Health inspection·January 6, 2025

F 0689 to send resident to the emergency room (ER) for evaluation and testing. Level of Harm - Minimal harm or potential for actual harm During an interview on 12/19/24, at 1:02 p.m., with Resident 1, inside her room, Resident 1 stated three staff members, a male Restorative Nursing Assistant 1 (RNA 1), a male Certified Nursing Assistant 2 (CNA 2) and a female CNA 1 (CNA 1) were present in the room and assisted the resident with after-shower care. Resident 1 stated during the resident's final turn to complete the incontinent brief application, while RNA 1 and CNA 2 were standing next to resident's left side and CNA 1 to resident's right side (to secure the tape to resident's brief), as resident was turned by the two male staff from her left to the right side, Resident 1 claimed CNA 1 pushed her real hard toward the right side of the bed, which made resident slip from the bed and fall, hit her right forehead on something, and landed face down onto the floor. Resident 1 stated there was blood all over the floor and people came running when resident somewhat lost her consciousness. Resident 1 stated she was taken to the hospital where they took X-rays (X-radiation, a quick, painless test to create images of the inside of the body) to several parts of her whole body. At this time during the interview, Resident 1 started crying as she continued with her recollection of the incident. Resident 1 stated she feared she was going to go to surgery. Residents Affected - Few Note: The nursing home is disputing this citation. During an interview on 12/19/24, at 1:10 p.m., with RNA 1, RNA 1 stated Resident 1 was a three to four (3-4) person assist with transfers using the Hoyer Lift (an electric lift designed to transfer patients between two surfaces), turning, and repositioning. RNA 1 stated during Resident 1's after-shower care that day, only three staff members, RNA 1 (male), CNA 2 (male), and CNA 3 (female) were available to assist the resident. During an interview on 12/19/24, at 2:16 p.m., with the Director of Staff Development (DSD), DSD stated CNA 1 was from registry (an agency that provided certified nursing assistant services to facilities as needed) and the CNA's first time being assigned to take care of Resident 1 on the day the fall incident happened. DSD stated the facility's licensed nurses and seasoned CNAs provided quick orientation to registry staff during the times registry services were called to report for work at the facility. During a telephone interview on 12/23/24, at 12:45 p.m., with CNA 1, CNA 1 stated during Resident 1's final turn to complete the after-shower care/incontinent brief application, CNA 1 stood next to resident's right lower side of the bed to secure and stick the tape to the incontinent brief. CNA 1 stated as RNA 1 and CNA 2 turned and pushed resident to the right side towards CNA 1, the locked bed jerked and moved a bit due to resident's dead, heavy weight, and Resident 1 fell onto the floor and hit her head on something, towards the wall where there was a bedside table in the corner, about two feet away from the bed, and started bleeding from the forehead. During a telephone interview on 12/23/24, at 12:45 p.m., with CNA 2, CNA 2 stated both RNA 1 and CNA 2 knew Resident 1 so well that staff had to follow resident's preferences/directions regarding provisions of the resident care. CNA 2 stated Resident 1 required 3-4 person assist, with usually four people to help when a fourth person was available. CNA 2 stated on the day of the incident, RNA 1 and CNA 2 assisted CNA 1 with Resident 1's after-shower care. CNA 2 further stated CNA 1 stood at the right side of the resident, next to the mid-lower part of the bed and it was unfortunate that CNA 1 was unable to control the force of gravity and weight of the resident during the turn, enough to cause Resident 1 to fall off the bed, upper body first, onto the floor. CNA 2 stated Resident 1 had severe bleeding to the forehead and was sent to the emergency room for evaluation. A review of Resident 1's clinical record titled, Emergency Department (ED) Provider Notes, dated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555446 If continuation sheet Page 2 of 3 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 555446 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rossmoor Post Acute 1226 Rossmoor Parkway Walnut Creek, CA 94595 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Note: The nursing home is disputing this citation. FORM CMS-2567 (02/99) Previous Versions Obsolete 11/12/24, indicated resident obtained ED procedures and critical care that included plastic surgery consultation, large right forehead laceration (seven cm long) repair, minor head injury, and trauma (tenderness and swelling likely component of sprain and contusion) to the right ankle on the resident's old site of chronic deformity. A review of the facility's policy and procedure (P&P) titled, Falls and Fall Risk, Managing, revision date March 2018, indicated, .The staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling .A fall is defined as: Unintentionally coming to rest on the ground, floor, or other lower level, but not as a result of an overwhelming external force .An episode where a resident lost his or her balance and would have fallen, if not for another person or if he or she had not caught him/herself, is considered, a fall. A fall without injury is still a fall. Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred . Event ID: Facility ID: 555446 If continuation sheet Page 3 of 3