Other·August 12, 2019

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: CA00617676 Complaint number: CA00617614 The inspection was limited to the specific complaint and facility reported incident investigated and does not represent the findings of a full inspection of the facility. Representing the Department of Public Health HFEN: 40212 One deficiency was written as a result of facility reported incident number: CA00617676, see

F689. Two deficiencies were written as a result of complaint number: CA00617614, see F690 and

F842.

F689 SS=G Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) 07/30/2019 §483.25(d) Accidents. The facility must ensure that §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents. 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: 7M4911 Facility ID: CA020000274 If continuation sheet 1 of 12 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: _______________ 555313 (X3) DATE SURVEY COMPLETED 07/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE REHABILITATION CENTER OF OAKLAND 210 40th Street Way Oakland, CA 94611 (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 This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure the bed was kept in a low position, in order to prevent fall injuries, for one of three residents (Resident 1) at increased risk of falling. For Resident 1, the failure to maintain his bed in a low position caused him to fracture his right humeral head and neck (break the bone in the upper arm at the shoulder level), when he used his right arm to slow his fall from the bed. Findings: A review of the facility Face Sheet reflected Resident 1's original admission was in July 2018, with a readmission on 12/28/18. The Face Sheet indicated Resident 1 had diagnoses of generalized muscle weakness, and seizures (a disorder of uncontrollable muscular contractions). A review of the Minimum Data Set (MDS, an assessment tool used to guide care) dated 9/13/18, reflected Resident 1 had intact thinking and remembering skills, with a Brief Interview for Mental Status (BIMS is an assessment tool for a resident's orientation to time, and capacity to remember. The BIMS range is from 0-15, with 15 an indication of intact skills.) score of 15. The MDS showed Resident 1 was totally dependent on one to two people for assistance with bed mobility, transfer from one surface to another, dressing, eating, and personal hygiene. A review of the facility form, "Fall Risk Assessment," dated 11/2/18, showed Resident 1's fall risk score was ten. The form instructions indicated, "If the total score is 10 or FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7M4911 Facility ID: CA020000274 If continuation sheet 2 of 12 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: _______________ 555313 (X3) DATE SURVEY COMPLETED 07/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE REHABILITATION CENTER OF OAKLAND 210 40th Street Way Oakland, CA 94611 (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 greater, the resident should be considered at high risk for potential falls. A prevention protocol should be initiated immediately and documented on the care plan." A review of the facility, "Fall Risk Prevention Care Plan," dated 11/4/18, indicated Resident 1's interventions to prevent falls included, "provide an environment that supports minimized hazards over which the facility has control, bed in low position, and remind resident to use call light." A review of the facility, "Situation, Background, Appearance, Review (SBAR)," dated 12/21/18 at 12:10 a.m., indicated Licensed Vocational Nurse 2 (LVN 2) completed a physical assessment of Resident 1 after a certified nursing assistant found Resident 1 on 12/20/18 at 11:25 p.m., "hanging on the edge of his bed with right leg and right arm touching the floor. Resident was using right hand and arm pushing down on floor to hold himself up to prevent falling to floor." During a concurrent observation and interview with Resident 1 on 1/8/19 at 10:45 a.m., Resident 1 lay in bed, his head pointed towards the left side rail; Resident 1 wore a sling (a fabric device used for support) on his right arm. Resident 1 stated he fell from his bed one night after a certified nursing assistant (CNA) elevated his bed too high. Resident 1 could not remember which CNA elevated his bed, but remembered he told the CNA it was painful, and asked for it to be lowered; the CNA left the room without lowering the bed. Resident 1 stated he later fell off the bed, and had to call for help. Resident 1 stated Certified Nursing Assistant 1 (CNA 1) answered his call, and assisted him back into bed. During an interview with Certified Nursing FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7M4911 Facility ID: CA020000274 If continuation sheet 3 of 12 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: _______________ 555313 (X3) DATE SURVEY COMPLETED 07/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE REHABILITATION CENTER OF OAKLAND 210 40th Street Way Oakland, CA 94611 (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 Assistant 2 (CNA 2) on 1/8/19 at 12:35 p.m., CNA 2 stated she was assigned to Resident 1 on the evening shift (3 p.m. to 11:30 p.m.) of 12/20/18. CNA 2 stated she assisted Resident 1 with hygiene needs at 9:30 p.m., and left his room with the head of the bed up "only a little bit." CNA 2 stated at 10:45 p.m. the same evening, she heard Resident 1 calling to have his eyes cleaned. CNA 2 stated she did not answer his call. A review of the facility care plan, "Activities of Daily Living," dated 11/4/18, indicated the intervention, "provide assistance with ADL [Activities of Daily Living] as needed." During an interview with CNA 1 on 1/23/19 at 2:58 p.m., CNA 1 stated he was Resident 1's primary CNA on the overnight shift (11 p.m. to 7 a.m. of the following day). CNA 1 stated he went to Resident 1's room on 12/20/18 at 11:24 p.m., when he heard Resident 1 yell. CNA 1 entered the room and saw Resident 1 hanging off the right side of his bed: his right arm and leg were off the bed, touching the floor; his left hand held onto the bed. CNA 1 stated Resident 1's bed was not in the lowest position, but at a medium height, and without the usual positioning pillows (two for the head, one at each side, and one under the right foot). During an interview with Licensed Vocational Nurse (LVN) 2 on 1/30/19 at 12:45 p.m., LVN 2 stated she assessed Resident 1 after CNA 1 reported the fall incident on 12/20/18. LVN 2 stated Resident 1 was on fall risk precautions, and known to "wiggle" a lot in bed, so precautions included keeping his bed in a low position, and the call light in reach. A review of the facility Interdisciplinary Team notes dated 12/21/18, reflected Resident 1 complained of falling the previous night and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7M4911 Facility ID: CA020000274 If continuation sheet 4 of 12 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: _______________ 555313 (X3) DATE SURVEY COMPLETED 07/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE REHABILITATION CENTER OF OAKLAND 210 40th Street Way Oakland, CA 94611 (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 now had pain on his right side. Resident 1 went to the acute care hospital for evaluation of the right sided pain, and blood in his urinary catheter (an artificial tube inserted through the urethra [the anatomical tube connecting the internal urinary bladder to the opening on the exterior of the body], and into the bladder in order to drain urine into an external collection bag). A review of the acute care hospital emergency department History and Physical, dated 12/21/18, indicated Resident 1 complained to the emergency department physician of right arm pain, in addition to the chief complaint of blood in the urinary catheter. The physician ordered radiology (X-ray) studies in addition to treatments for the catheter bleeding, and admitted Resident 1 to the acute care hospital. A review of the acute care hospital Orthopedic (the study of muscles and bones) Consultation Note dated 12/25/18, noted Resident 1 complained of right-sided shoulder pain. The orthopedic surgeon documented Resident 1's right arm X-ray showed an "acute comminuted humeral head/neck fracture" (a break or splintering of the upper arm bone at the shoulder, into more than two fragments). The surgeon, after consultation with Resident 1 and his medical decision-maker, recommended non-surgical treatment of the injury with a sling.

F690 SS=D Bowel/Bladder Incontinence, Catheter, UTI CFR(s): 483.25(e)(1)-(3)

F690 07/30/2019 §483.25(e) Incontinence. §483.25(e)(1) The facility must ensure that resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7M4911 Facility ID: CA020000274 If continuation sheet 5 of 12 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: _______________ 555313 (X3) DATE SURVEY COMPLETED 07/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE REHABILITATION CENTER OF OAKLAND 210 40th Street Way Oakland, CA 94611 (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 not possible to maintain. §483.25(e)(2)For a resident with urinary incontinence, based on the resident's comprehensive assessment, the facility must ensure that(i) A resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary; (ii) A resident who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary; and (iii) A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible. §483.25(e)(3) For a resident with fecal incontinence, based on the resident's comprehensive assessment, the facility must ensure that a resident who is incontinent of bowel receives appropriate treatment and services to restore as much normal bowel function as possible. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to provide appropriate urinary catheter treatment and care for one (Resident 1) of three sampled residents. For Resident 1, the failure to assess, and provide ordered treatments for his suprapubic catheter (a flexible tube surgically inserted into the bladder through the abdomen to drain urine into an external collection bag), had the potential to contribute to the development, or delay treatment, of a urinary tract infection. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7M4911 Facility ID: CA020000274 If continuation sheet 6 of 12 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: _______________ 555313 (X3) DATE SURVEY COMPLETED 07/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE REHABILITATION CENTER OF OAKLAND 210 40th Street Way Oakland, CA 94611 (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 See also F 842. Findings: A review of the acute care hospital Inter-Facility Transfer Report, dated 12/28/18, showed Resident 1 was hospitalized from 12/21/18 12/28/18 for hematuria (blood in urine). The Report indicated, during his hospitalization, Resident 1 had a hole in his urinary bladder repaired, and a suprapubic catheter placed. The Report indicated Resident 1's medical history included blindness, severe left sided weakness, and generalized weakness to the extent of functional quadriplegia (an inability to use his legs or arms effectively). A review of the Minimum Data Set (MDS, an assessment tool used to guide care) dated 9/13/18, reflected Resident 1 had intact thinking and remembering skills, with a Brief Interview for Mental Status (BIMS is an assessment tool for a resident's orientation to time, and capacity to remember. The BIMS range is from 0-15, with zero as the most impaired.) score of 15. The MDS showed Resident 1 was totally dependent on one to two people for assistance with bed mobility, transfer from one surface to another, dressing, eating, and personal hygiene. A review of the Physician Admission Orders dated 12/29/18 indicated Resident 1 was to receive a cleaning and dressing change of the suprapubic catheter site on a daily basis. During an observation of Resident 1 on 1/8/19 at 10:45 a.m., Resident 1's gown was soaked with yellow liquid around his stomach area; the urine collection bag hung from the left side of bed, with no urine in the bag. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7M4911 Facility ID: CA020000274 If continuation sheet 7 of 12 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: _______________ 555313 (X3) DATE SURVEY COMPLETED 07/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE REHABILITATION CENTER OF OAKLAND 210 40th Street Way Oakland, CA 94611 (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 During a concurrent observation and interview with the Director of Nursing (DON) 1 on 1/8/19 at 11:00 a.m., DON 1 confirmed Resident 1's gown was wet and needed to be changed. DON 1 lifted Resident 1's gown and confirmed the abdominal surgical wound staples were covered with yellow drainage, the surgical wound edges were red, and the suprapubic catheter site was surrounded by yellow leakage. DON 1 stated the physician needed notification that the suprapubic catheter was leaking. During an interview with Licensed Vocational Nurse (LVN) 1 on 1/8/19 at 11:10 a.m., LVN 1 stated she last saw Resident 1 around 9 a.m. when passing his morning medications. LVN 1 stated she had not noticed Resident 1 was wet. LVN 1 stated she had not checked the suprapubic catheter site or urine bag. During an interview with DON on 1/25/19 at 10:48 a.m., DON stated the physician had ordered Resident 1 to the acute care hospital on 1/8/19 to check his suprapubic catheter. DON stated Resident 1 had returned to the facility from the acute care hospital with a diagnosis of urinary tract infection (UTI), and suprapubic catheter malfunction. During an observation of Resident 1 and concurrent interview with DON 2 on 3/29/19 at 9:03 a.m., Resident 1's suprapubic catheter dressing had a foul odor, and was stained with dark yellow-orange drainage. DON 2 confirmed the dressing was labeled with the date "3/23/19." DON 2 stated the dressing needed changing. During an interview at 9:35 a.m., DON 2 stated the dressing should have been changed on a daily basis according to the physician order. A review of the facility policy and procedure FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7M4911 Facility ID: CA020000274 If continuation sheet 8 of 12 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: _______________ 555313 (X3) DATE SURVEY COMPLETED 07/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE REHABILITATION CENTER OF OAKLAND 210 40th Street Way Oakland, CA 94611 (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 titled, "Catheter - Care of," revised 1/1/12, indicated, "Residents with foley [urinary] catheters will be cared for utilizing the most current CDC [Center for Disease Control] Guidelines to prevent Urinary Tract Infections (UTI)." The procedure further indicated Licensed Nurses should reassess the residents for signs of complications of catheter use, and notify the physician of any sign or symptom of infection A review of the CDC, "Guidelines to Prevent Catheter Associated Urinary Tract Infections (2009)," dated 11/5/15, indicated the CDC strongly recommended changing a leaking catheter, and to prevent obstruction of urine flow in order to minimize infection.

F842 SS=D Resident Records - Identifiable Information CFR(s): 483.20(f)(5), 483.70(i)(1)-(5)

F842 07/30/2019 §483.20(f)(5) Resident-identifiable information. (i) A facility may not release information that is resident-identifiable to the public. (ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so. §483.70(i) Medical records. §483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are(i) Complete; (ii) Accurately documented; (iii) Readily accessible; and (iv) Systematically organized §483.70(i)(2) The facility must keep confidential all information contained in the resident's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7M4911 Facility ID: CA020000274 If continuation sheet 9 of 12 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: _______________ 555313 (X3) DATE SURVEY COMPLETED 07/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE REHABILITATION CENTER OF OAKLAND 210 40th Street Way Oakland, CA 94611 (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 records, regardless of the form or storage method of the records, except when release is(i) To the individual, or their resident representative where permitted by applicable law; (ii) Required by Law; (iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506; (iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512. §483.70(i)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use. §483.70(i)(4) Medical records must be retained for(i) The period of time required by State law; or (ii) Five years from the date of discharge when there is no requirement in State law; or (iii) For a minor, 3 years after a resident reaches legal age under State law. §483.70(i)(5) The medical record must contain(i) Sufficient information to identify the resident; (ii) A record of the resident's assessments; (iii) The comprehensive plan of care and services provided; (iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State; (v) Physician's, nurse's, and other licensed FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7M4911 Facility ID: CA020000274 If continuation sheet 10 of 12 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: _______________ 555313 (X3) DATE SURVEY COMPLETED 07/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE REHABILITATION CENTER OF OAKLAND 210 40th Street Way Oakland, CA 94611 (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 professional's progress notes; and (vi) Laboratory, radiology and other diagnostic services reports as required under §483.50. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to maintain complete and accurate medical record for one (Resident 1) of three sampled residents, when nursing documented providing a daily dressing change for a suprapubic urinary catheter (a flexible tube surgically inserted into the bladder through the abdomen to drain urine) for six days, without changing the dressing. For Resident 1, this failure resulted in miscommunication of actual provision of care, and potentially contributed to the lack of the dressing change. See also F 690. Findings: A review of the acute care hospital Inter-Facility Transfer Report, dated 12/28/18, showed Resident 1 was hospitalized from 12/21/18 12/28/18 for hematuria (blood in urine). The Report indicated, during Resident 1's hospitalization, surgeons repaired a hole in Resident 1's urinary bladder, and placed a suprapubic catheter. A review of the Physician Admission Orders dated 12/29/18 indicated Resident 1 was to receive a cleaning and dressing change of the suprapubic catheter site on a daily basis. A review of Resident 1's Treatment Administration Record (TAR) for March 2019, showed initials in each day's box from March 1 through March 28, as an indication of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7M4911 Facility ID: CA020000274 If continuation sheet 11 of 12 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: _______________ 555313 (X3) DATE SURVEY COMPLETED 07/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE REHABILITATION CENTER OF OAKLAND 210 40th Street Way Oakland, CA 94611 (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 completion of the suprapubic catheter site care tasks of cleaning and applying a new dressing. During an observation of Resident 1 and concurrent interview with DON 2 on 3/29/19 at 9:03 a.m., Resident 1's suprapubic catheter dressing had a foul odor, and was stained with dark yellow/orange drainage. DON 2 confirmed the dressing was labeled with the date "3/23/19." DON 2 stated the dressing needed changing. During a review of physician orders and the TAR, during an interview with DON 2 on 3/29/19 at 9:35 a.m., DON 2 confirmed the physician had ordered a daily cleaning and dressing change for the suprapubic catheter for Resident 1. DON 2 also confirmed the nurses had documented the daily treatment had been completed on 3/23/19, 3/24/19, 3/25/19, 3/26/19, 3/27/19, and 3/28/19. A review of the facility policy and procedure titled, "Catheter - Care of," revised date of 1/1/12, the policy showed, "Documentation of catheter care will be maintained in the resident's record." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7M4911 Facility ID: CA020000274 If continuation sheet 12 of 12