Health inspection·August 8, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, licensed nursing staff did not provide care according to professional standards for 1 of 3 sampled residents (Resident 1). Resident 1 had been prescribed oxycodone (narcotic) since 2024 and was in hospice (end-of-life care for a terminal illness.) When Resident 1 could no longer swallow her pills, facility staff did not have a plan in place to address withdrawal symptoms from the oxycodone.This resulted in Resident 1 experiencing unnecessary pain, agitation and distress.During a review of Resident 1's clinical document titled admission Record, the admission record indicated, the facility admitted Resident 1 on 12/14/2023 with multiple medical diagnoses including multiple fractures, cerebral infarction (stroke) and chronic pain syndrome. During a review of Resident 1's clinical document titled Physician's Order dated 4/7/2025, the document indicated, Resident 1 was admitted into hospice care with terminal diagnosis of Dysphagia (inability to swallow) due to cerebrovascular(stroke). During a review of Resident 1's clinical document titled MDS 3.0 Nursing Home Quarterly (NQ) Version 1.19.1 (Resident Assessment) dated 3/26/2025, the MDS indicated, Resident 1 was alert, could repeat the number of words presented to her and could identify the year and month. During a review of Resident 1's clinical document titled Order Summary Report dated 4/1/2025, the document indicated, staff were to administer Baclofen (muscle relaxant) 3 times per day, Lyrica (medication for nerve pain) 3 times per day and oxycodone 10 milligrams 4 times a day for pain management for Resident 1. During a review of Resident 1's clinical document titled Medication Administration Record (MAR), dated March 2025, the MAR indicated Resident 1 had received the medications Baclofen, Lyrica and Oxycodone every day in March and into April of 2025. Further review of the MAR showed the start date for the oxycodone was 1/2/2024. During a review of Resident 1's MAR dated April 2025, the MAR indicated Resident 1 was able to take the Baclofen and Lyrica the morning of 4/12/2025 but refused subsequent dosages. Further review of the MAR showed the last dose of oxycodone was administered on 4/11/2025 at 5 p.m. During a review of Resident 1's clinical document titled Progress Notes *NEW*, the progress notes indicated, on 4/12/2025 at 2:33 a.m., Resident 1 was Resting comfortably but arousable. No complaints of pain or discomfort. Review of the note dated 4/12/2025 at 11:07 p.m. showed Resident 1 Appeared to be (having) multiple (episodes of) confusions and episodes of screaming during shift. Resident 1 had Refused most of the medications, Morphine and Ativan given. (30 hours and 7 minutes since the last administered dose of oxycodone) (Morphine: pain medication) (Ativan: anti-anxiety medication) During a review of Resident 1's clinical document titled Pulse Summary indicated at 9:22 p.m. on 4/12/2025, Resident 1's pulse was elevated at 98. Her baseline range for April 2025 showed a pulse in the 60's and 70's. (normal range is 60-100) Review of the document O2 Sats Summary showed Resident 1's oxygen saturation at 9:22 p.m. on 4/12/2025 was 52% (amount of oxygen in the blood: normal range 95-100%) During further review of Resident 1 s progress notes showed the following: 4/13/2025 at 10:43 a.m. - Resident is having frequent episodes of restlessness, agitation and screaming. Residents Affected - Few (continued on next page) 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. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 055107 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055107 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/08/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bancroft Healthcare Center 1475 Bancroft Avenue San Leandro, CA 94577 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)