Other·October 4, 2018

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 one facility-reported incident and one complaint. Facility-reported incident number: CA00587286 Complaint number: CA00588942 Representing the Department: HFEN 36593. The inspection was limited to the specific facility-reported incipdent and complaint investigated and does not represent the findings of a full inspection of the facility. One deficiency was written as a result of the facility-reported incident number CA00587286 and complaint number CA00588942.

F919 SS=F Resident Call System CFR(s): 483.90(g)(2)

F919 09/06/2018 §483.90(g) Resident Call System The facility must be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area. §483.90(g)(2) Toilet and bathing facilities. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, for two of two (Residents 1 and 2), the facility failed to ensure Resident's 1 and 2 had a means of directly contacting caregivers when the facility's call system was out and facility 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: GODY11 Facility ID: CA020000112 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: _______________ 055715 (X3) DATE SURVEY COMPLETED 08/06/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE KYAKAMEENA CARE CENTER 2131 Carleton Street Berkeley, CA 94704 (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 staff asked residents to use their personal cell phones or a manual call bell (a hollow metal cup that when struck vibrates in a single strong tone, with its sides forming an efficient resonator) to call facility staff for assistance. For Resident's 1 and 2, this failure had the potential to result in the delay of care in an emergency. Findings: 1. Review of Resident 1's Minimum Data Set (MDS - a resident assessment tool used to guide care), dated 2/7/18, indicated Resident 1 was admitted to the facility with diagnoses that included insomnia (persistent problems falling and staying asleep). Resident 1's MDS also indicated he was cognitively intact (had the ability to clearly think, reason, and remember). In an interview on 7/9/18, at 11:48 a.m., Resident 1 stated when he needed assistance with care and medication services, staff were inconsistent in answering both the manual call bell and his cell phone calls to the facility. Resident 1 stated at times he had pain and a problem sleeping. Resident 1 stated at night time and weekends he had to walk to get a nurse because they (nursing) could not hear the (manual) call bell. Resident 1 stated he had to frequently get up and go looking for a nurse when he or his roommate (Resident 2) needed help. In an interview on 7/9/18, at 10:25 a.m. Resident 1 stated the call system had not worked for over six weeks. Resident 1 stated the facility asked residents to use personal cell phones or (manual) call bell to call facility staff for help. Resident 1 stated staff did not answer calls from his cell phone to the facility or the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GODY11 Facility ID: CA020000112 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: _______________ 055715 (X3) DATE SURVEY COMPLETED 08/06/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE KYAKAMEENA CARE CENTER 2131 Carleton Street Berkeley, CA 94704 (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 manual call bell at night time or on weekends, and the manual call bell could not be heard by staff. 2. Record review of Resident 2's MDS, dated 4/30/18, indicated Resident 2 had clear speech, was able to express his ideas and wants, and understood what other said to him. Resident 2's MDS also indicated he needed two persons extensive physical assist with movement from bed to chair, he was frequently incontinent (insufficient voluntary control over) of urine, he was always incontinent of bowel movement, and needed one person physical assist with urinary and bladder incontinent care. In an interview on 7/9/18, at 11:30 a.m., Resident 2 stated he had a stomach ulcer and was afraid he could bleed to death if he did not get assistance timely. Resident 2 stated he did not feel safe at the facility because staff were inconsistent in answering the (manual) call bell or calls from his cell phone (to the facility) when he needed assistance with care and pain medication at night time and on weekends. Resident 2 stated he was not able to get out of bed without assistance. During an observation at the nursing station closest to Resident 1's room and concurrent interview on 6/12/18, at 12:08 p.m., Resident 1 rang his manual call bell in his room. Licensed Vocational Nurse (LVN 1), who was at the nursing station closest to Resident 1's room, stated she heard a (manual) call bell sound, but could not tell where the sound came from. In an interview with the Administrator on 7/9/18 at 12:09 p.m., the Administrator stated the facility's call system was out and not working since May 2018. To call for assistance, the Administrator stated residents could use FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GODY11 Facility ID: CA020000112 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: _______________ 055715 (X3) DATE SURVEY COMPLETED 08/06/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE KYAKAMEENA CARE CENTER 2131 Carleton Street Berkeley, CA 94704 (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 manual calls bells, their cell phones, or residents come out of their rooms (for residents who could walk). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GODY11 Facility ID: CA020000112 If continuation sheet 4 of 4