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 represents the findings of the California Department of Public Health during the investigation of two complaints. Complaint Numbers: CA00529800 CA00535936 Representing the Department: 31403, HFEN The inspection was limited to the specific complaints investigated and does not represent the findings of a full iinspection of the facility. Deficiences were issued for complaint number CA00529800 (see F tag 157) and CA00535936 (see F Tag 323).

F157 SS=D NOTIFY OF CHANGES (INJURY/DECLINE/ROOM, ETC) CFR(s): 483.10(g)(14)

F157 06/19/2017 (g)(14) Notification of Changes. (i) A facility must immediately inform the resident; consult with the resident’s physician; and notify, consistent with his or her authority, the resident representative(s) when there is(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention; (B) A significant change in the resident’s physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening 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: M8I311 Facility ID: CA020000110 If continuation sheet 1 of 7 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 06/01/2017 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 conditions or clinical complications); (C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or (D) A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii). (ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request to the physician. (iii) The facility must also promptly notify the resident and the resident representative, if any, when there is(A) A change in room or roommate assignment as specified in §483.10(e)(6); or (B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section. (iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident representative (s). This REQUIREMENT is not met as evidenced by: Based on interview, and record review, the skilled nursing facility failed to report a change in status for one of 5 sampled residents (Resident 2). Resident 2 had a significant weight loss and the doctor was not notified. This failure resulted in the potential for dehydration and a delay in reaching health care goals. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: M8I311 Facility ID: CA020000110 If continuation sheet 2 of 7 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 06/01/2017 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 Findings: Record review on 5/18/17 of the document titled, Facesheet, showed the facility admitted Resident 2 on 4/6/16. Review of the documents titled, "Monthly Weights," showed the following for Resident 2: 9/5/16 - 135.2 pounds 10/5/16 - 130.2 pounds (a 5 pound drop in 1 month) 11/16 - 128.0 pounds 12/5/16 - 123.2 pounds (a 4.8 pound drop in 1 month) 1/5/17 - 123.00 pounds 2/17 - 121.9 pounds 3/17 - 120.5 pounds 4/17 - 114.7 pounds 5/17 - 113 pounds (an additional 10 pound drop in 5 months) In an interview on 5/18/17 at 10:35 a.m., the Director of Nursing, (DON), stated, when there are changes in a resident's weight, staff are to call the doctor, develop a care plan, call the Registered Dietician, and assess the patient. The DON stated the doctor had not been notified regarding Resident 2's weight loss. In an interview and concurrent record review at 10:45 a.m., the Registered Dietitician, (RD), stated the doctor should have been notified for Resident 2's 5 pound weight loss from 9/5/16 to 10/5/16.

F323 SS=J FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES CFR(s): 483.25(d)(1)(2)(n)(1)-(3) FORM CMS-2567(02-99) Previous Versions Obsolete

F323 Event ID: M8I311 06/19/2017 Facility ID: CA020000110 If continuation sheet 3 of 7 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 06/01/2017 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 (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 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 provide an environment free from accident hazards for one of five sampled residents (Resident 5) when an electrical wire below Resident 5's bed sparked and caused a burn on the floor as a result of faulty and exposed wiring. This failure resulted in power outage in three resident rooms and the potential for fire. The Director of Nursing (DON) was verbally notified on 5/18/17, at 1:15 p.m., that FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: M8I311 Facility ID: CA020000110 If continuation sheet 4 of 7 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 06/01/2017 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 Immediate Jeopardy (IJ), was identified in the facility related to the potential fire hazard caused by frayed electrical wires beneath Resident 5's bed. Findings: During an interview on 5/18/17 at 10:05 a.m., the DON stated a certified nursing assistant had unplugged a bed which created a spark and caused a power outage. In another interview with the DON on 5/18/17, at 11:10 a.m., the DON stated Certified Nursing Assistant 1 (CNA 1), had unplugged a resident's bed from an electrical outlet and there was a spark. As a result, Room 19, 20 and 21 had lost electrical power. In a concurrent observation and interview with CNA 1 on 5/18/17, at 11:15 a.m., CNA 1 stated Resident 5 was a total care resident (total care: requires full assistance with bathing, eating, toileting, moving in bed, and getting out of bed). CNA 1 stated Resident 5's bed brakes did not work. When he would turn Resident 5 in bed with the brakes engaged, the bed moved, and the wheels had been rolling side to side over electrical cords on the floor below the bed. CNA 1 stated at approximately 10 a.m., on 5/18/17, as he was repositioning Resident 5 in her bed, he noticed sparks shoot up from under the bed. At the time of the incident, Resident 5 was laying on an inflated air mattress (an airfilled mattress intended to prevent skin breakdown or wounds). The air mattress control device box (electrical device used to inflate the air mattress), was located at the foot of the bed. The electrical cord attached to the control device box was below the bed, on the floor, running from the bottom of the bed to the top and then plugged into an electrical outlet. CNA 1 showed the electrical cord which was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: M8I311 Facility ID: CA020000110 If continuation sheet 5 of 7 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 06/01/2017 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 the source of the spark. The cord was worn through in three spots and bare wire was exposed. There was an approximately 5-6 inch burn mark noted on the floor below the bed. CNA 1 stated he had written the faulty brakes on the maintenance log several times (maintenance log- list of items/equipment which needed to be repaired with a column for check off and date completed by the maintenance director) Review of the document titled, "Maintenance Log," showed an entry dated 2/17/17. The work request showed, the "bed weels [sic] won't lock". Further review of the Maintenance log indicated another work request entry dated 2/21/17 to "Change the bed completely." The Maintenance Log entry dated 2/17/17 and 2/21/17, was dated and signed indicating it was repaired on 3/8/17. During a concurrent observation and interview on 5/18/17 at 12:10 p.m., CNA 1 stated Resident 5's bed continued to roll when locked even after the bed had been changed. CNA 1 demonstrated how Resident 5's bed continued to roll when the bed wheels were locked. During a concurrent observation and interview with a licensed electrician (LE), who had been called by the facility, on 5/18/17 at 2:22 p.m., the LE stated, if the exposed, sparked wiring had been laying next to combustible materials, (for example sheets and blankets), the incident could have started a fire. Review of the facility's policy and procedure titled, "Maintenance Service," dated 12/2009, indicated, "Maintenance services shall be provided to all areas of the building, grounds, and equipment...Maintenance Department is responsible for maintaining the buildings, grounds and equipment in a safe and operable FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: M8I311 Facility ID: CA020000110 If continuation sheet 6 of 7 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 06/01/2017 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 manner at all times..Functions of maintenance personnel include, but are not limited to:...Maintaining the building in good repair and free from hazards." During a concurrent observation and interview with the DON, on 5/18/17, at 3:45 p.m., the DON stated the immediate plan of correction was the LE had ensured the electrical system was safe and Resident 5's air mattress and power equipment had been replaced. The DON was notified verbally the IJ was lifted on 5/18/17 at 3:45 p.m. The Administrator was not available in the facility for notification. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: M8I311 Facility ID: CA020000110 If continuation sheet 7 of 7