Health inspection·August 30, 2023

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, for one of two sampled residents (Resident 1), the facility failed to notify and consult with the physician when Resident 1 had a change in condition. This failure had potentially resulted in delayed management of a change in health status. Findings: During a review of Resident 1's Order Summary Report dated 3/1/22, the Order Summary Report indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included fracture of the right thigh, elevated white blood cell count (WBC, blood component that fights infection), and diabetes mellitus. During a telephone interview on 8/30/23 at 8:13 a.m. with Family Member (FM) 1, FM 1 stated there was a big change in Resident 1's health condition during a visit at the facility on 3/18/22 that licensed nurses failed to see. FM 1 stated Resident 1 had refused to eat and was lethargic (sluggish). During an interview and concurrent record review on 8/30/23 at 12:06 p.m. with Director of Nursing (DON), Resident 1's Progress Notes dated 3/16/22 were reviewed. The Progress Notes indicated, on 3/16/22, at 1:56 p.m., Resident 1 refused the 1 p.m. scheduled medication. The progress notes also indicated Resident 1 reported not feeling well and that Resident 1 had stated feeling nauseous. Another progress note, also dated 3/16/22, at 2:10 p.m., indicated Resident 1 had refused weight assessment because [Resident 1] feels sick and not willing to get OOB (out of bed). DON stated Resident 1's feeling nauseated and not being able to get out of bed for the entire shift was a change of condition that warranted physician notification. DON stated Resident 1's clinical record did not indicate a physician notification. Further review of the progress notes indicated, on 3/17/22, Resident 1 continued to refuse to get out of bed. On 3/18/22, the progress notes indicated Resident 1's representative was at bedside and requested for Resident 1 to be transferred to the hospital via 911 after Resident 1 refused to eat dinner and was observed with confusion. During further review of Resident 1's Progress Notes from 3/16/22 to 3/18/22, the progress notes did not indicate Resident 1 or Resident 1's representatives were notified of the change in condition. During a review of Resident 1's Hospital Discharge Summary Notes dated 8/31/23, the Discharge Summary Notes indicated diagnoses that included severe sepsis with acute organ dysfunction, acute UTI (urinary tract infection), acute renal failure, metabolic acidosis (when too much acid builds up in the body, causes include build up of toxins and kidney failure, symptoms include nausea, vomiting, fast (continued on next page) 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. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 4 Event ID: 555421 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555421 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stonebrook Post Acute 4367 Concord Boulevard Concord, CA 94521 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)