Health inspection·August 1, 2023

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a summary of the baseline care plan for one of two sampled residents (Resident 1). This failure resulted in the lack of information regarding care. Findings: During a review of Resident 1's admission Record, the document indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included severe protein calorie malnutrition, gastroenteritis (lining of the stomach and intestines are inflamed) and colitis (inflammation of the inner lining of the large bowels), cachexia (marked weight and muscle loss), esophagitis (inflammation of the esophagus/swallowing tube), diarrhea, and gastric ulcer (open sores develop on the stomach lining). During a review of Resident 1's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 7/6/23 indicated Resident 1's Brief Interview for Mental Status (BIMS, an assessment tool for resident's orientation to time and capacity to remember) score of 11 out of 15, indicating Resident 1 is moderately impaired. During an interview on 7/21/23 at 10:25 a.m. with Resident 1, Resident 1 stated the discharge plan was to either go home or go to the hospital. Resident 1 added discussions are still ongoing where Resident 1 tried to advocate for self. During an interview on 7/21/23 at 10:40 a.m. with Director of Nursing (DON), DON stated there was confusion about Resident 1's discharge plan. DON stated the plan was for Resident 1 to stay in the facility for long term, but Social Services Director (SSD) communicated to Resident 1 and Case Manager (CM) that Resident 1 was going to be discharged soon. DON stated Resident 1's tube feeding was re-started on 7/19/23 following discussion with Resident 1's CM who stated Resident 1 used to receive bolus feeding prior to admission to the facility. During an interview with SSD on 7/21/23 at 11:45 a.m., SSD stated there was no active discharge date yet. SSD also stated the goal was for Resident 1 to gain tube feeding compliance and achieve weight gain before discharge date and arrangements could be started. During a concurrent joint interview and review of Resident 1's Baseline Care Plan, dated 7/1/23, with DON and Medical Records Director (MRD) on 8/1/23 at 1:13 p.m., DON stated Resident 1's baseline care plan was not completed and Resident 1 was not given a copy of it. MRD stated a request to print (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 5 Event ID: 055876 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 055876 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Princeton Manor Healthcare Center, LLC 2124 57th Avenue Oakland, CA 94621 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)