Other·August 1, 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: CA00531749 Representing the Department: Health Facilities Evaluator Nurse: 32717 The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. One deficiency was written as a result of complaint CA00531749.

F323 SS=G FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES CFR(s): 483.25(d)(1)(2)(n)(1)-(3)

F323 06/19/2017 (d) Accidents. The facility must ensure that (1) The resident environment remains as free from accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. (n) - Bed Rails. The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, 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: FBUO11 Facility ID: CA020000110 If continuation sheet 1 of 5 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 06/06/2017 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 must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements. (1) Assess the resident for risk of entrapment from bed rails prior to installation. (2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation. (3) Ensure that the bed’s dimensions are appropriate for the resident’s size and weight. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure resident safety for one of three sampled residents (Resident 1), when Resident 1 was transferred from wheelchair to bed without an assistive device as recommended on the hospital discharge summary dated 1/10/17. This failure resulted in Resident 1 sustaining a 1 centimeter (cm) by 0.2 cm abrasion and bruising around the right eye. Findings: Review of Resident 1's "Minimum Data Set," (MDS - an assessment tool used to direct resident care), dated 2/16/17, indicated Resident 1 was a able clearly think, reason, remember, and make his needs known. The MDS also indicated Resident 1 was totally dependent (full staff performance of activity) on two staff persons for transfers from the bed to wheelchair. During an observation and concurrent interview with Resident 1 on 5/3/17 at 1:03 p.m., Resident 1 had purplish discoloration under the right eye and yellowish-blue discoloration FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: FBUO11 Facility ID: CA020000110 If continuation sheet 2 of 5 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 06/06/2017 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 on the side of the right eye. Resident 1 stated, "I fell in my room, hit the table." During an interview with Certified Nursing Assistant (CNA) 1 on 5/3/17 at 2:53 p.m., CNA 1 stated Resident 1 was in his room getting ready to go back to bed on the afternoon of 4/9/17. CNA 1 stated, since everybody else (other staff) was busy, she decided to transfer Resident 1 by herself. CNA 1 stated while Resident 1 was in a standing position, and ready to pivot to sit on the bed, Resident 1 started to lean to the right side. CNA 1 stated she was standing behind Resident 1 to assist with transfer, but was not able to hold Resident 1's weight. CNA 1 stated she fell on the floor with Resident 1 and the wheelchair on top of her. According to CNA 1, Resident 1's right eye hit the over bed table in the process. CNA 1 stated she never used a mechanical lift to transfer Resident 1 and only requested help from other CNAs when they were available. Otherwise, CNA 1 stated she had to do transfers by herself. CNA 1 further stated she was 4 feet and 11 inches tall while Resident 1 was 5 feet and 10 and a half inches tall and weighed 180 pounds. Review of Resident 1's "Nurse's Notes," dated 4/9/17, indicated Resident 1 and CNA 1 were found on the floor on 4/9/17 at 4:30 p.m. The Nurse's Notes also indicated Resident 1 was noted with an abrasion to the side of his right eye that measured 1 cm (centimeter) by 0.2 cm. During an interview with the Director of Nursing (DON) on 5/3/17 at 1:30 p.m., the DON stated Resident 1 required two staff persons to assist with transfers. Review of Resident 1's "Fall Risk Assessment," FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: FBUO11 Facility ID: CA020000110 If continuation sheet 3 of 5 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 06/06/2017 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 5/18/16, indicated a score of 15 (score of 10 or higher represents high risk for falls) and a higher fall risk score of 19 on 8/16/16. Review of the facility's policy and procedure titled, "Falls and Fall Risk, Managing" last revised December 2007, indicated "Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling." During an interview with the DON and concurrent record review on 5/3/17 at 2:10 p.m., the DON confirmed there was no care plan developed to address Resident 1's high risk for falls. There was no care plan to show how much staff assistance or how many staff were needed to transfer Resident 1 from bed to wheelchair and back. Review of Resident 1's "Hospitalist Discharge Summary," dated 1/12/17, indicated Resident 1 was transferred to the hospital on 1/10/17 for right side weakness and leaning to the right side. While at the hospital, Resident 1 underwent imaging of the brain to evaluate for stroke. Resident 1 was evaluated by physical therapy (PT) while in the hospital and was given the following recommendation upon discharge; "Recommend [patient] return to [facility] and staff at SNF (skilled nursing facility) to use lift for transfers for safety." The hospital PT evaluation also indicated Resident 1 was not able to walk, was dependent on staff for transfers, and was on falls precautions (a variety of actions to help reduce the number of accidental falls). During an interview with CNA 2 on 5/3/17 at 2:46 p.m., CNA 2 stated he transferred Resident 1 from the bed and onto the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: FBUO11 Facility ID: CA020000110 If continuation sheet 4 of 5 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 06/06/2017 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 wheelchair every morning with extensive assist (staff provides weight bearing support, resident helps) and a licensed nurse never told him to use a mechanical lift (with Resident 1). During an interview with Licensed Vocational Nurse (LVN) 1 on 5/3/17 at 3:26 p.m., LVN 1 stated Resident 1 was never transferred from wheelchair to bed with a mechanical lift. LVN 1 also stated CNAs who had a heavier build were able to transfer Resident 1 with one person assist because Resident 1 was able follow instructions. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: FBUO11 Facility ID: CA020000110 If continuation sheet 5 of 5