Health inspection·August 28, 2024

F 0684 right and left buttocks. RD stated Resident 1 was at risk for weight loss related to poor appetite. Level of Harm - Minimal harm or potential for actual harm During a review of the facility's policy and procedure (P&P) titled, Clinical Protocols Nutrition impaired/unplanned weight loss, dated 11/14/17, the P&P indicated, The threshold for significant unplanned and undesired weight loss will be based on the followings criteria: a. 1 month- 5% weight loss is significant; greater that 5% is severe. Residents Affected - Few During a concurrent interview and record review on 8/7/24 at 11:14 a.m., with RD, Resident 1's nutrition/hydration and skin integrity risk care plan dated 7/4/24 and 7/11/24 respectively were reviewed. Resident 1's nutrition at risk and skin integrity care plan did not address Resident 1's continued significant weight losses and buttocks redness with appropriate interventions. RD stated she did not revise Resident 1's care plan to address significant weight loss and bilateral redness on buttocks with interventions. During a concurrent interview and record review on 8/7/24 at 1:20 p.m., with MDS coordinator (MDS 1), Resident 1's MDS - Care Area Assessment (CAA) summary dated 7/15/24 was reviewed. The CAA indicated Resident 1's pressure injury care area was triggered and care planning decision was checked. MDS 1 stated she was responsible for the completion of CAA and did not know why Resident 1's care plans did not address right and left buttock redness. MDS 1 stated Resident 1's significant weight losses was not address on care plan. Further review of weight tracking system report indicated on 7/23/24 Resident 1 continued to lose weight of 5.3# in one week. During a concurrent interview and record review on 8/7/24 at 11:11 a.m. with Licensed Vocational Nurse (LVN 1), Resident 1's IDT notes dated 7/23/24 to 7/25/24 were reviewed. LVN 1 stated there was no documentation that Resident 1's family and physician was informed of 7/23/24 significant weight loss of 5.3# a week. LVN 1 stated licensed nurses are expected to notify residents, family representatives and physician with significant weight loss. During a concurrent interview and record review on 8/7/24 at 12:24 p.m. with Registered Nurse-Supervisor (RN 1), Resident 1's IDT notes dated 7/23/24 to 7/25/24 were reviewed. RN 1 stated facility's weight variance protocol included RD who notified nursing and nursing notify the family and physician of significant weight loss and documents in IDT notes nurses. RN 1 stated MDS update care plan. RN 1 could not provide documentation that physician and family representative were notified of Resident 1's 7/23/24 significant weight loss of 5.3# in a week. During an interview on 8/7/24 at 1:15 p.m., with Director of Nursing (DON), DON stated licensed nurses were expected to call family and notify Resident 1's physician of significant weight loss and update care plans. During a review of Resident 1's Skin Evaluation Form (SE), dated 7/3/24, the SE indicated, Resident 1 had persistent skin redness pressure injury type on right buttock and multiple reddened areas on left buttocks. During an interview on 8/27/24 at 12:03 p.m., DON stated Resident 1's comprehensive care plan did not address significant weight loss and redness bilateral buttocks. DON stated nurses were expected to notify family and physician of residents' significant weight loss. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555843 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 555843 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Masonic Home 34400 Mission Blvd Union City, CA 94587 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 0684 Level of Harm - Minimal harm or potential for actual harm During a review of the facility's P&P titled, Resident Assessment & Care Planning Care Plans, Comprehensive Person-Centered date revised 11/2/17, indicated Assessments of residents are ongoing and care plans are revised as information about the residents' condition change. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555843 If continuation sheet Page 3 of 3