Health inspection·October 15, 2024

F 0568 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of Resident 3 ' s, admission Record, printed 10/15/24, the record indicated Resident 3 was admitted to the facility in June 2021 with multiple diagnosis including Multiple Sclerosis, MS (A chronic, progressive disease involving damage to the nerve cells in the brain and spinal cord). A review of Resident 3 ' s MDS revealed Resident 3 had a BIMS score of 15 indicating Resident 3 was cognitively intact. During an interview on 10/15/24 at 12:00 p.m. with Resident 3, Resident 3 stated they last made purchases around nine months ago when resident requested clothing and received 2 pantsuits. Resident 3 stated that they did not know how much the pantsuits cost and were not given an itemized receipt after the purchase. Resident 3 also stated they have not received a quarterly report of the balance in their personal account and is unaware of how much money they have. During an interview on 10/21/24 at 4:05 p.m. with Resident 3 ' s Conservator (3), Conservator 3 stated she does not receive itemized receipts of Resident ' s purchases and has not received a quarterly report for Resident 3. During a review of Resident 4 ' s, admission Record, printed 10/15/24, the record indicated Resident 4 was admitted to the facility in November 2021 with multiple diagnosis including Schizoaffective Disorder (A mental illness that can affect thoughts, mood and behavior,) and Parkinson ' s Disease (A progressive disease of the nervous system, marked by tremor, muscular rigidity, and slow, and precise movements).A concurrent review of Resident 4 ' s MDS revealed, Resident 4 had a BIMS score of 6 indicating severe cognitive impairment. During an interview on 10/15/24 at 12:10 p.m. with resident 4, Resident 4 stated they are unaware how much money is in their personal account and they have no recollection of receiving a quarterly report of the spending and subsequent balance in their account. During an interview on 10/16/24 at 12:20 p.m. with Resident 4 ' s Conservator (4), Conservator 4 stated the facility had not sent her a quarterly report in a long time and cannot recall when the last quarterly report was received. Conservator stated that Resident 4 has money to purchase items but does not know or has receipt of what has been purchased. During an interview on 10/15/24 at 12:05 p.m. with Social Worker (SW), SW stated when Resident ' s request an item, the SW will check with the Business Office Manager (BOM) of how much money Resident has in their account and purchases the item. SW stated typically, this is done without Resident ' s feedback and in some cases, for Residents who want designer items, they will get Resident ' s permission before purchasing. Once purchase is completed, the SW will give item purchased to Resident and receipt of purchase to Business Office Manager (BOM). During an interview on 10/15/24 at 1:15 p.m. with Director of Nursing (DON), DON stated some residents have a conservator who manages Residents personal finances. DON stated they provided an itemized list of resident ' s balance of funds for the conserved residents to the conservator. During an interview on 10/15/24 at 1:45 p.m. with Administrator (ADM), ADM stated the Business Office Manager (BOM) handles accounting of Resident ' s personal financial accounts and trusts. Administrators had no knowledge of quarterly reports being issued out to Residents or Resident ' s Conservator. During an interview on 10/21/24 at 3:00 p.m. with BOM, BOM stated that the SW will provide a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555254 If continuation sheet Page 2 of 3 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 555254 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Medical Hill Healthcare Center 475 29th Street Oakland, CA 94609 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)

F 0568 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few receipt of purchase and that it will be itemized in resident ' s account. BOM does not provide the receipt to Resident or Conservator. BOM stated that they are behind in sending out the quarterly reports to Conservators and sends the reports by postal mail and not email. BOM was unable to provide receipt of when the Conservator receives quarterly reports and stated the facility does not give the reports or receipts of items purchased to the residents. BOM stated the SW will show them weekly how much they have in their account digitally. A review of the Policy & Procedure titled Management of Resident ' s Funds indicated . Policy Interpretation and Implementation .3. Should the facility manage the resident ' s funds, the facility acts a fiduciary of the resident funds and holds, safeguards, manages and accounts for the personal funds of the Resident . 3. Should our facility be appointed the resident's representative payee, and directly receive monthly benefits to which the Resident is entitled, such funds are managed in accordance with established policies and Federal/State requirements .5. Copies of financial transactions are managed by the business office. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555254 If continuation sheet Page 3 of 3