Health inspection·December 29, 2025

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete and record review on [DATE] at 5:30 p.m. with Medical Record Assistant (MRA), the physician progress notes titled, POLST Verbal Discussion dated [DATE], indicated, if patient has no pulse and is not breathing. with a check mark in the box in front of Do not attempt resuscitation/DNR (Allow Natural Death) and with a check mark in the box in front of selective treatment-. It also indicated the physician's signature and verbal consent obtained from Resident 2 dated [DATE]. When asked for an updated one, MRA stated they did not have an updated one and there was no POLST on file for Resident 2.During a review of Resident 2's physician admission note (PAN) dated [DATE], PAN indicated Code status: with an X in front of POLST reviewed/signed. PAN also indicated Patient: with an X in the front of has capacity to understand and make medical decisions.During a review of the facility's policy and procedure (P&P) titled, Do Not Resuscitate Order revised [DATE], the P&P indicated, Our facility will not use cardiopulmonary and related emergency measures to maintain life functions on a resident when there is a DO Not Resuscitate Order in effect.In addition to the. and DNR order form, state-specific forms may be used to specify whether to administer CPR in case of a medical emergency. Stated- specific forms include: POLST.Do not resuscitate (DNR) orders will remain in effect until the resident (or legal surrogate) provides the facility with a signed and dated request to end the DNR order.During a review of the blank POLST form, under the Directions for Health Care Provider, indicated, if found pulseless and not breathing, no defibrillator (including automated external defibrillators) or chest compressions should be used on a patient who has chosen Do Not Attempt Resuscitation. Event ID: Facility ID: 555421 If continuation sheet Page 2 of 4 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 12/29/2025 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)

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the results of the investigations of an abuse allegation were reported timely to the State Agency (SA, which is the California Department of Public Health, CDPH), for one sampled resident (Resident 1) when Resident 1 alleged that staff was rough with him.This failure had the potential to compromise the safety of all residents in the facility from unreported investigations and results of the investigations. Review of Resident 1's admission record, undated, indicated that he was admitted on [DATE] with diagnoses that included diabetes, urine retention, and hyperlipidemia.Review of Resident 1's Minimum Data Set (MDS- an assessment and care screening tool used to guide care) dated 8/23/25 indicated Resident 1's Brief Interview for Mental Status (BIMS- a short scanner to help detect cognitive impairment) score was 14, indicating no cognitive impairment.During a review of the social services note (SSN) note dated 8/7/25, the SSN note indicated, Resident 1 stated that a CNA (certified Nursing Assistant) has been rough with him and hurt him when she was putting his brief on by pulling it up aggressively 2 times, Resident claims his testicles were sore and he could not urinate for 2 days. CDPH, Ombudsman, Concord PD & MD notified by phone. Social Services notified. SOC341 faxed to CDPH & Ombudsman.During an interview on 12/18/25 at 9:10 a.m. with Director of Nursing (DON), When asked for the investigation summary for this allegation, DON stated they don't have it as the facility transitioned to a new company. DON stated they have all the documentation in the Point Click Care (PCCElectronic Health Record). DON stated the CNA was suspended for three days and when she came back, was assigned to a different station.During an interview on 12/18/25 at 11:10 a.m. Administrator (ADM) stated they are still unable to find the investigation documents done by former Administrator (ADM) and staff have been trying to reach her to ask about it.During a telephone interview on 12/18/25 at 1:39 pm, with the former ADM, former ADM stated she did the investigation for that incident. She stated she could not remember all the specific details. She stated former AADM would be able to remember the details. Former ADM stated she had left all her investigation documents/notes in the ADM's office.During a telephone interview on 12/18/25 at 2:30 p.m. with former Assistant Administrator (AADM), AADM stated she left a day before transition to the new company on 10/31/25, reported it to the new company and they left all the investigation documents. Former AADM stated she was the one that reported the abuse allegation to the appropriate agencies.During an interview on 12/18/25 at 4 p.m. with DON, DON stated the incident was reported to them on 8/7/25 and it happened on the night of 8/6/25 going to 8/7/25. DON stated he and the former AADM went in to interview Resident 1.During an interview on 12/22/25 at 5:55 p.m. with ADM, ADM stated he had searched for the former ADM's investigation notes and summary and cannot locate them.During a telephone interview on 12/26/25 at 10:18 a.m. with DON, DON stated it was very important to keep the investigation reports, to know what happened as everything is in that report; they can see what happened, what the allegation was, and what they could do about it and then they would let everybody know this and make sure this does not happen again. DON stated they do not have the policy and procedure for reporting of investigation notes/summary in the P&P provided but did not know why. DON stated that was the P&P they were following at the time of the incident. DON stated the new company for the facility took over on 11/1/25. During an interview on 12/29/25 at around 12:05 p.m. with ADM, ADM stated his expectation, after sending the SOC 341, is to conduct the investigation within 5 days, reach a conclusion and send it to the State agency. When asked, ADM stated he did not know if the 5 day investigation report about Resident 1's allegation was sent to the state agency. He also confirmed there was no fax confirmation that it was sent.During an interview on 12/29/25 at (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555421 If continuation sheet Page 3 of 4 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 12/29/2025 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)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete 12:14 p.m. with ADM, ADM stated the new company would hold onto the investigation records for seven years. ADM stated he expected the old company to follow the regulations to keep them. He stated further, .if they don't have documentation it didn't happen. ADM stated it was important for them to keep the investigation records to protect the patient, staff, and the building.During a review of the facility's P&P, titled, Abuse Prevention, undated, the P&P indicated, When an incident or suspected incident of resident abuse is reported, .shall utilize abuse/.investigation process as required by federal and stated law. Event ID: Facility ID: 555421 If continuation sheet Page 4 of 4