Other·October 27, 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 twoentity-reported incidents. Entity-reported incident numbers: 546644 and 538777. Representing the Department: HFEN 32717. The investigation was limited to the specific entity-reported incidents investigated and does not represent the findings of a full investigation of the facility. One deficiency was written as a result of entityreported incident 546644. No deficiencies were issued for entity-reported incident 538777.

F281 SS=G SERVICES PROVIDED MEET PROFESSIONAL STANDARDS CFR(s): 483.21(b)(3)(i)

F281 10/13/2017 (b)(3) Comprehensive Care Plans The services provided or arranged by the facility, as outlined by the comprehensive care plan, must(i) Meet professional standards of quality. This REQUIREMENT is not met as evidenced by: Based on interview and record review, for one of four sampled residents (Resident 1), the facility failed to provide nursing services that 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: H85F11 Facility ID: CA020000115 If continuation sheet 1 of 8 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: _______________ 055215 (X3) DATE SURVEY COMPLETED 09/25/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OAKLAND HEALTHCARE & WELLNESS CENTER 3030 Webster Street Oakland, CA 94609 (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 met professional standards of quality. Registered Nurse (RN) 1 did not verify Resident 1's identity before she gave Resident 1 methadone [an opioid narcotic used to treat pain or to help with detoxification in people with opioid dependence (addiction)] intended for another resident. This failure resulted in Resident 1 vomiting and experiencing an altered level of consciousness that required a five day hospital stay and treatment with Narcan (a medication for the emergency treatment of opioid overdose) for methadone poisoning (symptoms include vomiting, weakness, and an altered/decreased level of consciousness). Findings: Review of Resident 1's face sheet (a document that gives resident information at a quick glance), dated 7/14/17, indicated Resident 1 was admitted to the facility on 6/21/17 with multiple diagnoses that included generalized weakness and a referral for physical therapy. During an interview with RN 1 on 8/28/17, at 7:33 a.m., RN 1 stated that during the day shift on 7/24/17, a CNA approached her at 11 a.m. and told her a resident in the room adjacent to Resident 1 was in pain and asked RN 1 give him pain medication. RN 1 stated she prepared methadone solution and proceeded to give the medication to Resident 1 without checking for any identification. RN 1 stated she gave Resident 1 15 milliliters (150 milligrams) of methadone. RN 1 also stated that after she gave the methadone, she realized it was the wrong resident after she checked the MAR. Review of the facility's investigation follow up, dated 8/3/17, indicated the facility received a phone call from the hospital on 7/25/17 during FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: H85F11 Facility ID: CA020000115 If continuation sheet 2 of 8 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: _______________ 055215 (X3) DATE SURVEY COMPLETED 09/25/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OAKLAND HEALTHCARE & WELLNESS CENTER 3030 Webster Street Oakland, CA 94609 (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 evening shift that Resident 1 had methadone in his system. The investigation follow up also indicated RN 1 called the DON on 7/28/17 and admitted she made a mistake and gave medication to the wrong resident. According to Resident 1's Physician's Order, dated July 2017, there was no physician's order for methadone. Review of Resident 1's Medication Administration Record (MAR), dated July 2017, did not indicate Resident 1 received methadone. Review of the facility's policy and procedure titled "Preparation and General Guidelines," effective April 2008, indicated "...Medication Administration Administration-General Guidelines...B. Administration...7). Residents are identified before medication is administered. Methods of identification include: a. Checking identification band b. Checking photograph attached to medical record c. If necessary, verifying resident identification with other facility personnel...12). Medications supplied for one resident are never administered to another resident...." Review of the facility's policy and procedure titled "Medication-Errors," last revised 1/1/12, indicated "...Policy: I. All errors related to the administration of medications of treatments will be reported to the Director of Nursing Services, the attending physician and the Administrator immediately...II. Medication Error means the administration of medication: A. To the wrong resident...C. At the wrong dose...E. Which is not currently prescribed...Procedure I. Upon discovery of an error, the DON and the Administrator will be immediately notified. II. The Licensed Nurse will make an immediate assessment of the resident in relation to the nature of the error and continue to monitor the resident closely for any adverse effects from FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: H85F11 Facility ID: CA020000115 If continuation sheet 3 of 8 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: _______________ 055215 (X3) DATE SURVEY COMPLETED 09/25/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OAKLAND HEALTHCARE & WELLNESS CENTER 3030 Webster Street Oakland, CA 94609 (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 medication. III. If the error is potentially lifethreatening, the error and the assessment should be immediately communicated to the Attending Physician. IV. A medication error report should be completed for all medication errors. V. The medication in error is documented in the MAR. VI. Follow-up notes are written if any adverse effect is noted...." See F333 for additional information regarding Resident 1.

F333 SS=G RESIDENTS FREE OF SIGNIFICANT MED ERRORS CFR(s): 483.45(f)(2)

F333 10/13/2017 483.45(f) Medication Errors. The facility must ensure that its(f)(2) Residents are free of any significant medication errors. This REQUIREMENT is not met as evidenced by: Based on interview and record review, for one of four sampled residents (Resident 1), the facility failed to ensure Resident 1 was free of a medication error that jeopardized his health. Registered Nurse (RN) 1 gave Resident 1 methadone (an opioid narcotic used to treat pain or to help with detoxification in people with opioid dependence) intended for another resident. This failure resulted in Resident 1 vomiting and experiencing an altered level of consciousness that required a five day hospital stay and treatment with Narcan (a medication for the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: H85F11 Facility ID: CA020000115 If continuation sheet 4 of 8 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: _______________ 055215 (X3) DATE SURVEY COMPLETED 09/25/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OAKLAND HEALTHCARE & WELLNESS CENTER 3030 Webster Street Oakland, CA 94609 (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 emergency treatment of opioid overdose) for methadone poisoning (symptoms include vomiting, weakness, and an altered/decreased level of consciousness). Findings: Review of Resident 1's face sheet (a document that gives resident information at a quick glance), dated 7/14/17, indicated Resident 1 was admitted to the facility on 6/21/17 with multiple diagnoses that included generalized weakness and a referral for physical therapy. Review of Resident 1's Physical Therapy (PT) Evaluation and Plan of Treatment notes, dated 6/22/17, indicated Resident 1 needed PT services to improve his leg muscle strength, standing balance, activity tolerance and safety awareness to assist with transfers (i.e. moving from sitting to standing) and walking. During an interview with Physical Therapy Assistant (PTA) 1 on 8/24/17, at 3:36 p.m., PTA 1 stated that on 7/24/17 during the 3 o'clock hour, Resident 1 did not receive physical therapy at all because Resident 1 was sick and vomited. Review of Resident 1's Nurse's Notes, dated 7/24/17 at 7:45 p.m., indicated Resident 1 vomited three times in a large amount during physical therapy and also refused dinner. Review of Resident 1's Medication Administration Record (MAR), dated 7/24/17, indicated Resident 1 did not received his 5 p.m. scheduled medications because he was "unable to wakeup fully to take his 5 p.m. meds ...." According to Resident 1's Physician's Order, dated July 2017, there was no physician's order for methadone. Review of Resident 1's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: H85F11 Facility ID: CA020000115 If continuation sheet 5 of 8 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: _______________ 055215 (X3) DATE SURVEY COMPLETED 09/25/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OAKLAND HEALTHCARE & WELLNESS CENTER 3030 Webster Street Oakland, CA 94609 (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 Medication Administration Record (MAR), dated July 2017, did not indicate Resident 1 received methadone. Review of Resident 1's Situation, Background, Assessment, Recommendation (SBAR - a technique used to facilitate prompt and appropriate communication), dated 7/25/17 at 10 a.m., indicated Resident 1 had a decreased level of consciousness. Review of Resident 1's Physician's Telephone Orders, dated 7/25/17 at 10:30 a.m., indicated Resident 1 had a physician's order to be sent to the emergency room for evaluation and treatment. Review of the facility's investigation follow up, dated 8/3/17, indicated the facility received a phone call from the hospital on 7/25/17 during the evening shift that Resident 1 had methadone in his system. The investigation follow up also indicated RN 1 called the DON on 7/28/17 and admitted she made a mistake and gave medication to the wrong resident. During an interview with RN 1 on 8/28/17, at 7:33 a.m., RN 1 stated that during the day shift on 7/24/17, a CNA approached her at 11 a.m. and told her a resident in the room adjacent to Resident 1 was in pain and asked RN 1 give him pain medication. RN 1 stated she prepared methadone solution and proceeded to give the medication to Resident 1 without checking for any identification. RN 1 stated she gave Resident 1 15 milliliters (150 milligrams) of methadone. RN 1 also stated that after she gave the methadone, she realized it was the wrong resident after she checked the MAR. Review of the drug reference website, Lexicomp, indicated the maximum normal initial dose of methadone is 30 milligrams (mg). Further review of Lexicomp indicated " FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: H85F11 Facility ID: CA020000115 If continuation sheet 6 of 8 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: _______________ 055215 (X3) DATE SURVEY COMPLETED 09/25/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OAKLAND HEALTHCARE & WELLNESS CENTER 3030 Webster Street Oakland, CA 94609 (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 ...accidental ingestion of even one dose of methadone ...can result in a fatal overdose of methadone ..." [Reference: www.lexicomponline.com]. Review of Resident 1's Emergency Department Note (ED Note), dated 7/25/17 at 11:53 a.m., indicated Resident 1 was admitted to the emergency department with an altered level of consciousness that required a sternal rub (a painful stimulus) to arouse the resident. The ED Note also indicated Resident 1's lab test was positive for methadone. The ED Note also indicated Resident 1 received Narcan two times while in the ED. The ED Note further indicated Resident 1 had a diagnosis of methadone poisoning and was admitted to the acute hospital for further treatment. Review of Resident 1's Hospital Discharge Summary, dated 7/29/17, indicated Resident 1 was admitted to the hospital and had a five day (7/25/17 to 7/29/17) hospital stay for treatment of methadone poisoning that required several additional doses of Narcan. Review of the facility's policy and procedure titled "Preparation and General Guidelines," effective April 2008, indicated "...Medication Administration Administration-General Guidelines...B. Administration...7). Residents are identified before medication is administered. Methods of identification include: a. Checking identification band b. Checking photograph attached to medical record c. If necessary, verifying resident identification with other facility personnel...12). Medications supplied for one resident are never administered to another resident...." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: H85F11 Facility ID: CA020000115 If continuation sheet 7 of 8 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: _______________ 055215 (X3) DATE SURVEY COMPLETED 09/25/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OAKLAND HEALTHCARE & WELLNESS CENTER 3030 Webster Street Oakland, CA 94609 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) FORM CMS-2567(02-99) Previous Versions Obsolete ID PREFIX TAG Event ID: H85F11 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) Facility ID: CA020000115 (X5) COMPLETE DATE If continuation sheet 8 of 8