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 (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: 555851 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 555851 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/09/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bay Area Healthcare Center 1833 10th Avenue Oakland, CA 94606 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)