Other·May 15, 2017

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 reflects the findings of the California Department of Public Health during the investigation of a complaint. Complaint number: CA00532158 Representing the Department: Health Facilities Evaluaotr Nurse 05189 The inspection was limited to the specific complaint and does not represent the findings of a full inspection of the facility. One deficiency was written as a result of complaint number: CA00523158.

F206 SS=D POLICY TO PERMIT READMISSION BEYOND BED-HOLD CFR(s): 483.15(e)(1)(2)

F206 06/02/2017 (e)(1) Permitting residents to return to facility. A facility must establish and follow a written policy on permitting residents to return to the facility after they are hospitalized or placed on therapeutic leave. The policy must provide for the following. (i) A resident, whose hospitalization or therapeutic leave exceeds the bed-hold period under the State plan, returns to the facility to their previous room if available or immediately upon the first availability of a bed in a semiprivate room if the resident(A) Requires the services provided by the 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: 4GV011 Facility ID: CA020000110 If continuation sheet 1 of 4 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: _______________ 056350 (X3) DATE SURVEY COMPLETED 05/11/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAKE MERRITT HEALTHCARE CENTER LLC 309 Macarthur Boulevard Oakland, CA 94610 (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 facility; and (B) Is eligible for Medicare skilled nursing facility services or Medicaid nursing facility services. (ii) If the facility that determines that a resident who was transferred with an expectation of returning to the facility, cannot return to the facility, the facility must comply with the requirements of paragraph (c) as they apply to discharges. (e)(2) Readmission to a composite distinct part. When the facility to which a resident returns is a composite distinct part (as defined in § 483.5), the resident must be permitted to return to an available bed in the particular location of the composite distinct part in which he or she resided previously. If a bed is not available in that location at the time of return, the resident must be given the option to return to that location upon the first availability of a bed there. This REQUIREMENT is not met as evidenced by: Based on staff interview and record review, the facility failed to implements its policy and procedure to readmit one of two sampled residents (Resident 1) back to the facility from the acute care hospital. This failure resulted in the potential risk of the resident being discharged from the acute care hospital with no residency and provision of care and safety. Findings: On 4/24/17 and 4/25/17, the review of the record showed the facility admitted Resident 1 from the acute care hospital on 11/19/16. The review of the acute care hospital Discharge/Transfer -Non Surgical document FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4GV011 Facility ID: CA020000110 If continuation sheet 2 of 4 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: _______________ 056350 (X3) DATE SURVEY COMPLETED 05/11/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAKE MERRITT HEALTHCARE CENTER LLC 309 Macarthur Boulevard Oakland, CA 94610 (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 dated, 11/18/16 showed the principal diagnosis as Vascular Dementia. (Progressive loss of intellectual function when blood flow to the brain is decreased.) The review of Social Service Progress Notes dated, 4/20/17, showed, "Resident began to exhibit Bx [behavior] of attempting to assault staff member. Seen by psych [psychiatric] physician who gave SS [social service designee] go ahead to 5150 [official emergency transfer procedure to acute care health facility setting]." The review of a late Nurse's Note entry for 4/21/17 showed, "[acute care hospital] Discharge Planner called notifying facility that resident is ready to be back in the facility. Writer informed her we are not getting this resident back due to safety issues; he is not safe to himself and other residents. Administrator instructed facility not to take this resident back due to this issue." On 4/24/17 at 3:10 PM in his/her office during the review, the Administrator indicated he/she was aware of the regulation to readmit Resident 1, but stated, "I'd rather you [State Evaluator] write me up than to receive [him/her] back!" During an interview with the Acute Care Social Worker (ACSW) on 5/11/17, at 2:30 p.m., ACSW stated Resident 1 has been in the hospital unit for 20 days. Resident 1 was pleasant, likes to walk around and does not have any behavioral problem. ACSW further stated that she had reached out to the administrator but he had not returned his call. The review of the "Policy" section of the BedHold Acknowledgement/Notification Administrative Manual revised, 1/06/06 utilized FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4GV011 Facility ID: CA020000110 If continuation sheet 3 of 4 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: _______________ 056350 (X3) DATE SURVEY COMPLETED 05/11/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAKE MERRITT HEALTHCARE CENTER LLC 309 Macarthur Boulevard Oakland, CA 94610 (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 by the facility for staff to follow showed: "1. The facility shall provide a resident and a resident representative written notice that specifies the duration of the bed-hold policy at the time of admission... 2. A resident whose hospitalization or therapeutic leave exceeds the bed-hold period under the state plan shall be re-admitted to the facility..." The review of the "Transfer Bed-Hold Notification" section of the Bed-Hold Acknowledgement/Notification Administrative Manual revised, 1/06/06 utilized by the facility showed: "Current regulations require that each long term care facility: Inform the resident/representative that if the hospitalization or therapeutic leave exceeds the bed -hold period, the resident has the right to be readmitted to the facility immediately upon the first availability of a bed...." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4GV011 Facility ID: CA020000110 If continuation sheet 4 of 4