Health inspection·June 26, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure one of six sampled residents (Resident 1) was treated with dignity and respect when Resident 1's indwelling urinary catheter bag was exposed while resident was in wheelchair in hallway. This deficient practice negatively impacted Resident 1's sense of self-worth and self-esteem. Findings: During a review of Resident 1's, admission Record , printed on 6/26/23, the admission record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of dehydration (occurs because of abnormal water loss from the body) and Rhabdomyolysis (A breakdown of skeletal muscle due to direct or indirect muscle injury that can lead to kidney damage.) During a record review of Resident 1's Minimum Data Set (MDS, a resident assessment tool used to guide care) dated 2/17/22, the MDS assessment section G indicated Resident 1 needed staff's extensive assistance for toilet use, transfers and to maintain personal hygiene. The MDS assessment section C indicated Resident 1's Brief Interview of Mental Status (BIMS- an assessment for mental status) score was 13 out of 15 which indicated intact mental status. During a review of Resident 1's undated care plan, the care plan indicated, Resident 1 has indwelling catheter for urinary retention (a condition where your bladder doesn't empty all the way or at all when you urinate). During an observation on 6/26/23 at 10:20 am, observed Resident 1 wheeling herself in the hallway with their urinary bag attached to the bottom of the wheelchair with urinary bag and tubing exposed and touching the floor. During a concurrent observation and interview on 6/26/23 at 10:52 a.m., with Certified Nursing, Observed Resident 1's urinary bag and tubing touching the floor of hallway. CNA 1 stated the urinary bag should be secured without touching the floor. CNA 1 also stated it should be covered by a privacy bag. CNA 1 stated a privacy bag was important for maintaining dignity of Resident 1. During a concurrent observation and interview on 6/26/22 at 11:10 a.m., with Director of Nursing (DON), the DON stated Resident 1's urinary bag was exposed and not secured properly and was touching the floor. DON stated the privacy bag was important to protect Resident 1's dignity. (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 2 Event ID: 555819 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 555819 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elmwood Care Center 2829 Shattuck Avenue Berkeley, CA 94705 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)