Stonebrook Healthcare Center

F-F644 483.20(c) i. Incorporating the recommendations from the [PASARR] level II determination and the [PASARR] evaluation report into a resident's assessment, care planning, and transitions of care. ii. Referring all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment.

An Admission Record revealed the facility admitted Resident #22 on 08/28/2015. According to the Admission Record, the resident had a medical history to include a diagnosis of bipolar disorder. Per the Admission Record, the resident received a diagnosis of major depressive disorder with psychotic symptoms on 01/20/2023.

A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/11/2025, revealed Resident #22 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. The MDS indicated the resident had an active diagnosis to include depression.

Resident #22's Care Plan Report included a focus area initiated 12/03/2024, that indicated the resident had depression manifested by complaints of depression with mood disorder and episodes of tearfulness and sleeplessness. Interventions directed the staff to administer antidepressant medication as ordered by the physician.

Resident #22's Order Summary Report, revealed an order dated 08/21/2024, for duloxetine hydrochloride capsule delayed related particles 20 milligrams, give one capsule by mouth every 12 hours related to major depressive disorder.

Resident #22's medical record revealed no evidence to indicate the facility referred the resident to the appropriate state-designated authority for a Level II PASARR evaluation once the resident was identified to have a diagnosis of major depressive disorder on 01/20/2023.

During an interview on 03/06/2025 at 11:32 AM, the Receptionist stated she was responsible for the process of PASARR in the facility. The Receptionist stated she was unaware another screening needed to be done when a resident received a new mental illness diagnosis.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 14 555421 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555421 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Stonebrook Healthcare Center 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 0644 During an interview on 03/06/2025 at 1:54 PM, the Administrator stated if a resident had a new mental illness diagnosis, a new PASARR should be completed. Level of Harm - Minimal harm or potential for actual harm

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 14 555421 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555421 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Stonebrook Healthcare Center 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 0700 Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed Level of Harm - Minimal harm or consent; and (4) Correctly install and maintain the bed rail. potential for actual harm 45555 Residents Affected - Few Based on observation, interview, record review, and facility policy review, the facility failed to assess a resident for the use of a bed rail for 2 (Resident #20 and Resident #34) of 4 sampled residents reviewed for accidents.

Findings included:

A facility policy titled, Proper Use of Bed Rail Policy, dated 01/30/2025, indicated, 1. An assessment will be made to determine the resident's symptoms or reason for using bed rails. This assessment may be completed at the following intervals: upon admission, readmission, quarterly and change of condition status.

1. An Admission Record indicated the facility readmitted Resident #20 on 10/30/2021. According to the Admission Record, the resident had a medical history that included diagnoses of polymyalgia rheumatica (an inflammatory disorder that caused muscle pain and stiffness) and a history of falling.

A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/12/2025, revealed Resident #20 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. The MDS indicated the resident required substantial/maximal assistance to roll left and right, sit to lying, and lying to sitting on the side of the bed and was dependent on staff for chair/bed-to-chair transfer.

Resident #20's Care Plan Report, included a focus area, initiated 02/12/2025, that indicated the resident was totally dependent on staff for activities of daily living to include bed mobility, dressing and locomotion. Interventions directed staff to transfer the resident in and out of bed as needed (initiated 02/04/2023).

During an observation on 03/03/2025 at 10:20 AM, Resident #20 was noted lying in bed with quarter rails in

the up position on both sides of the upper portion of the resident's bed.

During an interview on 03/05/2025 at 12:22 PM, the Administrator stated the facility did not have an assessment for the use of bed rails for Resident #20.

During an interview on 03/06/2025 at 8:20 AM, the Administrator stated therapy was supposed to assess a resident for the use of a bed rail but had failed to assess the resident. Per the Administrator, there had been

a break in their system in all their departments to include maintenance, therapy and nursing. The Administrator stated those residents that had not been assessed for a bed rail, should not have a bed rail in use.

During an interview on 03/06/2025 at 9:31 AM, the Director of Rehabilitation (DOR) stated if a resident wanted a bed rail, there should be a full evaluation to assess the resident for the use of a bed rail. The DOR stated she did not think Resident #20 had been assessed for the use of a bed rail.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 14 555421 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555421 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Stonebrook Healthcare Center 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 0700 During an interview on 03/06/2025 at 11:39 AM, the Director of Nursing (DON) stated the nurses should make sure that the use of the bed rail was appropriate when requested by the resident, and then therapy Level of Harm - Minimal harm or should assess the resident, and if appropriate then they would submit a work order to maintenance for the potential for actual harm bed rails. According to the DON, he was not aware that so many residents had bed rails in use without an assessment. Residents Affected - Few 2. An Admission Record indicated the facility admitted Resident #34 on 12/22/2023. According to the Admission Record, the resident had a medical history that included diagnoses of hemiplegia (partial paralysis of one side of the body) and hemiparesis (weakness of one side of the body) following nontraumatic intracerebral hemorrhage which affected the right dominant side and epilepsy.

A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/12/2025, revealed Resident #34 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. The MDS indicated the resident required substantial/maximal assistance to roll left and right, sit to lying, and lying to sitting on the side of the bed and was dependent on staff for chair/bed-to-chair transfers.

Resident #34's Care Plan Report included a focus area initiated 01/01/2024, that indicated the resident had a decreased in functional performance related to a recent illness and muscle weakness. Interventions revealed

the resident required total assistance from two staff for bed mobility and transfers.

During an observation on 03/03/2025 at 10:23 AM, Resident #34 was noted in bed with a bed cane (rail) on each side of the upper portion of their bed.

During an observation on 03/04/2025 at 3:02 PM, Resident #34 was noted in bed with a bed cane (rail) on each side of the upper portion of their bed. Resident #34 was not able to state whether they used the bed cane (rail) or not.

During an interview on 03/05/2025 at 12:19 PM, Licensed Vocational Nurse (LVN) #3 stated Resident #34 used the bed canes (rails) to hold themself over when the staff provided care. LVN #3 stated therapy was responsible for assessing the resident for the use of bed rails.

During an interview on 03/05/2025 at 12:22 PM, the Administrator stated the facility did not have an assessment for the use of bed rails for Resident #34.

During an interview on 03/06/2025 at 8:20 AM, the Administrator stated therapy was supposed to assess a resident for the use of a bed rail but had failed to assess the resident. Per the Administrator, there had been

a break in their system in all their departments to include maintenance, therapy and nursing. The Administrator stated those residents that had not been assessed for a bed rail, should not have a bed rail in use.

During an interview on 03/06/2025 at 9:31 AM, the Director of Rehabilitation (DOR) stated if a resident wanted a bed rail, there should be a full evaluation to assess the resident for the use of a bed rail. The DOR stated she did not think Resident #34 had been assessed for the use of a bed rail.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 14 555421 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555421 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Stonebrook Healthcare Center 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 0700 During an interview on 03/06/2025 at 9:41 AM, Certified Nursing Assistant (CNA) #1 stated a resident should not have beds rails on their bed if they had not been assessed for them. CNA #1 stated Resident #34 used Level of Harm - Minimal harm or their bed rails for positioning in bed while care was being provided. potential for actual harm

During an interview on 03/06/2025 at 11:39 AM, the Director of Nursing (DON) stated the nurses should Residents Affected - Few make sure that the use of the bed rail was appropriate when requested by the resident, and then therapy should assess the resident, and if appropriate then they would submit a work order to maintenance for the bed rails. According to the DON, he was not aware that so many residents had bed rails in use without an assessment.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 14 555421 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555421 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Stonebrook Healthcare Center 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 0745 Provide medically-related social services to help each resident achieve the highest possible quality of life.

Level of Harm - Minimal harm or 52219 potential for actual harm Based on interview, record review, and document review, the facility failed to provide timely follow up of Residents Affected - Few medically related social services to obtain dental services related to the replacement of dentures for 1 (Resident #54) of 1 sampled resident reviewed for dental services.

Findings included:

The undated Social Service Designee/Discharge Planner job description, revealed, The primary purpose of your job position is to assist in planning, developing, organizing, implementing, evaluating, and directing social service programs in accordance with current existing federal, state, and local standards, as well as our established policies and procedures, to assure that the medically related emotional and social needs of the resident are met/maintained on an individual basis. The job description specified the duties and responsibilities included, Assist in obtaining resources from community social, health and welfare agencies to meet the needs of the resident.

An Admission Record revealed the facility admitted Resident #54 on 08/15/2022. According to the Admission Record, the resident had a medical history to include a diagnosis of hypertensive chronic kidney disease.

A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/22/2025, revealed Resident #54 had a Brief Interview for Mental Status Score (BIMS) of 8, which indicated the resident had moderate cognitive impairment.

Resident #54's Dental Evaluation Form, dated 09/14/2024, revealed the resident had ill-fitting upper and lower dentures.

Resident #54's physician Progress Notes dated 11/14/2024, revealed the resident's concern was that their denture situation was still not resolved. Per the Progress Notes, Resident #54 specified the dental people told them recently that their denture care was not covered by Medicaid. The Progress Notes indicated Resident #54 specified they had not heard back from the Director of Social Services (DSS) regarding this. According to the Progress Notes, the resident needed dentures especially in their bilateral lower teeth and

the physician called and spoke with the DSS about this. Per the Progress Notes, the DSS indicated she needed to follow up with the dentist, to which the physician indicated that if the dentist did not treat the resident, that the DSS should assist the resident in finding another dentist that would treat the resident under Medicaid.

Resident #54's Social Services Quarterly Assessment, dated 11/22/2024, revealed it had been recommended by the dentist to have the resident's dentures realigned.

Resident #54's physician's Progress Notes dated 01/30/2025, revealed the resident was seen with the DSS present. Per the Progress Notes, the DSS notified the resident that their dentist indicated their denture work was not covered under their current medical plan. The Progress Notes indicated the DSS would follow up with the state's Medicaid plan about denture coverage for the resident and would look for a different dentist for the resident as the resident wanted to switch dentists

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 14 555421 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555421 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Stonebrook Healthcare Center 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 0745 During an interview on 03/06/2025 at 8:05 AM, Resident #54 stated they could not wear their lower partial dentures because they did not fit. Resident #54 stated initially there was a problem with their top set of Level of Harm - Minimal harm or dentures, but that was fixed then they started to have a problem with their bottom set of dentures. Resident potential for actual harm #54 stated their dentures were not aligned. Resident #54 stated the DSS kept telling them that she was taking care of their dentures but never did. Residents Affected - Few

During an interview on 03/06/2025 at 10:31 AM, the DSS confirmed she was aware that Resident #54 had ill-fitting dentures, but stated she was not aware the resident's dental plan denied the claim for a new set of dentures for the resident. The DSS stated she followed up with the resident, but acknowledged she did not document such follow-up interaction. The DSS stated the facility did not have a dental care policy or procedure.

During an interview on 03/06/2025 at 1:14 PM, the Dental Hygienist (DH) stated Resident #54 informed her

on 09/14/2024 that their lower partial denture was ill fitting. The DH stated she reported the resident's concern to the dentist and even tried to put the resident's dentures in, but the dentures would not go into the resident's mouth.

During an interview on 03/06/2025 at 1:28 PM, the dental Office Manager (OM) stated the dentist examined Resident #54 on 09/14/2024 and determined the resident needed a new set of dentures. The OM stated a denial for new dentures from the state insurance company was received 09/30/2024 and this information was conveyed to the DSS on 10/01/2024.

During an interview on 03/06/2025 at 1:47 PM, the Administrator stated that was the first time she heard about Resident #54 not having lower dentures that fit. The Administrator stated her expectation was if something was denied there was follow-up with the resident and possibly offer a personal dentist or ask what

the resident would like. Per the Administrator, the DSS should have followed up with Resident #54.

During an interview on 03/06/2025 at 2:05 PM, the Director of Nursing stated usually social services coordinated dental.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 14 555421 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555421 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Stonebrook Healthcare Center 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 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or 45555 potential for actual harm Based on observation, interview, record review, and facility policy review, the facility failed to: implement Residents Affected - Few enhanced barrier precautions for 1 (Resident #34) of 1 sampled resident reviewed for tube feeding; perform hand hygiene when gloves were removed during the provision of care for 1 (Resident #29) of 1 sampled resident reviewed for pressure ulcer/injury and 1 (Resident #34) of 1 sampled resident reviewed for tube feeding; and store respiratory equipment for 1 (Resident #24) of 4 sampled residents reviewed for respiratory care.

Findings included:

A facility policy titled, Enhanced Standard (Barrier) Precautions, last reviewed 01/30/2025, indicated, Policy:

The facility will implement Enhanced Standard Precautions (ESP), also known as Enhanced Barrier Precautions (EBP), when performing any direct patient care where close body contact presents the potential of transmitting known or unknown organisms. Definitions: Enhanced Barrier Precautions (EBP) refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities. The policy specified, 1. Enhanced Standard (Barrier) Precautions (ESP) are to be used in conjunction with standard precautions. 2. ESP expands the use of PPE (gown and gloves) during high-contact resident care activities that include: a. Dressing b. Bathing/showering c. Transferring d. Providing hygiene e. Changing linens f. Changing briefs or assisting with toileting g. Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator.

A facility policy titled, Hand Washing, reviewed 01/30/2025, indicated, 1. All personnel shall follow our established hand washing procedures to prevent the spread of infection and disease to other personnel, patients, and visitors. 2. Appropriate 20 to 30 second handwashing must be performed under the following conditions: j. After removing gloves. The policy specified, 5. The use of gloves does not replace hand washing.

1. An Admission Record indicated the facility admitted Resident #34 on 12/22/2023. According to the Admission Record, the resident had a medical history that included diagnoses of dysphagia following a cerebrovascular disease and gastrostomy status.

A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/12/2025, revealed Resident #34 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment.

Resident #34's Care Plan Report, included a focus area initiated 12/27/2023, that indicated the resident had

a need for enteral feeding.

Resident #34's Order Summary Report with active orders as of 03/06/2025, revealed an order dated 01/27/2025, for gastrostomy tube dressing that instructed staff to cleanse the area, pat dry, apply 2 x 2 split antimicrobial dressing and secure with retention ring, then a split gauze secured with paper tape every dayshift.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 14 555421 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555421 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Stonebrook Healthcare Center 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 0880 During a concurrent observation and interview on 03/03/2025 at 1:37 PM, Certified Nursing Assistant (CNA) #1 entered Resident #34's room and stated she was about to change the resident's incontinence brief. CNA Level of Harm - Minimal harm or #1 did not wear a gown when she provided care to the resident. potential for actual harm

During a concurrent observation and interview on 03/05/2025 at 10:05 AM, Licensed Vocational Nurse (LVN) Residents Affected - Few #3 and LVN #4 entered Resident #34's room to change the resident's gastrostomy tube. LVN #3 and LVN #4 did not wear a gown. Once LVN #4 removed the dressing from around Resident #34's gastrostomy site, she discarded her gloves and put on a pair of clean gloves, without first performing hand hygiene.

During an interview on 03/05/2025 at 10:10 AM, both LVN #3 and LVN #4 stated they should have worn a gown when they provided care for the resident.

During an interview on 03/05/2025 at 2:24 PM, LVN #4 stated hand hygiene should be performed whenever

she changed her gloves. LVN #4 confirmed that she did not perform hand hygiene when she changed her gloves during wound care for Resident #34 but should have.

During an interview on 03/06/2025 at 11:25 AM, the Infection Preventionist (IP) stated EBP should be used for any resident with a catheter, wound, central lines and a feeding tube. The IP stated staff should wear a mask and gown if they were to provide a resident on EBP with a wound dressing change, a bath, a shower, incontinence care, and hygiene. According to the IP, staff should have worn a gown and gloves when they provided care to Resident #34.

During an interview on 03/06/2025 at 11:39 AM, the Director of Nursing (DON) stated EBP should be used

on any residents with an invasive line, a feeding tube, or a wound that required care. The DON stated staff should wear gloves, and a gown and hand hygiene should occur before staff put on gloves and whenever gloves were removed prior to new gloves being put on.

During an interview on 03/06/2025 at 11:51 AM, the Administrator stated any resident that had a wound or line in their body, like a catheter or feeding tube, the staff should wear a gown and gloves every time they went in the room to provide care. Per the Administrator, hand hygiene should occur before and after and in between glove changes.

2. An Admission Record indicated the facility readmitted Resident #29 on 08/08/2022. According to the Admission Record, the resident had a medical history that included a diagnosis of displaced spiral fracture of

the shaft of the right tibia.

A significant change in status Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/17/2025, revealed Resident #29 had a Brief Interview for Mental Status (BIMS) score of 8, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident had one unstageable pressure injury that presented as a deep tissue injury.

Resident #29's Care Plan Report, included a focus area initiated 12/05/2024, that indicated the resident had

a skin integrity issue related to the right heel deep tissue injury. Interventions directed staff to complete the treatment as ordered on scheduled days; keep the dressing clean, dry, and intact; and monitor of signs of infection.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 14 555421 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555421 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Stonebrook Healthcare Center 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 0880 Resident #29's Order Summary Report with active orders as of 03/05/2025, revealed an order dated 01/09/2025, that directed the staff to clean the resident's right heel deep tissue pressure injury with sterile Level of Harm - Minimal harm or water, pat dry, apply providone iodine Betadine soak gauze on areas with eschar, cover with abdominal pad, potential for actual harm wrap with kerlix then an elastic bandage wrap every day and as needed for soiling.

Residents Affected - Few During an observation on 03/05/2025 at 2:30 PM, Licensed Vocational Nurse (LVN) #2 removed her gloves and put on a pair of clean gloves, without performing hand hygiene during the provision of wound care for Resident #29.

During an interview on 03/05/2025 at 2:37 PM, LVN #2 stated hand hygiene should occur before and after gloves are changed. LVN #2 confirmed he did not perform hand hygiene when he removed his gloves but should have.

During an interview on 03/06/2025 at 11:39 AM, the Director of Nursing stated hand hygiene should occur

before staff put on gloves and whenever gloves were removed prior to new gloves being put on.

During an interview on 03/06/2025 at 11:51 AM, the Administrator stated hand hygiene should occur before and after and in between glove changes.

46258

3. An Admission Record revealed the facility admitted Resident #24 on 06/11/2016. According to the Admission Record, the resident had a medical history that included diagnoses of chronic obstructive pulmonary disease (COPD) and dementia.

An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/24/2024, revealed Resident #24 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. The MDS indicated Resident #24 utilized a non-invasive mechanical ventilator.

Resident #24's care plan included a focus area initiated 12/18/2024, that indicated the resident's breathing patterns were impaired due to COPD. Interventions directed staff to administer medication as ordered (initiated 06/27/2023).

Resident #24's Order Summary Report, with active orders as of 03/06/2025, revealed an order dated 07/30/2024, for continuous positive airway pressure (CPAP) every evening and night shift. There was also

an order dated 08/09/2024, for budesonide suspension 0.5 milligram/2 milliliters, inhale one vial orally by way of a nebulizer two times a day for COPD.

During an observation on 03/03/2025 at 10:31 AM, the surveyor noted a CPAP mask lying on its side on top of the machine in Resident #24's room and a nebulizer mask on the resident's bedside table in the upward position. The CPAP and nebulizer mask were not in use and not stored in a bag.

During an observation on 03/04/2025 at 3:39 PM, the surveyor noted a CPAP mask lying on top of the machine in Resident #24's room and a nebulizer mask lying on the bedside table. The CPAP and nebulizer mask were not in use and not stored in a bag.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 14 555421 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555421 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Stonebrook Healthcare Center 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 0880 During an observation on 03/05/2025 at 9:09 AM, the surveyor noted a CPAP mask lying on top of the CPAP machine in Resident #24's room. The CPAP mask was not in use and not stored in a bag. Level of Harm - Minimal harm or potential for actual harm During a concurrent observation and interview on 03/05/2025 at 9:13 AM, Licensed Vocational Nurse (LVN) #2 stated both a nebulizer mask and a CPAP mask must be stored in a bag when not in use. LVN #2 entered Residents Affected - Few Resident #24's room and acknowledged the resident's CPAP mask was not in use and not stored in a bag.

During an interview on 03/05/2025 at 2:25 PM, LVN #6 stated a CPAP mask should be stored in a bag after each use.

During an interview on 03/05/2025 at 4:24 PM, the Administrator stated the facility did not have a policy that referenced how respiratory equipment should be stored.

During an interview on 03/06/2025 at 9:07 AM, the Infection Preventionist stated masks should be stored in a black infection prevention bag after each use as it helped to prevent infections.

During an interview on 03/06/2025 at 1:03 PM, the Director of Nursing stated masks should be stored in a bag when not in use to prevent infections.

During an interview on 03/06/2025 at 1:17 PM, the Administrator stated she did not know the procedure, but if the expectation was the masks should be cleaned and stored in a bag after each use, then that was what should happen.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 14 555421