Health inspection·June 6, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a record review of Resident 3's AR, dated 5/9/25, the AR indicated Resident 3 was admitted to the facility in February 2025 with diagnoses of cerebral infarction (occurs when the blood supply to part of the brain is blocked or reduced) and gastrostomy status (an opening into the stomach from the abdominal wall, made surgically for the introduction of food). During a record review of Resident 3 ' s Brief Interview for Mental Status dated 3/18/25, Resident 3 ' s BIMS was not attempted and the record indicated Resident 3 was rarely/never understood. During an observation on 5/8/25 at 12:46 p.m. with Resident 3, Resident 3 was lying in bed with an ongoing tube feeding (medical device used to provide nutrition to people who cannot obtain nutrition by mouth, are unable to swallow safely, or need nutritional supplementation). Resident 3 ' s handheld call bell was located on the bedside drawer table and not within Resident 3 ' s reach. During an inteview on 5/8/25 at 12:49 p.m. with Certified Nurse Assistant (CNA) 1, CNA 1 stated Resident 3 was not cognitively alert and unable to verbalize his needs. CNA 1 further stated Resident 3 needed a lot of supervision to prevent falls and injuries. During an interview on 5/8/25 at 12:51 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated the call lights in the long-term unit had been broken more than a year ago and ever since then the residents had been using the handheld call bells. LVN 1 stated having no working call lights posed a lot of risks including falls and injuries. LVN 1 stated some residents were physically and mentally not able to use the handheld bells. LVN 1 stated some residents also refrained from using the handheld call bell because the sound was too loud and annoying them. During a record review of Resident 4 ' s AR, dated 5/9/25, the AR indicated Resident 4 was admitted to the facility in April 2025 with diagnoses of history of falling and schizophrenia (a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions). During a record review of Resident 4 ' s Brief Interview for Mental Status dated 4/15/25, Resident 4 ' s BIMS score was 10 indicating moderate cognitive impairment. During an observation and interview on 5/8/25 at 2:18 p.m. with Resident 4, Resident 4 had a handheld bell on top of the tray table within reach. Resident 4 stated he had a fall a week ago because he tried to get up on his own and he tripped. Resident 4 stated there were times when he used the handheld bell provided to him, the staff took a while to respond. During a record review of Resident 5 ' s AR, printed on 5/8/25, the AR indicated Resident 5 was admitted to the facility in February 2025 with diagnosis of Alzheimer ' s disease (a progressive disease that destroys memory and other important mental functions). During a record review of Resident 5 ' s Brief Interview for Mental Status dated 4/15/25, Resident 5 ' s BIMS score was 8 indicating moderate cognitive impairment. During a concurrent observation and interview on 5/8/25 at 2:25 p.m. with Resident 5, Resident 5 was lying in bed. Resident 5 had a handheld bell on top of the tray table not within Resident 5 ' s reach. Resident 5 was observed to be confused when Resident 5 stated he was asking for his mother in the room. Resident 5 stated he did not like using the handheld bell because he did not need think he needed it. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555819 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 555819 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2025 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)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 5/8/25 at 5:43 p.m. with the Director of Nursing (DON), the DON stated they did not develop a person-centered comprehensive care plan to Residents 1, 2, 3, 4, and 5 when the call light system stopped working. The DON stated they should have developed a person-centered care plan for all residents who were using the handheld bells so that everyone from the Interdisciplinary Team (IDT, a team that includes staff members from multiple disciplines such as nursing, therapy, physicians, and other advanced practitioners) could have been all aware of how to provide care accordingly. During a record review of the policy and procedure (P&P), titled, Care Plans, Comprehensive Person-Centered, revised in December 2016, the P&P indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident ' s physical, psychosocial and functional needs is developed and implemented for each resident . 7. The care planning process will . a. Facilitate resident and/or representative involvement; b. Include an assessment of the resident ' s strengths and needs . 8. The comprehensive, person-centered care plan will a. Include measurable objectives and timeframes; b. Describe the services that are to be furnished to attain or maintain the resident ' s highest practicable physical, mental, and psychosocial well-being; c. Describe services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment; g. Incorporate identified problem areas; h. Incorporate risk factors associated with identified problems; i. Build on the resident ' s strengths . 12. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required comprehensive assessment (MDS). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555819 If continuation sheet Page 3 of 3