Health inspection·January 16, 2025

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Based on interview, record review, and facility policy review, the facility failed to address and make prompt efforts to resolve complaint allegation for one (Resident 1) of three sampled residents when facility did not thoroughly investigate and provide timely response to Resident 1 ' s allegation that Certified Nursing Assistant (CNA1) dragged and bumped his right foot into a wall while pushing him in wheelchair. This failure had the potential to cause Resident 1 emotional distress. Findings: During a review of Resident 1's Admission-Minimum Data Set (MDS - a federally mandated resident assessment and care guide tool), dated 10/3/24, the MDS indicated Resident 1's Basic Interview of Mental status (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.) score was 15 and indicated intact mental status. MDS indicated Resident 1 was able to recall the correct year, month and day of the week. Resident 1 had clear speech, able to express ideas and wants, and understood others. MDS indicated Resident 1 does not use a wheelchair and/or scooter. Resident 1 had limitation in range of motion to lower extremity. Resident 1 diagnoses included heart failure (when heart cannot pump of fill adequately) and muscle wasting and atrophy. During an interview on 1/16/25 at 11:09 a.m. with Rehabilitation Director/Occupational Therapy Assistant (OTA1), OTA 1 stated the Occupational Therapist (OT) informed OTA1 that while CNA1 pushed Resident 1 out of weight room Resident 1 ' s right foot on leg rest bumped into the door frame. OTA1 stated incident was discussed with Director of Nursing (DON) and mentioned during facility ' s daily stand up meeting. During an interview on 1/16/25 at 11:34 a.m. with CNA1, CNA1 stated DON informed CNA1 that Resident 1 alleged that CNA1 bumped Resident 1 ' s right foot into the doorway while pushing Resident 1 out of weight room. CNA1 stated she knew that Resident 1 ' s right foot did not hit the wall or door frame because Resident 1 ' s wheelchair had foot rest attached. During an interview on 1/16/25 at 12:04 p.m. with Occupational Therapy (OT), OT stated OT observed CNA1 push Resident 1 out of weight room while OT held the door opened. OT stated she observed Resident 1 ' s wheelchair right foot rest bumped and hit the corner of the wall by door frame. OT stated she did not observed the actual right foot hit or bumped the wall or door frame. OT stated Resident 1 complained that right foot hit the wall. OT stated she immediately notified OTA1. (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 3 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 01/16/2025 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)