Health inspection·August 16, 2023

F 0600 COVID-19; Level of Harm - Minimal harm or potential for actual harm Start date 4/7/23: hydrocodone-acetaminophen 10-325 milligrams (mg), (A combination medication of 325 mg of acetaminophen and 10 mg of hydrocodone. Hydrocodone is a narcotic pain medication. Narcotics are medications subject to regulations enforced by the U.S. Drug Enforcement Agency due to a potential for abuse and dependence.), give one tablet by mouth every 6 hours for pain; Residents Affected - Few Start date 4/7/23: hydrocodone-acetaminophen 10-325 mg, give two tablets, by mouth every 6 hours as needed for moderate pain; Start date 3/25/23: hydromorphone hydrochloride (a narcotic pain medication) 2 mg, one tablet by mouth every 4 hours as needed for pain. During a review of Resident 1 ' s care plan for Pain, dated 3/16/23, the care plan indicated Resident 1 had pain due to a recent surgery, chronic low back pain, and peripheral neuropathy (nerves located outside of the brain and spinal cord are damaged and cause weakness, numbness and pain, usually in the hands and feet). Care plan interventions included: report nonverbal expressions of pain such as moaning, striking out, grimacing, crying, thrashing, change in breathing; administer pain medication per physician orders; notify physician if pain frequency/intensity was worsening or if current pain regimen was ineffective. During a concurrent observation and interview on 6/1/23 at 10:45 a.m., Resident 1 sat upright while he lay in bed. Resident 1 stated he had been in and out of the hospital in the past four months and was so weak he was unable to stand, walk, or even hold items in his hands. Resident 1 stated on one occasion he had gone to the hospital after he woke during the night around 3:30 a.m. with horrendous chest pain. Resident 1 stated he yelled for assistance and Certified Nursing Assistant 1 (CNA 1) came to his room. Resident 1 stated he told CNA 1 he could not breathe, and CNA 1 said, You ' re breathing, and shut his door. Resident 1 stated he was helpless, weak, desperate, in pain, and could not breathe. Resident 1 stated he yelled multiple times he wanted to go to the hospital and he was worried because staff were not helping him. Resident 1 stated his cell phone was out of reach, but he used voice activation to call Emergency Medical Service (EMS) and be transported to the hospital. Resident 1 stated the hospital diagnosed him as having a serious blood clot and saved his life, all because he had called EMS himself, not the facility. During an interview and concurrent record review on 6/2/23 at 2:09 p.m., with LVN 1, Resident 1 ' s nursing notes were reviewed. LVN 1 stated the first time she had cared for Resident 1 he had called 9-1-1 and gone to the hospital. LVN stated other staff had told her Resident 1 had a frequent behavior of yelling. LVN 1 stated she had done a visual check and administered Resident 1 ' s ordered as needed pain medications, but Resident 1 continued to complain of pain. LVN 1 was unable to provide documentation the physician had been notified when Resident 1 ' s pain continued even after administration of pain medications. LVN 1 stated she had not called 9-1-1 for Resident 1. During a review of Resident 1 ' s progress notes dated 4/25/23 at 07:06 a.m., by Licensed Vocational Nurse 1 (LVN 1), the progress notes indicated LVN 1 had noted a Change of Condition, (COC). The COC notes indicated Resident 1 had started to complain of chest pain at 5:45 a.m. and kept yelling and cursing, and complaining he couldn ' t breathe. The notes indicated Resident 1 called 9-1-1, and was taken to the hospital by Emergency Medical Transport at 7:10 a.m. During a review of Resident 1 ' s Medication Administration Record (MAR), dated April 2023, the MAR (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555710 If continuation sheet Page 2 of 5 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 555710 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tice Valley Post Acute 1975 Tice Valley Blvd. 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 0600 indicated Resident 1 ' s pain levels on 4/25/23 were two at 12 a.m. and one at 6 a.m. Level of Harm - Minimal harm or potential for actual harm During a review of Resident 1 ' s Controlled Drug Records, the Controlled Drug Records indicated Resident 1 last received one hydromorphone tablet on 4/24/23 at noon, and two Hydrocodone-Acetaminophen 10-325 tablets on 4/25/23 at 1 a.m. Residents Affected - Few During an interview and concurrent record review on 6/30/23 at 4:10 p.m., with the Director of Nursing (DON), Resident 1 ' s progress notes, Medication Administration Record (MAR), and Weights and Vital Signs Summary (records of heart rate, respiratory rate, blood pressure, temperature, and blood oxygen saturation) were reviewed. The DON stated when Resident 1 complained of pain and shortness of breath, the policy and procedure would have been to assess Resident 1 ' s vital signs, pain level, and oxygen saturation, give oxygen if the saturation was low, and call the physician. The DON was unable to provide documentation that Resident 1 ' s oxygen saturation was monitored on 4/25/23, or that oxygen was provided to Resident 1. The vital signs recorded on 4/25/23 at 6:29 a.m. indicated a blood pressure: 129/60, pulse: 68, respiration:18 and temperature: 97.8 degrees Fahrenheit. The DON stated Resident 1 should not have needed to call 9-1-1 himself. During a review of Resident 1 ' s emergency medical services [Ambulance company] report, Patient Care Report, dated 4/25/23, the Report indicated the request for transport was received on 4/25/23 at 6:53 a.m. and the ambulance arrived at Resident 1 ' s bedside at 7 a.m. The Report indicated Resident 1 ' s vital signs at 7 a.m. as heart rate of 113, respirations of 28, blood pressure of 164/64, and oxygen saturation of 87%. The Report indicated Resident 1 complained of difficulty breathing, and sharp, right-sided chest pain, with increased pain with deep breaths. The Report indicated the ambulance crew administered supplemental oxygen with improvement in Resident 1 ' s oxygen saturation but Resident 1 remained in distress during transport to the acute care hospital. During a review of Resident 1 ' s ED notes, dated 4/25/23 at 07:27 a.m., the ED notes indicated Resident 1 was anxious and complained of sharp, tight, continuous pain in his right chest, at a level of ten (on a scale of zero to ten, with ten the worst possible pain). The ED notes indicated a computed tomography (CT, a type of X-ray study) scan indicated Resident 1 had a pulmonary embolism. During a review of Resident 1 ' s emergency department (ED) History and Physical (H&P), dated 4/25/23, the H&P indicated Resident 1 ' s chief complaint was right-sided chest pain upon awakening. During a review of the facility ' s policy and procedure (P&P), titled, Pain Management Guidelines, dated 11/2021, the P&P indicated, Pain is evaluated and documented .whenever there is a change in condition, using an appropriate pain scale, determined by nursing .using a numeric rating scale used for patients whose cognitive functioning ranges from intact to mildly or moderately impaired .patients are asked to choose a number from 0 (indicating no pain) to 10 (indicating worst pain imaginable) .alternative scale for patients who are alert and oriented and unable to utilize the Numeric Rating Scale are to use descriptors: no pain, mild pain, moderate pain, severe pain, very severe horrible pain . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555710 If continuation sheet Page 3 of 5 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 555710 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tice Valley Post Acute 1975 Tice Valley Blvd. 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 0755 Level of Harm - Minimal harm or potential for actual harm Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview, and record review, the facility failed to ensure Resident 1 ' s narcotics were recorded on both the controlled substances sheet and Medication Administration Record (MAR). Residents Affected - Few This failure to follow facility policy resulted in prevention of accurate reconciliation of controlled substances. Findings: During a review of Resident 1 ' s Minimum Data Set (MDS, a resident assessment tool used to guide care), dated 3/29/23, the MDS indicated Resident 1 had a score of 15 on the Brief Interview for Mental Status exam (BIMS, The Brief Interview for Mental Status is a scoring system used to determine the resident ' s cognitive status in regard to attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.) The MDS indicated Resident 1 required extensive assistance from two people for bed mobility and had not left his bed during the seven-day look-back period. The MDS indicated Resident 1 had diagnoses of peripheral venous insufficiency (impaired blood circulation in the extremities) and lymphedema (excessive fluid outside the blood vessels in body tissues causes swelling of the effected parts). During a review of Resident 1 ' s care plan for Pain, dated 3/16/23, the care plan indicated Resident 1 had pain due to a recent surgery, chronic low back pain, and peripheral neuropathy (nerves located outside of the brain and spinal cord are damaged and cause weakness, numbness and pain, usually in the hands and feet). Care plan interventions included: report nonverbal expressions of pain such as moaning, striking out, grimacing, crying, thrashing, change in breathing; administer pain medication per physician orders; notify physician if pain frequency/intensity was worsening or if current pain regimen was ineffective. During a review of Resident 1 ' s physician Order Summary Report, dated active April 2023, the Summary Report indicated the following orders: Start date 4/7/23: hydrocodone-acetaminophen 10-325 milligrams (mg), (A combination medication of 325 mg of acetaminophen and 10 mg of hydrocodone. Hydrocodone is a narcotic pain medication. Narcotics are medications subject to regulations enforced by the U.S. Drug Enforcement Agency due to a potential for abuse and dependence.), give one tablet by mouth every 6 hours for pain; Start date 4/7/23: hydrocodone-acetaminophen 10-325 mg, give two tablets, by mouth every 6 hours as needed for moderate pain; Start date 3/25/23: hydromorphone hydrochloride (a narcotic pain medication) 2 mg, one tablet by mouth every 4 hours as needed for pain. During an interview and concurrent record review on 6/2/23, at 2:09 p.m., with LVN 1, Resident 1 ' s nursing notes were reviewed. LVN 1 stated the first time she had cared for Resident 1 he had called 9-1-1 and gone to the hospital. LVN 1 stated she had done a visual check and administered Resident 1 ' s ordered as needed pain medications, but Resident 1 continued to complain of pain. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555710 If continuation sheet Page 4 of 5 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 555710 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tice Valley Post Acute 1975 Tice Valley Blvd. 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of Resident 1 ' s MAR, dated April 2023, the MAR indicated no hydrocodone-acetaminophen or hydromorphone hydrochloride was administered to Resident 1 on 4/25/23. During a review of Resident 1 ' s Controlled Drug Records, the Controlled Drug Records indicated Resident 1 last received one hydromorphone tablet on 4/24/23 at noon, and two Hydrocodone-Acetaminophen 10-325 tablets on 4/25/23 at 1 a.m. During a review of the facility ' s policy and procedure (P&P), titled, Medication Administration: Medication Pass,, dated 6/2021, the P&P indicated for controlled/narcotic medication to circle initials on MAR and document refusal on back side of MAR and to circle initials on Controlled Substance Charting Record and document refusal and to notify physician. The policy titled, Omnicare, a CVS Heat company, dated 4/2022, indicated the facility routinely reconcile the number of doses remaining in the package to the number of doses recorded on the Controlled Substance Verification Shift Count Sheet, to the medication administration record. Cross reference. See also F600. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555710 If continuation sheet Page 5 of 5