Health inspection·October 15, 2024

F 0572 Give residents a notice of rights, rules, services and charges. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a written notice of rights and services prior to or upon admission for three of three sampled residents (Resident 1, Resident 2 and Resident 3), when: Residents Affected - Some - For Resident 1, the admission agreement was provided more than nine months after Resident 1's admission to the facility. - For Resident 2 and Resident 3, there was no admission agreement provided during the residents' stay. This failure had the potential to result in Residents 1, 2 and 3 ' s lack of information and awareness of their rights and how to use them as residents of the facility. Findings: During a review of Resident 1's, Face Sheet, the Face Sheet indicated, Resident 1 was admitted to the facility in [DATE] with diagnoses that included fracture of one rib on the right side, unspecified dementia (a progressive state of decline in mental abilities) mild with other behavioral disturbance, major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), hypertension (HTN-high blood pressure), and chronic pain syndrome (pain that lasts longer than three months). The Face Sheet indicated, Resident Representative (RR) 1 as Resident 1's Responsible Party. During a review of Resident 1's SNF (Skilled Nursing Facility) Visit Notes dated [DATE], the notes indicated Resident 1 had no capacity to understand choices in healthcare decisions. During an interview and concurrent record review on [DATE] at 11:04 a.m., with Assistant Director of Nursing (ADON), Resident 1's admission agreement was reviewed. ADON stated, although Resident 1 was admitted in [DATE], the admission agreement was not provided and signed until [DATE]. During a review of Resident 2's,Face Sheet dated [DATE], the Face Sheet indicated, Resident 2 was admitted to the facility in February 2024 with diagnoses that included Palliative (a specialized medical approach that aims to improve quality of life and reduce suffering for people with serious illnesses) care for cancer of the Pancreas, Alzheimer's disease (a brain disorder that gradually destroys memory and thinking skills, and eventually the ability to perform everyday tasks) and Chronic Obstructive Pulmonary Disease (a common lung disease that makes it difficult to breathe). Resident 2 expired few days later on [DATE]. Page 1 of 3 056103 056103 10/15/2024 West Shore Post Acute 508 Westline Drive Alameda, CA 94501

F 0572 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of Resident 2's, Clinical Notes Report dated [DATE], the Clinical Notes Report indicated, Resident 2 was oriented to room, roommate, call lights, visiting hours, mealtimes, call light, TV/bed remote and Resident 2 verbalized understanding. The Clinical Notes Report did not indicate if the admission agreement was ever brought up. During a telephone interview on [DATE] at 1:06 p.m., with Medical Records Director (MRD), MRD stated there was no signed admission agreement for Resident 2 on file. During a review of Resident 3's,Face Sheet, the Face Sheet indicated, Resident 3, who was self-responsible, was admitted to the facility in [DATE] and discharged to home on [DATE]. During an interview on [DATE] at 11:30 a.m., with MRD, MRD stated there was no signed admission agreement for Resident 3 on file. During an interview on [DATE] at 12:27 p.m., with Admissions Director (AD), AD stated if a resident is not capable of making healthcare decisions, the resident's representative is asked to sign the admission agreement. AD also stated it was important to provide the admission agreement to the resident or resident's representative within 24-48 hours of admission to the facility for the resident or the resident representative to know their rights while a resident is residing at the facility. During a review of the facility's admission agreement, the admission agreement indicated, information that included resident's right to Consent to Treatment, Your Rights as a Resident, information about Financial Arrangements, Charges for Medical, Medicare or Uninsured residents, Transfers and Discharges, Bed hold and Readmission, Confidentiality, and Facility Rules and Grievance Procedure that included information about the ombudsman program. During a review of the facility's policy and procedure (P&P) titled admission Agreement, last revised in 2018, the P&P indicated, at the time of admission, the resident or the resident's representative must sign an admission agreement coordinated by the facility's Admissions Coordinator. A copy of the admission agreement is provided to the resident or the resident's representative and a copy is placed in the resident's permanent file. 056103 Page 2 of 3 056103 10/15/2024 West Shore Post Acute 508 Westline Drive Alameda, CA 94501

F 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) or Resident Representative (RR), was provided written information that specified the duration of the state bed-hold policy (Bed-hold, holding or reserving a resident's bed while the resident is absent from the facility for therapeutic leave or hospitalization), how reserve bed payments would be made (if applicable), and the conditions upon which the resident would return to the facility. This failure had the potential to result in the lack of awareness of Resident 1's right to hold a bed during hospitalization. Findings: During a review of Resident 1's, Face Sheet, the Face Sheet indicated, Resident 1 was admitted to the facility in January 2024 with diagnoses that included fracture of one rib on the right side, unspecified dementia (a progressive state of decline in mental abilities) mild with other behavioral disturbance, Major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), Hypertension (HTN-high blood pressure), and Chronic pain syndrome (pain that lasts longer than three months). The Face Sheet indicated, Resident Representative (RR) 1 as Resident 1's Responsible Party. During an interview and concurrent record review on 10/1/24 at 11:04 a.m., with Assistant Director of Nursing (ADON), Resident 1's Bed hold Notification Form dated 1/31/23 and signed by RR 1 was reviewed. The Bed hold Notification Form indicated an acknowledgement I have received the facility's policy regarding seven (7) day bed hold and fully understand that in the event of transfer to an acute facility, I will be notified of my right to hold a vacant space . The section To Be Completed Upon Transfer was not filled out and not signed by Resident 1 or RR 1. During a review of the facility's policy and procedure (P&P) titled, Bed-Holds and Returns, last revised in 2017, the P&P indicated, prior to transfers, residents or the resident's representative will be informed in writing of the bed hold and return policy. A written information will be given to the resident and the resident's representative about the rights and limitations of the resident regarding bed-hold, reserve bed payment policy as indicated by the state plan and details of the transfer. 056103 Page 3 of 3