Health inspection·June 27, 2024

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to administer medications timely for one of three sampled residents (Resident 1), when multiple medications for Resident 1 were administered after the ordered administration time. This failure had the potential for exacerbating Resident 1's health condition and compromising their overall health and well-being. Findings: A record review of Resident 1 ' s Face Sheet, (undated), indicated Resident 1 was re-admitted to the facility on [DATE] with primary diagnoses including Human Immunodeficiency Virus (HIV, a virus that attacks cells that help the body fight infection, making a person more vulnerable to other infections and diseases), Chronic Obstructive Pulmonary Disease (COPD, refers to a group of diseases that cause airflow blockage and breathing-related problems. It includes emphysema and chronic bronchitis), End-Stage Renal Disease (ESRD, the final stage of long-term kidney disease when the kidneys are no longer sufficiently able to remove waste products and excess water to support the body ' s needs), Essential (primary) Hypertension (HTN, high blood pressure that is multi-factorial and doesn't have one distinct cause), Hyperlipidemia (an abnormally high concentration of or lipids in the blood), Clostridium Difficile (C-diff, a bacterium that can cause diarrhea and colitis, an inflammation of the colon. Infections can range from asymptomatic to life-threatening, and are the leading cause of diarrhea associated with antibiotics). A record review of Resident 1 ' s Minimum Data Set (MDS, a tool for assessing the health status of residents in long-term care nursing facilities that are certified to participate in Medicare or Medicaid), dated 5/21/24, indicated a Brief Interview for Mental Status (BIMS, is a scoring system used to determine the resident ' s cognitive status in regard to attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status) could not be assessed for Resident 1, and a staff assessment of mental status was conducted. The facility found Resident 1 had a short-term memory problem, and Resident 1 was moderately impaired in making decisions regarding tasks of daily life. During a record review of Resident 1 ' s Physician Order Report dated 6/1/24 - 6/11/24, the following prescribed medications included: 1. Amlodipine 5 mg (milligram-a unit of measurement) tablet, oral, one time daily at 9:00 a.m. for hypertension, start 5/23/24 - open ended. (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 4 Event ID: 056389 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 056389 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vale Healthcare Center 13484 San Pablo Avenue San Pablo, CA 94806 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)