care plan for the use of antidepressant medication and antipsychotic medication. She stated that when admitting a resident, she assessed the resident, and she went by the paper the resident came with. She stated she did not look at Resident #162's hospital discharge records. She stated that she was not aware of the resident's PTSD diagnosis. She stated she was not aware of the triggers related to the resident's PTSD diagnosis. During an interview on 04/17/2025 at 10:45 AM, the Assistant Director of Nursing (ADON) stated if a resident was admitted with medications, the admitting nurse was the one who put in the care plan the medication and the diagnosis of PTSD. The ADON stated the Director of Nursing (DON), MDS staff, the Director of Staff Development, the Infection Preventionist, and himself reviewed the care plan the following day. He stated if they saw that something needed to be updated, they did it during that review. The ADON stated the use of antipsychotic and antidepressant medications and the diagnosis and triggers for PTSD might have been overlooked for Resident #162. During an interview on 04/17/2025 at 12:26 PM, the ADON stated the diagnosis of PTSD should be in the care plan. During an interview on 04/17/2025 at 1:03 PM, the Administrator stated his expectation was that the care plan be accurate based on the current assessment. 555104 Page 9 of 9