Other·April 16, 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 represents the findings of the California Department of Public Health during the investigation of one complaint. Complaint Number: CA00570002. Representing the Department: HFEN 38533. For Complaint CA00570002, one deficiency was issued.

F600 SS=G Free from Abuse and Neglect CFR(s): 483.12(a)(1)

F600 04/29/2018 §483.12 Freedom from Abuse, Neglect, and Exploitation The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. §483.12(a) The facility must§483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion; This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was free from neglect when: 1. Certified Nursing Assistant 1 (CNA 1) notified Licensed Vocational Nurse 1 (LVN 1) of 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: 2UFM11 Facility ID: CA020000880 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: _______________ 555570 (X3) DATE SURVEY COMPLETED 03/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OAKLAND HEIGHTS NURSING AND REHABILITATION 2361 East 29th Street Oakland, CA 94606 (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 Resident 1's shortness of breath (SOB) and LVN 1 did not assess the resident's breathing; 2. The facility did not provide Resident 1 with breathing medications (Spiriva and Advair inhalers) as ordered by the physician; 3. Staff did not answer calls of distress from Resident 1 and she called 911 from her bedside. These deficient practices resulted in Resident 1's condition deteriorating without intervention and was admitted to the acute care hospital where she later died. Findings: Review of Resident 1's Minimum Data Set (MDS - an assessment tool used to guide care), dated 12/18/17, indicated Resident 1 was admitted to the facility on 12/16/17 with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe) and Chronic Respiratory Failure (the inability of lungs to perform effectively). The MDS also indicated Resident 1's cognitive (mental) skills for daily decision making were independent and her decisions were consistent and reasonable. Review of Resident 1's Order Summary Report, dated 12/16/17, indicated Resident 1 had physician order to receive Advair 500-50 micrograms (mcg) per dose - one puff two times a day and Spiriva HandiHaler 18 mcg one time a day. Review of Resident 1's Physician Order, dated 12/17/17, indicated "Please ensure (Resident 1) is getting breathing treatments around the clock as ordered." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2UFM11 Facility ID: CA020000880 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: _______________ 555570 (X3) DATE SURVEY COMPLETED 03/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OAKLAND HEIGHTS NURSING AND REHABILITATION 2361 East 29th Street Oakland, CA 94606 (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 Review of Resident 1's care plan for "Impaired Respiratory Function" initiated on 12/16/17, indicated the licensed nurse should provide "Breathing treatments as ordered." Resident 1's care plan also indicated the staff should "Observe/report signs symptoms of respiratory distress...." Symptoms of respiratory distress that may indicate that a person is working harder to breathe and may not be getting enough oxygen include increased breathing rate, bluish skin color around the mouth or fingernails, grunting, nose flaring, sweating, and wheezing. Review of Resident 1's Progress notes, dated 12/17/17, at 12:52 a.m., indicated Resident 1 complained of shortness of breath, wheezing and chest tightness. There was no documentation in the progress notes to show the physician was notified of Resident 1's breathing problems. Review of Resident 1's Progress Notes, dated 12/17/17, at 4:16 p.m., indicated Resident 1 complained of shortness of breath. There was no documentation in Progress Notes to show the physician was notified of Resident 1's breathing problems. During an interview with CNA 1 on 2/8/18, at 2:19 p.m., CNA 1 stated on 12/18/17 she noticed Resident 1 was breathing heavily, and she told LVN 1. CNA 1 stated LVN 1 said that was just how she breathes. During an interview with LVN 1 on 1/31/18, at 12:19 p.m., LVN 1 stated that on 12/18/17 she did not remember a CNA telling her about Resident 1 having shortness of breath. LVN 1 stated Resident 1's Spiriva inhaler and Advair inhaler were not administered because the medications had not been delivered to the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2UFM11 Facility ID: CA020000880 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: _______________ 555570 (X3) DATE SURVEY COMPLETED 03/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OAKLAND HEIGHTS NURSING AND REHABILITATION 2361 East 29th Street Oakland, CA 94606 (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. LVN 1 stated that when she went to administer pain medication to Resident 1 at the end of her shift, she noticed Resident 1 was on the phone with 911 (emergency services). LVN 1 stated they were short-handed that day. LVN 1 further stated they did not have a supervisor and it was "crazy." Review of Resident 1's Medication Administration Record (MAR), dated 12/1/17 through 12/31/17, indicated Resident 1 did not receive Advair or Spiriva on 12/17/17 and 12/18/17. During an interview with Resident 1's roommate's private caregiver (RPC) on 2/12/18, at 10:30 a.m., the RPC stated on 12/18/17 Resident 1 was yelling and screaming for help because Resident 1 was having problems breathing. The RPC stated Resident 1 said she called 911 because it was taking forever for someone to help her. Review of Resident 1's Progress Notes, dated 12/20/17, at 3:03 p.m., indicated "Late Entry for 12/18/17 am shift" Resident 1 was on the phone with 911 and had labored breathing. Further review of the Progress Notes, indicated Resident 1 was transferred from the facility by ambulance at 3:25 p.m. According to Resident 1's acute hospital Emergency Department (ED) note, dated 12/18/17, Resident 1 presented to the ED with "Continued shortness of breath, source of breath was severe, worsening, not improving over time...." According to acute hospital's Hospitalist History and Physical report, dated 12/18/17, Resident 1 "...presents back to the emergency department today with cough and difficulty breathing that is only worsened since discharge FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2UFM11 Facility ID: CA020000880 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: _______________ 555570 (X3) DATE SURVEY COMPLETED 03/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OAKLAND HEIGHTS NURSING AND REHABILITATION 2361 East 29th Street Oakland, CA 94606 (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 approximately 2 days ago...." Resident 1 was readmitted for COPD exacerbation (increase in COPD severity). According to the Death Summary, dated 12/21/2017, Resident 1's condition worsened and she expressed her wishes to be comfort care (medical care focused on improving the quality of life of patients with serious illnesses, as by treating symptoms and providing emotional support). Resident 1 passed away on 12/21/17. Review of the facility's "Abuse Prevention" policy and procedure revised 7/14, indicated "...Neglect is defined as failure to provide goods and services necessary to avoid physical harm..." See F760 for additional information regarding Resident 1.

F760 SS=D Residents are Free of Significant Med Errors CFR(s): 483.45(f)(2)

F760 04/29/2018 The facility must ensure that its§483.45(f)(2) Residents are free of any significant medication errors. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was free of significant medication errors (an error which causes the resident discomfort or jeopardizes their health and safety). For two days, Resident 1 did not receive Advair and Spiriva inhalers [breathing medications to treat Chronic Obstructive Pulmonary Disease (DOPD - a group of lung diseases that block airflow and make it difficult FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2UFM11 Facility ID: CA020000880 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: _______________ 555570 (X3) DATE SURVEY COMPLETED 03/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OAKLAND HEIGHTS NURSING AND REHABILITATION 2361 East 29th Street Oakland, CA 94606 (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 to breather)]. This deficient practice resulted in Resident 1 being transferred to the acute hospital for increased respiratory distress (severe difficulty in achieving adequate oxygenation in spite of significant efforts to breathe). Findings: Review of Resident 1's Minimum Data Set (MDS - an assessment tool used to guide care), dated 12/18/17, indicated Resident 1 was admitted to the facility on 12/16/17 with diagnoses that included COPD and Chronic Respiratory Failure (the inability of lungs to perform effectively). The MDS also indicated Resident 1's cognitive (mental) skills for daily decision making were independent and her decisions were consistent and reasonable. Review of Resident 1's Order Summary Report, dated 12/16/17, indicated Resident 1 had physician order to receive Advair 500-50 micrograms (mcg) per dose - one puff two times a day and Spiriva HandiHaler 18 mcg one time a day. Review of Resident 1's Physician Order, dated 12/17/17, indicated "Please ensure pt. is getting breathing treatments around the clock as ordered." Review of Resident 1's care plan for Impaired Respiratory Function, initiated on 12/16/17, indicated the licensed nurse should provide "Breathing treatments as ordered." Resident 1's care plan also indicated the staff should "Observe/report signs symptoms of respiratory distress..." Review of Resident 1's Progress notes, dated 12/17/17, at 12:52 a.m., indicated Resident 1 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2UFM11 Facility ID: CA020000880 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: _______________ 555570 (X3) DATE SURVEY COMPLETED 03/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OAKLAND HEIGHTS NURSING AND REHABILITATION 2361 East 29th Street Oakland, CA 94606 (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 complained of shortness of breath, wheezing and chest tightness. Review of Resident 1's Progress Notes, dated 12/17/17, at 4:16 p.m., indicated Resident 1 complained of shortness of breath. During an interview with Licensed Vocational Nurse (LVN) 1 on 1/31/18 at 12:19 p.m., LVN 1 stated that on 12/18/17 Resident1's Spiriva inhaler (breathing medication) and Advair inhaler (breathing medication) were not administered because the medications had not been delivered to the facility. LVN 1 stated she did not call the pharmacy regarding the medication not being there. Review of Resident 1's Medication Administration Record (MAR), dated 12/1/17 through 12/31/17, indicated Resident 1 did not receive Advair or Spiriva on 12/17/17 and 12/18/17. Review of the facility's Delivery Manifest document, dated 12/18/17 at 9:34 p.m., indicated Resident 1's Spiriva and Advair medications were delivered to the facility on 12/18/17 at 9:31 p.m. Review of Resident 1's Progress Notes, dated 12/20/17, at 3:03 p.m., indicated "Late Entry for 12/18/17 am shift" Resident 1 was on the phone with 911 and had labored breathing. Further review of the Progress Notes, indicated Resident 1 was transferred from the facility by ambulance at 3:25 p.m. According to Resident 1's acute hospital Emergency Department (ED) note, dated 12/18/17, Resident 1 presented to the ED with "Continued shortness of breath, source of breath was severe, worsening, not improving over time...." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2UFM11 Facility ID: CA020000880 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: _______________ 555570 (X3) DATE SURVEY COMPLETED 03/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OAKLAND HEIGHTS NURSING AND REHABILITATION 2361 East 29th Street Oakland, CA 94606 (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 According to the Death Summary, dated 12/21/2017, Resident 1's condition worsened and she expressed her wishes to be comfort care (medical care focused on improving the quality of life of patients with serious illnesses, as by treating symptoms and providing emotional support). Resident 1 passed away on 12/21/17. During an interview with the DON on 1/31/18, at 1:52 p.m., the DON stated the facility nurses should call the pharmacy to inquire why medications had not been delivered and inform the doctor. Review of the facility's policy and procedure titled, "Medication Ordering and Receiving from Pharmacy," dated 4/08, indicate "Procedures...3) New medications...are ordered as follows: a. If needed before the next regular delivery, inform pharmacy of the need for prompt delivery. b. The emergency kit or emergency drug supply as applicable is used when the resident needs a medication prior to pharmacy deliver..." Se F600 for additional information regarding Resident 1. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2UFM11 Facility ID: CA020000880 If continuation sheet 8 of 8