Health inspection·June 16, 2021

F 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, for one of 13 sampled residents (Resident 157), the facility failed to complete the annual Minimum Data Set (MDS, an assessment tool used to guide care) as required. This deficient practice had the potential to result in Resident 157 not receiving the appropriate care and services. Findings: During a review of the admission Face Sheet for Resident 157, Resident 157 was admitted to the facility with multiple diagnoses that included cognitive (mental) deficits following a cerebral infarction (stroke). During an interview and concurrent record review with the Minimum Data Set Coordinator (MDSC), on 6/16/21 at 11:20 a.m., MDSC stated Resident 157's annual MDS dated [DATE], was not completed and should have been completed within 14 days of 9/19/20. MDSC further stated Resident 157's annual MDS assessment was comprehensive (full assessment) which identifies the resident's care needs. Review of Resident 157's annual MDS, dated [DATE], indicated the Assessment Reference Date was 9/19/20. Review of the facility's policy and procedure titled, CHAPTER 5: SUBMISSION AND CORRECTION OF THE MDS ASSESSMENTS, indicated 5.2 Timeliness Criteria, In accordance with the requirements at 42 CFR §483.20 (f) (1), (2), and (3), long-term care facilities participating in the Medicare and Medicaid programs must meet the following conditions: Completion Timing: -For all other comprehensive MDS Reference Date (A3a). Page 1 of 7 555466 555466 06/16/2021 Ashby Care Center 2270 Ashby Avenue Berkeley, CA 94705

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility staff did not notify the physician to re-evaluate the resident's mental capability or capacity to be their own responsible party (RP) for medical decisions for one, (Resident 110) of six sampled residents. After hospitalization, Resident 110 became more aggressive and confused and was not able to give consent in the absence of a conservator (a judge appoints a RP to care for another adult who does not have the capacity to make decisions about their health and finances). Residents Affected - Few This resulted in Resident 110 signing consents for antipsychotic (Seroquel) and anti-anxiety medications (Ativan) without full awareness and understanding of the medications and their potential side effects or have a conservator act on the resident's behalf. Definition: Antipsychotic medication: Used to alter the brain chemistry to decrease psychotic episodes such as hallucinations (seeing or hearing things that no one else can) and delusions (false beliefs). Findings: During the initial tour of the facility on 6/14/21 at 9:15 a.m., Resident 110 stated she was not Ms. (her last name). Resident 110 had delusions and stated she was Mrs (first and last name of the state's governor) and she was pregnant. Record review on 6/16/21 of the document, admission Record, (not dated) showed Resident 110's diagnoses included schizophrenia (mental illness that affects how a person thinks, feels and behaves). A local mental health care agency was listed as the RP for Resident 110. In an interview on 6/14/21 at 12:40 p.m., the Clinical Director (CD) of the local mental health agency listed as the RP, stated CD or her agency were not Resident 110's RP or conservator. In a second interview on 6/14/21 at 3:36 p.m., CD stated she did not believe Resident 110 had full capacity to make her own decisions regarding care. In an interview on 6/14/21 at 2:15 p.m., the facility's Director of Nursing (DON) stated Resident 110 was, Conserved by the mental health agency. DON confirmed there was no documentation in the clinical record which showed a doctor had reassessed Resident 110's mental capacity to be her own RP. In an interview on 6/15/21 at 10:25 a.m., DON stated Resident 110 had originally gone to the hospital because she had been found down on the floor. She had physically assaulted the hospital staff and was sent to a psychiatric facility. During that time, her medications were changed. In a concurrent interview, the Administrator/Registered Nurse (ADM/RN) stated, when Resident 110 returned to the facility on 6/3/21, she was different, with more aggressive speech. DON stated Resident 110 needed to be admitted to a psychiatric facility, which required a conservator to do so. DON further stated the facility had not taken the steps necessary to have Resident 110 conserved. In a concurrent record review of the document, MDS 3.0 Nursing Home Comprehensive (NC) Version 1/17.2, (resident assessment) dated 5/24/21, showed Resident 110 had hallucinations, and delusions with verbal behavioral symptoms directed toward others. These behaviors,Significantly interfere with the resident's care and her participation in activities or social interactions and Significantly intrude 555466 Page 2 of 7 555466 06/16/2021 Ashby Care Center 2270 Ashby Avenue Berkeley, CA 94705

F 0684 on the privacy or activity of others and disrupt care or living environment. Level of Harm - Minimal harm or potential for actual harm In an interview on 6/15/21 at 11:04 a.m., the ADM/RN confirmed the facility had not yet called the doctor to reassess Resident 110's mental capacity since her arrival back to the facility on 6/3/21. Residents Affected - Few During an observation on 6/15/21 at 12:48 p.m., Resident 110 began yelling out random thoughts from her room. In a concurrent interview, with the Certified Nursing Assistant 1 (CNA 1), CNA 1 stated Resident 110 was Worse, since she got back from the hospital. She would yell out prior to her hospitalization but now more aggressive. In an interview on 6/16/21 at 2:23 p.m., the ADM/RN confirmed Resident 110 had been signing consents for antipsychotic and anti-anxiety medications since returning from the hospital. The ADM/RN stated she did not believe Resident 110 had the capacity to sign consents regarding her medical care and doing so, had been a mistake. Record review on 6/16/21 of the Daily Skilled Nurses Notes, for Resident 110 showed the following: 6/5/21: .Resident with on and off delusions . 6/10/21: Resident noted with agitation and delusions of being pregnant with multiple babies. 6/14/21: Remains to be extremely restless, anxious, delusional, hallucinations . up walking in the hallway stating, I want to get out and gather all of those apples . Review of the document, Verification of Resident Informed Consent, dated 6/3/21 showed Resident 110 had signed a consent for Seroquel medication and crossed out her name and put the governor's last name. Resident 110 also signed a consent for Ativan medication on 6/14/21. Review of the policy and procedure, Notification of Physicians, (not dated) showed the attending physician will be notified promptly of a change of condition .sudden changes in mental status. 555466 Page 3 of 7 555466 06/16/2021 Ashby Care Center 2270 Ashby Avenue Berkeley, CA 94705

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 observation, interview, and record review, the facility failed to maintain accurate records and account of discontinued controlled medications (medications which fall under United States Drug Enforcement Agency (DEA) Scheduled II-V (2 through 5) which have a potential for abuse, ranging from low to high, and may also lead to physical or psychosocial dependency) medications for two (Resident 153, and Resident 159) of three sampled residents. This failure had the potential for the diversion of the antianxiety medication Ativan (lorazepam) and sedative temazepam (Restoril) for unauthorized use. Findings: During a review of Resident 153's face sheet, Resident 153 was admitted to the facility in 2016 with diagnoses that included unspecified dementia (general term for the impaired ability to remember, think, or make decisions, that interferes with doing everyday activities) with behavioral disturbances. During a review of Resident 159's face sheet, Resident 159 was admitted to the facility with diagnoses that included cognitive deficits following a cerebrovascular accident (CVA, a loss of blood supply to the brain, commonly known as stroke). During a review of Resident 153's Controlled Drug Record Sheets, (an approved form by the facility called Omniview used by authorized staff to record and report controlled medications and intended to be destroyed in [Product Destruction,] with a scanner bar code of the product label or type the prescription label or type the prescription number in the box provided. Sheet one dated [DATE] indicated, Lorazepam 0.5 mg (milligram), take one tablet by mouth every six hours as needed for moderate anxiety and take 2 tabs (tablets) by mouth every 6 hours as needed for severe anxiety. Sheet two dated [DATE] indicated, Lorazepam 1 mg-give 1 tab by mouth every 6 hours as needed for anxiety. There were no documented signatures by authorized responsible personnel (DON and Pharmacy Consultant (Pharm) to witness the, disposition of remaining doses, after controlled drugs were discontinued or disposed of by the facility. During a review of Resident 159's Controlled Drug Sheet dated [DATE], indicated no documented signatures on the disposition of remaining doses section by the two responsible parties (the DON and Pharm) after the controlled drug (temazepam 7.5 mg) was discontinued or disposed of by facility staff and Pharm. During a concurrent interview and an observation on [DATE] at 11:22 a.m., the Director of Nursing (DON) stated the discontinued medication for Resident 153 and 159 was kept in the locked cabinet in the storage room and used only for medication discontinuation and disposition. DON opened the medication disposition locked cabinet, and there were no discontinued controlled medication packs stored in it. DON was not able to provide an account of the disposed medication. DON further stated it was a busy day and she went by what the Pharm did, by documenting the controlled drugs disposal on a blank white printing paper rather than on the disposition of remaining doses section of the sheets that came with the medications. 555466 Page 4 of 7 555466 06/16/2021 Ashby Care Center 2270 Ashby Avenue Berkeley, CA 94705

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a record review of the email exchanges between DON and Pharm dated [DATE], DON asked Pharm for an explanation of the medication destruction for Resident 159, Resident 153, and Resident 108. Further review indicated Pharm responded,, .the staff were busy, and the sheets were not attached at the time I wanted to destroy (medications) and you didn't have time to find them. During an interview with Pharm on [DATE] at 11:30 a.m., Pharm stated the significance of having the prescription number as part of the required controlled drug documented was to keep track of the drug. Pharm further stated it was important to keep track of the drug from the beginning to the end and ensure nothing is missing. Pharm stated she was in a rush that day and thought she would sign the forms later. During a review of the facility's policy and procedure (P&P) titled, Disposition of Medications, Syringes and Needles, dated 2007, which indicated, A controlled medication disposition log, or equivalent form, shall be used for documentation. The consultant pharmacist .will verify accuracy and records shall be retained as per federal privacy and state regulations. This log contains the following information: resident's name, medication name and strength, prescription number, quantity/amount disposition, date of disposition, and signatures of the required witnesses .medication included in the Drug Administration Enforcement (DEA) classification as controlled substances (or those classified as such by state regulation) are subject to special handling, storage, disposal, and record keeping in the nursing care center in accordance with federal and state law and regulations. During a review of the P&P, Disposal/Destruction of Expired or Discontinued Medication, dated [DATE], and last revised on [DATE] indicated, .destruction of controlled medications should be documented on the controlled medication count sheet and signed by the registered nurse and witnessing licensed professional who should record the quantity destroyed, date of destruction, and signature of registered nurse and pharmacist.Authorized facility staff should use Omniview TM to record and report controlled medications that are intended to be destroyed in (Product Destruction,) scan the bar code of the product label or type the prescription label or type the prescription number in the box provided, enter the quantity of each medication to be destroyed, and save or print the Record of Product Destruction. 555466 Page 5 of 7 555466 06/16/2021 Ashby Care Center 2270 Ashby Avenue Berkeley, CA 94705

F 0912 Level of Harm - Potential for minimal harm Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. Based on observation and record review, the facility had six resident rooms (Rooms 1, 3, 5, 7, 8, and 9) with multiple beds that provided less than 80 square feet (sq. ft) per resident who occupied these rooms. Residents Affected - Some This deficient practice had the potential to result in inadequate space for the delivery of care to each of the residents in each room, or for storage of the residents' belongings. Findings: During an observation on 6/14/21 at 9:30 a.m., the following Resident (Rt) rooms and corresponding square footage (sq. ft) were identified: Room Activity Room Size Floor Area 1 Rt Room 299.63 sq.ft 74.9 sq.ft/bed 3 Rt Room 293.25 sq.ft 73.32 sq.ft/bed 5 Rt Room 299 sq.ft 74.75 sq.ft/bed 7 555466 Page 6 of 7 555466 06/16/2021 Ashby Care Center 2270 Ashby Avenue Berkeley, CA 94705

F 0912 Rt Room Level of Harm - Potential for minimal harm 299 sq.ft 74.75 sq.ft/bed Residents Affected - Some 8 Rt Room 299 sq.ft 74.75 sq.ft/bed 9 Rt Room 299 sq.ft 74.75 sq.ft/bed During random observations of care and services from 6/14/21 to 6/16/21, there was sufficient space for the provision of care for the residents in all rooms. There was no heavy equipment kept in the rooms that might interfere with residents care and each resident had adequate personal space and privacy. There were no complaints from residents regarding insufficient space for their belongings. There were no negative consequences attributed to the decreased space and/or safety concerns in the six rooms identified. Granting of room size waiver recommended. 555466 Page 7 of 7