Health inspection·February 9, 2026

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the physician of Resident 1's changes in condition when:1. Resident 1 developed warmth and tenderness on the left knee2. Resident 1 experienced episodes of respiratory distressThese failures could result in delayed medical evaluation by the physician including interventions that may be ordered by the physician on the resident.Findings:A review of resident 1's admission Record (AR), printed on 1/29/26, indicated, Resident 1 was admitted to the facility on [DATE].A review of Resident 1's Progress Note (PN), dated 6/2/25, indicated, that Resident 1 had diagnoses that included Hypertension (high blood pressure), Prediabetes, Atherosclerosis of Aorta (the main large blood vessel coming out of the heart becomes hardened and narrowed because fatty build up inside the blood vessel walls), a right distal humerus (elbow) fracture, and a frontal bone (facial bone) fracture resulting from an accidental fall.On 2/9/26 at 10:23 a.m., a record review of Resident 1's nursing admission Progress Note (APN) dated 5/30/25, the APN indicated, Resident 1 was admitted with bilateral lower leg 2+ edema (is characterized by a 3-4 millimeter deep depression in the skin that indicates fluid retention) and the skin was dry and cool.On 2/9/26 at 10:33 a.m., during a concurrent interview with the DON and review of the PN dated 6/9/25 at 9:34 a.m., the PN indicated, Change of Condition (COC). Resident [1] seen at 2300 [11 p.m.] and reported left knee swelling and weakness. The PN also indicated, Resident 1's knee was noted to be bruised, warm to touch, and mildly tender. DON stated these were new signs and symptoms noted on Resident 1 and should have been reported by the nurse to the physician.On 2/9/26 at 10:40 a.m., a review of Resident 1's PN dated 6/10/25, indicated, that at 2:30 a.m., Resident 1 experienced shortness of breath and difficulty breathing, which Resident 1 described as an asthma attack. Further, the PN indicated that at 3:26 a.m., Resident 1 was observed gasping for air with an elevated respiratory rate of 24 breaths per minute. The episode lasted less than five seconds.During an interview on 1/30/26 at 9:42 a.m., with the Licensed Vocational Nurse (LVN) who assessed Resident 1's breathing and wrote the PN on 6/10/26, stated Resident 1 assumed the symptoms were related to asthma and that the resident refused to be sent to the hospital. LVN stated that he did not recall notifying the physician because the vital signs remained normal for the rest of the shift. LVN stated he was uncertain whether Resident 1 had a diagnosis of asthma.On 2/9/26 at 10:42 a.m., during a concurrent interview with the DON and a review of Resident 1's Order Summary Report (OSR) dated 1/29/26, the OSR indicated an instruction to call MD if respiratory rated greater than 20. The DON stated Resident 1's respiratory symptoms namely, difficulty breathing, gasping for air, and a respiratory rate of 24 should have been reported to the physician.During a review of the facility's Policy and Procedure (P&P), titled, Change of Condition, undated, the P&P indicated, A Resident Change of Condition will be assessed and documented in the medical record with appropriate follow through to physician. Procedure. The Licensed Nurse will document such information in the Medical Record on the progress notes Page 1 of 2 555851 555851 02/09/2026 Bay Area Healthcare Center 1833 10th Avenue Oakland, CA 94606

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and if appropriate notify the physician and the Responsible Party of the change of condition. Change of Condition includes, but is not limited to, the following. altered Vital signs including: significantly elevated/decreased temperature, significant increase or decrease in blood pressure or heart rate, significant decrease or increase or change in characteristics of respiratory rate. Events that require MD notification ASAP include, but are not limited to, the following. Symptoms: abnormal V.S. such as elevated temperature, markedly low or high HR or B/P; development of vomiting or diarrhea, development of severe pain in a new area or at a new intensity, new significant edema, and so on. 555851 Page 2 of 2