Health inspection·March 14, 2024

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm Based on record review and interviews, the facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for 2 (Resident #2 and Resident #86) of 24 sampled residents. Specifically, the facility failed to ensure Resident #2's visual status and Resident #86's nutritional status was accurately reflected on each resident's MDS assessment. Residents Affected - Few Findings included: On 03/14/2024 at 12:18 PM, the MDS Nurse stated the facility followed the Centers for Medicare and Medicaid Services Resident Assessment Instrument (RAI) Manual for MDS assessments and did not have an MDS policy. 1. Review Resident #2's admission Record revealed the facility admitted Resident #2 on 09/12/2005 with diagnoses that included legal blindness. Review of Resident #2's Care Plan revealed a Focus area, last revised on 02/08/2018, that indicated the resident had impaired visual function related to being legally blind. The care plan indicated the resident was able to see large print in a well-lit room and required large print books as a visual aid. Interventions instructed staff to ensure appropriate visual aids were available to support the resident's participation in activities and to identify and record factors affecting visual function, including physiological and environmental factors and the resident's choices. Review of a quarterly MDS, with an Assessment Reference Date (ARD) of 01/18/2024, revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 0, which indicated the resident had severe cognitive impairment. The MDS indicated Resident #2's vision was adequate (saw fine detail, such as regular print in newspapers/books). During an interview on 03/13/2024 at 12:27 PM, the MDS Nurse stated the information for the MDS came from the resident's electronic health record, their chart, and hospital records. She stated the MDS was completed by the interdisciplinary team member responsible for their section, and each person was accountable for their section. After reviewing Resident #2's record, she stated the resident had a diagnosis of being legally blind and confirmed that the resident's visual status was not captured correctly on the MDS. She stated a nurse and the social worker completed the hearing, speech, vision section of the MDS and was unsure why the resident's impaired vision was not captured. During an interview on 03/14/2024 at 9:12 AM, the Director of Nursing (DON) stated the information for the MDS should come from the residents' assessments and hospital records. She stated each department was responsible for their section of the MDS and its accuracy, and the MDS Nurse was responsible for ensuring the MDS was accurate. The DON stated if a resident was blind it should be captured on Page 1 of 9 555254 555254 03/14/2024 Medical Hill Healthcare Center 475 29th Street Oakland, CA 94609

F 0641 the MDS. She confirmed that Resident #2 was blind and that the resident's MDS was inaccurately coded. Level of Harm - Minimal harm or potential for actual harm During an interview on 03/14/2024 at 12:07 PM, the Administrator stated the MDS should be accurate and reflect the resident's true condition. He stated the MDS Nurse was responsible for the overall accuracy of the MDS. Residents Affected - Few 2. A review of Resident #86's admission Record revealed the facility admitted the resident on 06/03/2022 with diagnoses that included dysphagia (difficulty swallowing). Review of a quarterly MDS, with an Assessment Reference Date (ARD) of 11/21/2023, revealed Resident #86 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. The MDS indicated Resident #86 received parenteral (method of administering medication or nutrients that bypasses the digestive system)/intravenous feeding and had a feeding tube while a resident at the facility. Review of Resident #86's Order Summary Report, listing active orders as of 03/14/2024, revealed an order started on 07/24/2023 for a mechanical soft, ground texture diet and thin consistency liquids. The Order Summary Report did not reflect any orders for parenteral/intravenous feedings or a feeding tube. During an interview on 03/13/2024 at 12:27 PM, the MDS Nurse stated the information for the MDS came from the resident's electronic health record, their chart, and hospital records. She stated the MDS was completed by the interdisciplinary team member responsible for their section, and each person was accountable for their section. She stated Resident #86 did not have a feeding tube and the person that completed that section of the MDS clicked on the wrong button when completing the form. During an interview on 03/13/2024 at 8:52 AM, the Dietary Director stated she was responsible for completing the dietary section of the MDS and that the Director of Nursing (DON) brought the incorrect MDS coding to her attention. She stated she did not realize she had been coding that section of the MDS incorrectly. During an interview on 03/14/2024 at 9:12 AM, the DON stated the information for the MDS should come from the residents' assessments and hospital records. She stated each department was responsible for their section of the MDS and its accuracy, and the MDS Nurse was responsible for ensuring the MDS was accurate. During an interview on 03/14/2024 at 12:07 PM, the Administrator stated the MDS should be accurate and reflect the resident's true condition. He stated the MDS Nurse was responsible for the overall accuracy of the MDS. 555254 Page 2 of 9 555254 03/14/2024 Medical Hill Healthcare Center 475 29th Street Oakland, CA 94609

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and facility document and policy review, the facility failed to ensure a Preadmission Screening and Resident Review (PASRR) was completed for 1 (Resident #45) of 5 sampled residents reviewed for PASRR requirements. Specifically, the facility failed to ensure a Level I PASRR Screening was resubmitted when Resident #45 remained in the facility longer than 30 days. Residents Affected - Few Findings included: A review of a facility policy titled, admission Criteria, revised in March 2023, revealed, 9. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process. a. The acute hospital performs a Level I PASARR screen for all potential admissions, regardless of payor source, to determine if the individual meets the criteria for a MD, ID, or RD. The policy further indicated, 11. The state may choose not to apply the preadmission screening requirement if: a. the individual is admitted directly to the facility from a hospital where he or she received acute inpatient care; b. the individual requires facility services for the condition for which he or she received care in the hospital; and c. the attending physician has certified (prior to admission) that the individual will likely need less than 30 days of care at the facility. A review of Resident #45's admission Record revealed the facility admitted the resident from a hospital on [DATE] with diagnoses that included schizophrenia, bipolar disorder, and anxiety disorder. A review of Resident #45's Preadmission Screening and Resident Review (PASRR) Level 1 Screening, dated 11/21/2023, revealed Resident #45 was exempt due to a 30-day Exempted Hospital Discharge. A review of an associated letter from the Department of Health Care Services regarding the results of the resident's Level I PASRR, dated 11/21/2023, revealed, If the individual remains in the NF [nursing facility] longer than 30 days, the facility should resubmit a Level I Screening as a Resident Review on the 31st day. There was no documented evidence the facility submitted another Level I PASRR for Resident #45 when the resident's stay at the facility exceeded 30 days. A review of Resident #45's Care Plan revealed a Focus area, initiated on 11/22/2023, that indicated the resident was at risk for decreased psychosocial wellbeing, adjustment issues, emotional distress, ineffective coping skills, poor impulse control, and adverse effects on function. The Focus area also indicated Resident #45 was at risk for mental, physical, social, and spiritual wellbeing related to feeling down, depressed, or hopeless due to a diagnosis of schizophrenia. A review of Resident #45's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/22/2024, revealed Resident #45 had a Brief Interview for Mental Status (BIMS) of 7, indicating the resident had severe cognitive impairment. According to the MDS, at the time of the assessment, Resident #45 had active diagnoses of anxiety disorder, bipolar disorder, and schizophrenia and received antipsychotic and antianxiety medications. During an interview on 03/13/2024 at 12:26 PM, the MDS Nurse confirmed Resident #45's PASRR should have been resubmitted. During an interview on 03/14/2024 at 9:56 AM, the Director of Nursing (DON) stated Resident #45's PASRR should have been resubmitted. 555254 Page 3 of 9 555254 03/14/2024 Medical Hill Healthcare Center 475 29th Street Oakland, CA 94609

F 0645 Level of Harm - Minimal harm or potential for actual harm During an interview on 03/14/2024 at 10:22 AM, the Administrator stated that if the facility was instructed to resubmit a Level I PASRR Screening, the PASRR should have been resubmitted within the timeframe specified. Residents Affected - Few 555254 Page 4 of 9 555254 03/14/2024 Medical Hill Healthcare Center 475 29th Street Oakland, CA 94609

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, record review, and facility policy review, the facility failed to monitor the implementation of physician prescribed fluid restrictions for 1 (Resident #178) of 3 sampled residents reviewed for nutrition. Specifically, Resident #178, who received renal dialysis, had a physician's order for a 1200 milliliter (mL) fluid restriction each day, and the facility failed to ensure the resident did not routinely exceed 1200 mL of fluids per day. Residents Affected - Few Findings included: Review of a facility policy titled, Encouraging and Restricting Fluids, revised in October 2010, revealed, The purpose of this procedure is to provide the resident with the amount of fluids necessary to maintain optimum health. This may include encouraging or restricting fluids. Preparation 1. Verify that there is a physician's order for this procedure. 2. Review the resident's care plan and/or daily assignment sheet to assess for any special needs of the resident. The policy further specified, Follow specific instructions concerning fluid intake or restrictions. Review of an admission Record revealed the facility admitted Resident #178 on 12/26/2023 with diagnoses that included end stage renal disease and dependence on renal dialysis. Review of an admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/31/2023, revealed Resident #178 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. According to the MDS, the resident required setup or clean-up assistance from staff with eating. Review of Resident #178's comprehensive care plan revealed a Focus area, initiated on 12/27/2023, that indicated the resident needed dialysis related to renal failure. An intervention dated 12/27/2023 directed staff to monitor intake and output. Another Focus area, initiated on 02/01/2024, indicated the resident was at risk for malnutrition. Interventions dated 02/01/2024 directed staff to assist with meals/fluid as needed and to provide the resident's diet as ordered, including an order for fluid restriction of 1200 mL per day. Review of Resident #178's Order Summary Report revealed an active order dated 01/24/2024 for a consistent carbohydrate renal diet, regular texture, with a fluid restriction of 1200 mL. Another active order, dated 03/13/2024, indicated of the 1200 mL fluids each day, dietary was to provide 600 mL and nursing was to provide 600 mL. Review of Resident #178's FLUID INTAKE documentation for the timeframe from 02/12/2024 through 03/11/2024 revealed 15 days during which the resident consumed over 1200 mL of fluids: - 02/12/2024 - 650 mL, 360 mL, and 240 mL, for a daily total of 1250 mL; - 02/13/2024 - 720 mL, 500 mL, and 240 mL, for a daily total of 1460 mL; - 02/14/2024 - 980 mL and 588 mL, for a daily total of 1568 mL; - 02/19/2024 - 360 mL, 980 mL, and 240 mL, for a daily total of 1580 mL; - 02/20/2024 - 980 mL and 580 mL, for a daily total of 1560 mL; 555254 Page 5 of 9 555254 03/14/2024 Medical Hill Healthcare Center 475 29th Street Oakland, CA 94609

F 0692 - 02/21/2024 - 360 mL, 840 mL, and 120 mL, for a daily total of 1320 mL; Level of Harm - Minimal harm or potential for actual harm - 02/25/2024 - 480 mL and 1280 mL, for a daily total of 1760 mL; - 02/26/2024 - 240 mL, 980 mL, and 480 mL, for a daily total of 1700 mL; Residents Affected - Few - 02/28/2024 - 120 mL, 840 mL, and 480 mL, for a daily total of 1440 mL; - 03/03/2024 - 360 mL, 280 mL, and 590 mL, for a daily total of 1230 mL; - 03/04/2024 - 240 mL, 1000 mL, and 360 mL, for a daily total of 1600 mL; - 03/05/2024 - 240 mL, 860 mL, and 240 mL, for a daily total of 1340 mL; - 03/09/2024 - 480 mL, 680 mL, and 580 mL, for a daily total of 1740 mL; - 03/10/2024 - 300 mL, 980 mL, and 300 mL, for a daily total of 1580 mL; and - 03/11/2024 - 200 mL, 960 mL, and 480 mL, for a daily total of 1640 mL. During an observation on 03/13/2024 at 9:32 AM, Resident #178 had a pitcher of water at their bedside. During an interview on 03/13/2024 at 11:21 AM, Resident #178 said no one had spoken to them regarding the amount of fluid they were allowed to drink each day. Resident #178 said they kept a thermal pitcher in their room full of water to drink at their leisure. During an interview on 03/13/2024 at 11:11 AM, Certified Nursing Aide (CNA) #9 stated she was not aware of any of her assigned residents having fluid restrictions. CNA #9 revealed each resident's fluid intake was documented in their electronic health record daily. Later in the interview, CNA #9 stated she was aware that Resident #178 was on a fluid restriction. However, she did not know the amount of the resident's fluid restriction. During an interview on 03/13/2024 at 1:10 PM, Registered Nurse (RN) #7 stated she asked Resident #178 how many cups of water they drank and documented the amount Resident #178 told her. RN #7 did not know who provided the thermal pitcher of water to Resident #178, but stated the resident did not always drink the entire pitcher of water. RN #7 said Resident #178 was allowed to have up to 1200 mL of fluids per day. After reviewing fluid intake documentation for Resident #178, RN #7 could not explain why the resident exceeded the ordered fluid restriction of 1200 mL per day. During an interview on 03/13/2024 at 1:22 PM the Director of Nursing (DON) stated the Dietary Director had provided Resident #178 with the thermal water pitcher. The DON stated the water pitcher was provided to the resident each day. During an interview on 03/14/2024 at 10:09 AM, the Dietary Director stated Resident #178's fluid restriction was not reflected on their meal tickets until the surveyor inquired about fluids. The Dietary Director said Resident #178 was provided a 1.8 liter (1800 mL) thermal water pitcher upon the resident's request. The Dietary Director stated Resident #178 was drinking less than half of the pitcher, but they were not monitoring the amount that was consumed by the resident. 555254 Page 6 of 9 555254 03/14/2024 Medical Hill Healthcare Center 475 29th Street Oakland, CA 94609

F 0692 Level of Harm - Minimal harm or potential for actual harm During an interview on 03/14/2024 at 10:26 AM, the DON stated she expected orders for fluid restrictions to be carried out, monitored, and communicated with different departments. During an interview on 03/14/2024 at 11:38 AM, the Administrator stated his expectation was for orders for fluid restrictions to be followed and documented in the resident's electronic health record. Residents Affected - Few 555254 Page 7 of 9 555254 03/14/2024 Medical Hill Healthcare Center 475 29th Street Oakland, CA 94609

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, interviews, and facility policy review, the facility failed to ensure staff prepared and served foods for residents in a sanitary manner. Specifically, staff failed to implement proper hand hygiene practices during meal service to prevent potential cross-contamination. This failure had the potential to affect 115 of 115 residents who received meals from the dietary department. Findings included: Review of a facility policy titled, Food Preparation, dated 2023 (no month specified), revealed, Employees will prepare food in a clean and safe manner to protect residents and staff from foodborne illness. The policy specified, 1. Hands should be properly washed prior to food preparation. Plastic gloves should be worn to avoid direct contact with food, i.e. [id est, Latin for that is] handling ground beef, mixing salads, ready-to-eat foods, etc. [et cetera, and so forth]. Hands must be washed prior to putting on gloves and any glove changes. The policy also indicated, 7. Proper utensils should be used when preparing and serving food. On 03/12/2024 beginning at 12:15 PM, meal service was observed. [NAME] #4 was observed on the meal service line serving foods. She was handling plates and serving utensils with gloved hands. At 12:24 PM, [NAME] #4 left the meal service line and opened the oven door to retrieve a foil package of a grilled cheese sandwich. Without changing gloves or washing hands, [NAME] #4 returned to the meal service line and continued serving food. At 12:25 PM, [NAME] #4 retrieved another foil package of a grilled cheese sandwich from the oven, then returned to the meal service line without washing hands or changing gloves. [NAME] #4 opened the grilled cheese and used her gloved hands to place the sandwich on a plate. [NAME] #4 was then observed plating pasta, and each time she placed a serving on a plate, she touched the pasta with her gloved hands. [NAME] #4 also served meatballs using a serving utensil but then used her gloved hands to place the meatballs more precisely on the plate. [NAME] #4 had not washed hands or changed gloves, despite leaving the meal service line more than once. At 12:59 PM, after retrieving another grilled cheese sandwich, [NAME] #4 performed hand hygiene for the first time and applied new gloves, and continued meal service. At 1:07 PM, [NAME] #4 again left the meal service line to cook a vegetable burger in the microwave. She returned to the meal service line and continued serving food without washing hands or changing gloves. During an interview on 03/13/2024 at 1:36 PM, with translation provided by Dietary Aide #5, [NAME] #4 said she did not recall touching the pasta with her hands during meal service, but she confirmed that she should not touch food items while on the serving line. [NAME] #4 did recall touching the sandwiches after pulling them from the oven and indicated she should have washed her hands and changed her gloves since she handled non-food items. During an interview on 03/13/2024 at 1:44 PM, the Dietary Director stated that staff should use a utensil rather than their hands while plating foods on the meal service line. 555254 Page 8 of 9 555254 03/14/2024 Medical Hill Healthcare Center 475 29th Street Oakland, CA 94609

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on observations, interviews, record review, and facility policy review, the facility failed to ensure an order for oxygen use was transcribed into the electronic health record (EHR) for 1 (Resident #178) of 1 sampled resident reviewed for respiratory care. Findings included: A review of a facility policy titled Telephone Orders, revised in February 2014, revealed Verbal telephone orders may be accepted from each resident's Attending Physician. The policy specified, Orders must be reduced to writing, by the person receiving the order, and recorded in the resident's medical record. A review of an admission Record revealed the facility admitted Resident #178 on 12/26/2023. According to the admission Record, the resident had a medical history that included diagnoses of end stage renal disease, malignant neoplasm of the rectum, anemia, and pneumonia. A review of Resident #178's comprehensive care plan revealed a Focus area, initiated on 01/08/2024, that indicated the resident required the use of intermittent oxygen related to shortness of breath. A review of a handwritten Comprehensive Physician's Order Sheet For: Telephone/Standing/Clarified Orders, dated 01/24/2024, revealed an order for Resident #178 to receive oxygen. However, review of Resident #178's Order Summary Report, generated from the resident's EHR, revealed the order for oxygen use was not transcribed until 03/12/2024, during the survey. A review of Resident #178's Treatment Administration Record and Medication Administration Record for February 2024 and March 2024 revealed no documentation related to the administration of oxygen. An observation of Resident #178 on 03/11/2024 at 10:55 AM revealed the resident's oxygen concentrator was infusing oxygen at a rate of 5 liters per minute (LPM). An observation on 03/11/2024 at 1:51 PM revealed Resident #178's oxygen concentrator was infusing oxygen at a rate of 4.5 LPM. An observation on 03/12/2024 at 8:15 AM revealed Resident #178's oxygen concentrator was infusing oxygen at a rate of 4.5 LPM. During an interview on 03/12/2024 at 9:31 AM, Registered Nurse (RN) #7 reviewed Resident #178's EHR and stated there was no current order for oxygen for the resident. She stated there was a telephone order dated 01/24/2024 for the resident to receive oxygen; however, the order was not transcribed to Resident #178's active physician's orders. During an interview on 03/14/2024 at 10:34 AM, the Director of Nursing (DON) said Resident #178 was previously transferred out of the facility and after their return, the order for oxygen use was not transcribed into the system as an active order. 555254 Page 9 of 9