Other·November 6, 2019

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following represents the findings of the California Department of Public Health during a recertification survey conducted on 9/9/19 through 9/12/19. Representing the Department: HFENs 40748, and 40212.

F678 SS=J Cardio-Pulmonary Resuscitation (CPR) CFR(s): 483.24(a)(3)

F678 §483.24(a)(3) Personnel provide basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advance directives. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, for one of fourteen sampled residents (Resident 131) the facility failed to ensure staff provided immediate and continuous life saving measures (cardio pulmonary resuscitation [CPR] - any medical intervention used to restore circulatory and/or respiratory function that has ceased) when Resident 131 was found in bed without vital signs (clinical measurements of breaths, blood pressure, heart rate and temperature). Licensed Vocation Nurse (LVN) 3 did not continuously provide CPR. LVN 3 left Resident 131 in bed for an undetermined amount of time prior to the arrival of emergency personnel. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: FPWP11 Facility ID: CA020000010 If continuation sheet 1 of 13 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555466 (X3) DATE SURVEY COMPLETED 09/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASHBY CARE CENTER 2270 Ashby Avenue Berkeley, CA 94705 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE As a result of LVN 3's inaction, Resident 131 subsequently died. The failure of LVN 3 to provide continuous CPR until the arrival of emergency personnel was determined to constitute an Immediate Jeopardy (IJ) situation. The interim Administrator (ADM) and Director of Nursing (DON) were verbally notified of the IJ on 9/12/19 at 1 p.m. The facility failed to ensure that staff provided basic life support in a continuous manner in an emergency situation. Through observations and interviews with the staff members and record reviews of the facility's training records, the facility showed they initiated the plan of action through training of employees regarding CPR in-service course and how to initiate a response in an emergency situation. The IJ was lifted on 9/12/19 at 4:23 p.m. Findings: Review of Resident 131's Admission Face Sheet, printed 8/1/19, indicated Resident 131 was admitted to the facility with diagnoses that included hypertension (high blood pressure above normal 120/80), and heart failure (failure of the heart to pump blood with normal efficiency). Review of Resident 131's POLST (Physicians Order for Life Sustaining Treatment - directs individual end-of-life preferences during a medical emergency), dated 1/12/19, was signed by Resident 131's legally recognized decision-maker and his physician. The POLST form included " ...Cardiopulmonary Resuscitation (CPR) ...If patient has no pulse and is not breathing ...Attempt Resuscitation/CPR ...." Review of Resident 131's September 2019 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: FPWP11 Facility ID: CA020000010 If continuation sheet 2 of 13 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555466 (X3) DATE SURVEY COMPLETED 09/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASHBY CARE CENTER 2270 Ashby Avenue Berkeley, CA 94705 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Physician's Orders indicated an order dated 5/26/19 that Resident 131's "Code Status (refers to the level of medical interventions a person wishes to have started if their heart or breathing stops) ...[was] Full Code (Attempt resuscitation/CPR and other lifesaving measures)." During an observation on 9/12/19, at 7:59 a.m., Paramedics were walking through the hallway. At 8:01 a.m. the Paramedics began CPR on Resident 131. Emergency Personnel (EP) 1 came out of Resident 131's room looking for facility staff to come in and give them information regarding Resident 131. LVN 3 walked into Resident 131's room and told EP 1 that at around 7:15 a.m. she went into the room to feed Resident 131 his breakfast and found him non-responsive. LVN 3 told EP 1 she checked Resident 131's vital signs, there were no readings, and called for help, and did CPR (on Resident 131) for three to five minutes and then stopped. In an interview with Emergency Personnel (EP 1), on 9/12/19, at 8:41 a.m., EP 1 stated a dispatch call for resident "non-responsive" was received at 7:53 a.m. and emergency personnel were on the scene (at the facility) at 7:58 a.m. EP 1 stated the emergency personnel team started CPR on Resident 131 at 8:01 a.m., performed Advanced Cardiac Life Support (ACLS - a set of clinical algorithms for the urgent treatment of sudden loss of heart function) on Resident 131, and called Resident 131's time of death at 8:31 a.m. During an interview with LVN 3 on 9/12/19, at 8:39 a.m., LVN 3 stated she was the nurse in charge for Resident 131 from 11 p.m. on 9/11/19 to 7:30 a.m. on 9/12/19. LVN 3 stated that on 9/12/19, when she went to feed Resident 131 breakfast around 7:30 a.m., she FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: FPWP11 Facility ID: CA020000010 If continuation sheet 3 of 13 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555466 (X3) DATE SURVEY COMPLETED 09/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASHBY CARE CENTER 2270 Ashby Avenue Berkeley, CA 94705 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE found him not responsive. LVN 3 stated she immediately checked Resident 131's vital signs - there was no reading for his blood pressure, she could not feel any pulse, and there was no reading for oxygen saturation (blood oxygen level - a normal reading is typically between 95 and 100 percent), but Resident 131's body was warm to the touch. LVN 3 stated she did CPR for only three to five minutes. LVN 3 further stated at that point, the morning shift charge nurse (LVN 1) came to help assess Resident 131. LVN 3 stated LVN 1 then called 911 (emergency personnel), Resident 131's brother, and Resident 131's physician. During an interview with LVN 1 on 9/12/19, at 9 a.m., LVN 1 stated that he came to work on 9/12/19 at 7 a.m. LVN 1 stated that around 7:30 a.m. he heard LVN 3 yelling for help, so he went to check on her and saw LVN 3 assessing (check vital signs) Resident 131. LVN 1 further stated he went to check Resident 131's chart for his code status and to call 911. LVN 1 stated he also called Resident 131's responsible party, and his physician. Resident 131's unsigned "Nurses Notes," dated 9/12/19, documented, " ...medications were given as ordered this morning around 6:30 a.m., and he took it. When breakfast time around 7:30 a.m., I found patient [Resident 131] not respond to me. I checked his vital signs with blood pressure machine and (oxygen) finger application, there was no reading, then I notified the a.m. charge nurse [LVN 1], and we checked the patient's chart. He is full code. I did the CPR for 5 (minutes) till I got exhausted and the a.m. nurse (LVN 1) called 911. Around 7:45 a.m., 911 came. 911 did half an hour CPR for [Resident 131]. He passed away at 8:30 a.m." During an interview with Director of Nursing FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: FPWP11 Facility ID: CA020000010 If continuation sheet 4 of 13 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555466 (X3) DATE SURVEY COMPLETED 09/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASHBY CARE CENTER 2270 Ashby Avenue Berkeley, CA 94705 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (DON) on 9/12/19, at 12:17 p.m., DON stated she received a call from LVN 1 around 7:30 a.m. stating that he was going to call 911, because Resident 131 was not responding. DON stated in an emergency, staff were expected to do CPR immediately and call 911. Review of the facility's policy and procedure titled, "Emergency/Cardio Pulmonary Resuscitation (CPR), undated, indicated "...Purpose...To ventilate the resident until adequate circulation to the brain is reestablished ...Procedure...1. Summon medical aid. 2. Begin external cardiac massage [kind of external squeezing of the heart causing its voiding and filling to a certain extent and thus preserving cardiac output and blood flow to vital body organs for the duration of the resuscitation] and assisted ventilation [any artificial method of ventilation in which air is forced into and out of the lungs of a person who has stopped breathing] within four minutes immediately after the following symptoms occur...a. No pulse. b. No respirations. c. No heartbeat. d. Unconsciousness...ESSENTIAL POINTS...Once CPR is initiated, it must be continued until help arrives...."

F760 SS=D Residents are Free of Significant Med Errors CFR(s): 483.45(f)(2)

F760 The facility must ensure that its§483.45(f)(2) Residents are free of any significant medication errors. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, for one (Resident 14) of four residents who received medications during the medication pass observation, the facility failed FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: FPWP11 Facility ID: CA020000010 If continuation sheet 5 of 13 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555466 (X3) DATE SURVEY COMPLETED 09/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASHBY CARE CENTER 2270 Ashby Avenue Berkeley, CA 94705 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE to ensure its medication error rate did not exceed five percent. There were two medication errors out of 30 opportunities for error that totaled 6.67 percent (%) when Resident 14 did not receive Citalopram (medication that treats depression) and Claritin (an allergy medication). For Resident 14, this failure had the potential to result in unpleasant withdrawal symptoms (Citalopram - irritability, nausea, feeling dizzy, vomiting, nightmares, headache, and/or a prickling, tingling sensation on the skin) or severe itching (Claritin). Findings: Review of Resident 14's Physician's Orders, dated September 2019, indicated Resident 14 was admitted to the facility with diagnoses that included major depressive disorder. The Physician's Orders also indicated Resident 14 was to receive 20 milligrams (mg) of Citalopram and 10 mg of Claritin every day. Review of the Resident's Care Plan, dated 10/27/16, indicated instructions to the licensed nurse to administer Resident 14's medication as ordered. During observation on 9/10/19, at 8:13 a.m., Resident 14 did not receive Citalopram or Claritin from Licensed Vocational Nurse (LVN) 1, although LVN 1 marked the medications as given on Resident 14's Medication Administration Record (MAR). During an interview on 9/11/19, at 9:17 a.m., LVN 1 stated she was not sure how she missed giving Citalopram and Claritin to Resident 14.

F761 Label/Store Drugs and Biologicals FORM CMS-2567(02-99) Previous Versions Obsolete

F761 Event ID: FPWP11 Facility ID: CA020000010 If continuation sheet 6 of 13 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555466 (X3) DATE SURVEY COMPLETED 09/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASHBY CARE CENTER 2270 Ashby Avenue Berkeley, CA 94705 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) SS=D CFR(s): 483.45(g)(h)(1)(2) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.45(g) Labeling of Drugs and Biologicals Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. §483.45(h) Storage of Drugs and Biologicals §483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. §483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected. This REQUIREMENT is not met as evidenced by: Based on observation, and interview, the facility failed to ensure safe storage of biologicals (used to treat, prevent, or diagnose diseases and medical conditions) when there were multiple expired biologicals stored with non-expired biologicals in the medication room. This failure had the potential to adversely affect a resident's diagnosis, treatment, or assessment. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: FPWP11 Facility ID: CA020000010 If continuation sheet 7 of 13 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555466 (X3) DATE SURVEY COMPLETED 09/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASHBY CARE CENTER 2270 Ashby Avenue Berkeley, CA 94705 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Findings: During an observation and concurrent interview with Licensed Vocational Nurse (LVN) 2 on 9/11/19, at 1 p.m., LVN 2 stated the following expired supplies were in the medication room: a. 10 Fluringe syringes - expiration date of 2018; b. 18 monojet needles - expiration date of 2014; c. 2 monojet needles - expiration date of 2013; d. 6 monojet needles - expiration date of 2014; e. 9 monojet needles - expiration date of 2015; f. 1 leg bag strap - expiration date of 2015; g. 1 nasopharyngeal sample collection kit expiration date 2018; h. 4 BD vacutainer Culture and Sensitivity (C&S) transfer kits - expiration of 8/2019; i. 7 E-swab collection kits - expiration date of 5/2019, and; j. 2 Medi-vac tubing connector - expiration date of 8/2011. During an interview with the director of nursing (DON) on 9/11/19, at 11:36 a.m., DON stated the expired supply items should be disposed of.

F812 SS=E Food Procurement,Store/Prepare/ServeSanitary CFR(s): 483.60(i)(1)(2)

F812 §483.60(i) Food safety requirements. The facility must §483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities. (i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations. (ii) This provision does not prohibit or prevent facilities from using produce grown in facility FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: FPWP11 Facility ID: CA020000010 If continuation sheet 8 of 13 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555466 (X3) DATE SURVEY COMPLETED 09/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASHBY CARE CENTER 2270 Ashby Avenue Berkeley, CA 94705 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE gardens, subject to compliance with applicable safe growing and food-handling practices. (iii) This provision does not preclude residents from consuming foods not procured by the facility. §483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure food was served and stored under sanitary conditions when: 1. Licensed Vocational Nurse Certified Nursing Assistant (CNA) 1, 2, and 3 did not wash their hands during meal service to residents; 2. there were multiple food items with freezer burn in the facility's two freezers, two bottles of expired condiments in the refrigerator, and two bins containing dry bulk items that had open lids. This failure had the potential to result in foodborne illness. Findings: 1. During an observation on 9/9/19, at 12:13 p.m., Licensed Vocational Nurse 3 (LVN3) and Certified Nursing Assistant 1 (CNA) 1 did not wash their hands before delivering meal trays to residents in Room 1, and setting up the meals or after disposing the trash, and leaving the residents' room. LVN 3 and CNA 1 then returned to the dining room and did not wash their hand before serving meal trays to other residents. During an observation on 9/9/19, at 12:15 p.m., CNA 2 scratched his back under his uniform FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: FPWP11 Facility ID: CA020000010 If continuation sheet 9 of 13 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555466 (X3) DATE SURVEY COMPLETED 09/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASHBY CARE CENTER 2270 Ashby Avenue Berkeley, CA 94705 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE top and did not wash his hands before delivering a meal tray to a resident in their room or after throwing away trash. During an observation on 9/10/19, at 12:15 p.m., CNA 3 entered the facility through the front door and did not wash their hands before delivering meal trays to residents in the dining room or after throwing away trash. During an interview with CNA 2 on 9/9/19, at 12:15 p.m., CNA 2 stated hand washing needed to be done every time tray is serviced. During an interview with LVN 2 on 9/9/19, at 12:30 p.m., LVN 2 stated hand hygiene needed to be done before and after serving trays or touching anything possibly dirty. Review of the facility's undated policy and procedure titled, "Handwashing," indicated "...2. Appropriate ten to fifteen second handwashing must be performed under the following conditions...a. When coming on duty...i. After personal body function (e.g., use of toilet, blowing or wiping the nose, smoking, combing the hair, etc...n. before passing in tray and after resident contact...o. before food handling...." 2. During an observation on 9/9/19, at 8:10 a.m., in the presence of the Dietary Cook (DC), the following items were noted: a. in Freezer 1, there was one open nonsealable bag of frozen carrots with ice build-up; b. in the door panel of the top freezer, there were three packs of frozen turkey slices with freezer burn; c. in the refrigerator, there was one 48-ounce (oz) jar of brown mustard (use by date 8/6/19), and one 32-oz bottle of browning and seasoning sauce (expired 5/9/19), and; FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: FPWP11 Facility ID: CA020000010 If continuation sheet 10 of 13 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555466 (X3) DATE SURVEY COMPLETED 09/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASHBY CARE CENTER 2270 Ashby Avenue Berkeley, CA 94705 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE d. in the dry storage room, there was one storage container of split peas and one storage container of white beans had open lids, and that were not closed and sealed tight. The DC stated the carrots and turkey slices should not have ice build-up in them. DC stated the sauces should have been thrown away, and the lids for the dry bulk food should have been closed and sealed. Review of the facility's policy and procedure titled, "Procedure for Freezer Storage," dated 2018, indicated "...5. Store frozen foods in an air tight moisture-resistant wrapper...to prevent freezer burn...." Review of the facility's policy and procedure titled, "Procedure for Refrigerated Storage," dated 2018, indicated "...13. Food that has been freezer burned must be discarded...." Review of the facility's policy and procedure titled, "Storage of Food and Supplies," dated 2017, indicated "...6. Dry bulk foods (flour, sugar, dry beans...) should be stored in seamless metal or plastic containers with tight covers, or in bins which are easily sanitized...."

F912 SS=B Bedrooms Measure at Least 80 Sq Ft/Resident F912 CFR(s): 483.90(e)(1)(ii) §483.90(e)(1)(ii) Measure at least 80 square feet per resident in multiple resident bedrooms, and at least 100 square feet in single resident rooms; This REQUIREMENT is not met as evidenced by: Based on observation and interview, the facility had six resident (Rt) rooms (Rooms 1, 3, 5, 7, 8, and 9) with multiple beds that provided less FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: FPWP11 Facility ID: CA020000010 If continuation sheet 11 of 13 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555466 (X3) DATE SURVEY COMPLETED 09/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASHBY CARE CENTER 2270 Ashby Avenue Berkeley, CA 94705 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE than 80 square feet (sq.ft) per resident who occupied these rooms. This deficient practice had the potential to result in inadequate space for the delivery of care to each of the residents in each room, or for storage of the residents' belongings. Findings: During an observation in the presence of Maintenance Supervisor (MS) and Facility Operations Manager on 9/11/19, at 10:30 a.m., the following rooms and corresponding square footage (sq. ft) per bed were identified: Room 1 3 5 7 8 9 Activity / Room Size Floor Area Rt room / 299.63 sq.ft 74.9 sq.ft Rt room / 293.25 sq.ft 73.32 sq.ft Rt room / 299 sq. ft 74.75 sq.ft Rt room / 299 sq. ft 74.75 sq.ft Rt room / 299 sq. ft 74.75 sq.ft Rt room / 299 sq. ft 74.75 sq.ft During an interview with Certified Nursing Assistant (CNA) 2 on 9/11/19, at 12:45 p.m., CNA 2 stated he had enough space and there was no problem getting in and out of the room. CNA 2 added there were no complaints from the residents and family. During random observations of care and services on 9/11/19, at 9:20 a.m. and again on 9/11/19, at 2:30 p.m., there was sufficient space for the provision of care for the residents in all rooms. There was no heavy equipment kept in the rooms that might interfere with residents care and each resident had adequate personal space and privacy. There were no complaints from the residents regarding insufficient space for their belongings. There were no negative consequences attributed the decreased space and/or safety concerns in the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: FPWP11 Facility ID: CA020000010 If continuation sheet 12 of 13 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555466 (X3) DATE SURVEY COMPLETED 09/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASHBY CARE CENTER 2270 Ashby Avenue Berkeley, CA 94705 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE six rooms. Granting of room size waiver recommended. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: FPWP11 Facility ID: CA020000010 If continuation sheet 13 of 13