Health inspection·October 19, 2023

F 0623 Level of Harm - Minimal harm or potential for actual harm it is suggested you do so within 10 calendar days of being notified . ADON/CM stated the Notice of Transfer/Discharge was the only formal discharge notice that was given to Resident 1, in addition to the NOMNC dated 10/2/23. ADON/CM also stated there was no confirmation/proof that the notice was sent to the State Long Term Care Ombudsman office because the facility's fax machine did not print a confirmation page. Residents Affected - Some During further review of the second page of Resident 1's Notice of Transfer/discharge date d 10/5/23, the discharge notice indicated signature of the facility representative but did not indicate Resident 1's signature. The notice indicated a copy of it was faxed to the State Long Term Care Ombudsman office, and proof that it was sent was filed in Resident 1's medical record. The notice also indicated it was Resident 1's right to appeal the discharge decision and it should be done within 10 working days of being formally notified, additional rights available to Resident 1 included .[To] be given the opportunity to examine, at the reasonable time before the date of the hearing and during the hearing the content of the medical records and all documents and records to be used by the State at the hearing .you should be prepared to discharge at the end of the thirty (30) days from the date you were formally notified. The Notice of Transfer/Discharge indicated Resident 1 did not have 30 days as the notice was given on the actual day of discharge. During a telephone interview on 10/26/23 at 12:12 p.m. with Resident 1, Resident 1 stated receiving the NOMNC on 10/2/23 (three days before actual discharge date ). Resident 1 stated she was frustrated hearing about upcoming discharge for the first time, on 10/2/23, while not being physically ready to go home. Resident 1 stated she filed an appeal to be allowed to stay at the facility for more days. Resident 1 stated the three days' notice from the facility was not enough time to file a second appeal. Resident 1 stated she had to arrange for a 24-hour caregiver and home health, all in one day. Resident 1 stated she was not given information about the State Long Term Care Ombudsman program. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses that included encephalopathy (brain disease that alters brain function), unspecified asthma, malignant neoplasm (abnormal tissue growth as a characteristic of cancer) of the head and neck, morbid obesity and need for assistance with personal care. During a review of Resident 2's 72-hour Charting dated 9/25/23, the 72-hour charting indicated Resident 2 was alert and oriented to person, time, place, and situation. During a review of Resident 2's Notice of Transfer/discharge date d 10/1/23, the Notice of Transfer/Discharge indicated Resident 2 was to be discharged the same day, on 10/1/23. The notice indicated FM 2 was the individual who was notified of the discharge, and it did not indicate Resident 2's signature. The notice also indicated it was faxed to the State Long Term Care Ombudsman office on 10/12/23, 11 days after Resident 2 was discharged from the facility. During a telephone interview on 10/27/23 at 11:33 a.m. with Resident 2, Resident 2 stated she felt there was not enough time to appeal the discharge for the third time after losing the first two appeals to stay at the facility for few more days. Resident 2 stated she was discharged to home on [DATE]. During a telephone interview on 10/20/23 at 2:15 p.m. with Ombudsman (OMB), OMB stated she did not receive Resident 1 and Resident 2's Notice of Transfer/Discharge until both residents were already discharged from the facility. OMB stated calling the facility on 10/12/23 to ask for the discharge notices that were issued by the facility but were not received by the State Long-Term Care Ombudsman (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555926 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 555926 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shadelands Post Acute 2765 Mitchell Dr Walnut Creek, CA 94598 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 0623 Level of Harm - Minimal harm or potential for actual harm office the last two months. OMB also stated the first page of the notices had the incorrect address for Ombudsman's office and the second page where residents were supposed to sign, were always missing. OMB stated she had to call the facility to ask for the second page to make sure the residents signed off the discharge notices. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555926 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 555926 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shadelands Post Acute 2765 Mitchell Dr Walnut Creek, CA 94598 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, for three of three sampled residents (Resident 1, Resident 2, and Resident 3), the facility failed to provide a summary of the Baseline Care Plan. This failure had the potential to result in the lack of information about Resident 1, 2 and 3's goals of care and discharge plan. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included fracture of the left femur (thigh), fracture of the left arm, urinary tract infection, muscle weakness, and need for assistance with personal care, and anxiety disorder (feeling of fear, dread and uneasiness that does not go away and can get worse over time). The admission Record indicated Resident 1 was self-responsible. During an interview on 10/19/23 at 11:36 a.m. with Assistant Director of Nursing/Case Manager (ADON/CM), ADON/CM stated discharge planning was done and documented in Resident 1's Baseline Care Plan dated 7/31/23, followed by an Interdisciplinary Team (IDT, a group composed of individuals representing different departments) care conference where all disciplines that included nursing, rehabilitation, and social services met to discuss any issues that came up. During a review of Resident 1's Baseline Care Plan Person-Centered Care Planning dated 7/31/23, the Baseline Care Plan indicated assessments of Resident 1's ability to perform activities of daily living like transfers, walking, dressing, and eating. Under Section E. Baseline Care Plan Summary, the following response was entered; Resident and/or Resident Representative (RR) participated in the Baseline Care Plan review with a printed/written summary provided. There were no responses to additional questions if the printed Baseline Care Plan was given in person, via fax, mailed, emailed, or the date it was provided to Resident 1 or Resident 1's representative. During a follow-up interview on 10/19/23 at 2:08 p.m. with ADON/CM, ADON/CM stated a copy of the Baseline Care Plan was not given to Resident 1. During a telephone interview on 10/26/23 at 12:12 p.m. with Resident 1, Resident 1 stated she was not given a copy of the Baseline Care Plan. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses that included encephalopathy (brain disease that alters brain function), unspecified asthma, malignant neoplasm (abnormal tissue growth as a characteristic of cancer) of the head and neck, morbid obesity and need for assistance with personal care. During a review of Resident 2's 72-hour Charting dated 9/25/23, the 72-hour charting indicated Resident 2 was alert and oriented to person, time, place, and situation. During a telephone interview on 10/27/23 at 11:33 a.m. with Resident 2, Resident 2 stated she did not receive a copy of the Baseline Care Plan. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555926 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 555926 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shadelands Post Acute 2765 Mitchell Dr Walnut Creek, CA 94598 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE] with diagnoses that included left hip dislocation, diabetes mellitus, urinary tract infection and need for assistance with personal care. The admission Record also indicated Resident 3 was self-responsible. During an interview on 10/19/23 at 12:58 p.m. with Resident 3, Resident 3 stated she did not receive a copy of the Baseline Care Plan. During a concurrent interview and record review on 10/19/23 at 2:48 p.m. with Director of Nursing (DON), the facility's policy and procedure (P&P) titled Care Plans-Baseline last revised December 2022 was reviewed. The facility's P&P indicated the resident and/or representative should be provided a written summary of the baseline care plan. DON stated she was not aware of the policy that a written summary of the baseline care plan should be given to the resident or their representative. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555926 If continuation sheet Page 5 of 5