Health inspection·August 27, 2024

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on interview and record review, the facility failed to ensure a licensed vocational nurse (LVN 1) administered medication accurately and safely to one of two sampled residents (Resident 1) according to the physician orders when Bengay cream (used to treat minor aches and pains of the muscles/joints) was administered instead of a skin barrier cream on Resident 1 ' s moisture associated skin damage (a form of incontinence-associated dermatitis, which is inflammation of the skin from extended exposure to urine or stool). This failure resulted in pain and discomfort for Resident 1. Findings: A review of the admission Record for Resident 1 indicated Resident 1 was initially admitted in March 2018 with diagnoses that included dementia, diabetes, asthma, and osteoarthritis. A review of Resident 1 ' s Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan), dated 8/14/24, indicated a score of 3 on her Brief Interview for Mental Status (BIMS, is a scoring system used to determine the resident ' s cognitive status in regard to attention, orientation, and ability to register and recall information.) indicating severe cognitive impairment. The MDS for Resident 1 ' s skin conditions indicated Moisture Associated Skin Damage (MASD) (e.g. incontinence-associated dermatitis (IAD), perspiration, drainage). During an interview on 8/27/24 at 1:35 p.m. with Director of Nursing (DON), DON stated LVN 1 had a medication error by administering Bengay cream on Resident 1. DON stated Coloplast Critic-Aid cream, a barrier cream, was supposed to be applied on Resident 1. During a telephone interview on 8/27/24 at 5:18 p.m. with LVN 1, LVN 1 confirmed that he made an error of wrong medication to Resident 1. LVN 1 stated he handed Bengay cream instead of the barrier cream to CNA 1 to apply on Resident 1 ' s skin on her buttocks, while CNA 1 and another CNA were changing Resident 1. LVN 1 stated he was present there during the time. LVN 1 stated Resident 1 experienced pain and burning sensation in the buttock area. LVN 1 stated he knew afterwards that it was Bengay cream that was applied on Resident 1 instead of the barrier cream (Coloplast critic-aid). During a telephone interview on 8/28/24 at 9:20 a.m. with CNA 1, CNA 1 stated while she was changing Resident 1 with the help of another CNA on 8/8/24 after dinner, LVN 1 gave her the cream in a medicine cup to apply on Resident 1 ' s skin. CNA 1 stated she put the cream on Resident ' s groin area, then she smelt something like menthol, then Resident 1 complained of burning in that area. CNA 1 (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 2 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 08/27/2024 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)