Bay Area Healthcare Center

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Fahrenheit. This incident was reported to both the physician and to the Regional Case Manager, who determined that Resident 1 had a history of fabricating stories. As a result, SOC 341 was not filed at that time. Furthermore, the SOC 341 indicated that the abuse allegation made by Resident 1 to NP on 10/23/25 was not reported to the State Agency. The section titled Written Report, which specifies the agencies to which the incident was reported, was left blank.During a telephone interview on 1/29/26 at 2:54 p.m. with Administrator (ADM), ADM stated, on 10/26/25, the facility reported the incident to the Local Ombudsman, believing that was sufficient. ADM stated she did not send a written report to the State Survey Agency.During a review of the facility's policy and procedure (P&P) titled Abuse Prevention and Mandated Reporting, undated, the P&P requires the Administrator to report suspected abuse or allegations to the California Department of Health within 24 hours.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

01/29/2026

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)

F 0686

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and record review, for one of two sampled residents (Resident 2), the facility failed to ensure treatment and services were done to heal and prevent re-opening of a coccyx (tailbone) pressure ulcer (damage to skin and underlying tissue caused by prolonged pressure or friction, commonly occurring over bony prominences like the heels, tailbone, or hips) when physician ordered treatment was not done and the open area was not measured during assessment.This failure had the potential to result in delayed healing and re-opening of the pressure ulcer.During a review of Resident 2's admission Record (AR) printed 1/29/26, the AR indicated Resident 2 was admitted to the facility on [DATE REDACTED] with diagnoses that included type 2 diabetes mellitus (high blood sugar resulting from insulin resistance or insufficient insulin production), chronic kidney disease (a long-term condition characterized by a gradual loss of kidney function over months or years), and left hemiplegia (paralysis that affects only one side of the body).During

a review of Resident 2's Weekly Pressure Ulcer Injury Record (WPUIR), a clinical tool used to monitor the healing progress and effectiveness of treatment for pressure ulcers, documenting the stage, size, wound bed tissue type and surrounding skin color) dated 11/3/25, the WPUIR indicated Resident 2 had a Stage II (partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed) pressure ulcer on the coccyx that measured 1 x 0.3 cm.During a review of Resident 2's pressure ulcer care plan dated 11/3/25, the care plan indicated interventions to promote discomfort and to prevent development of infections around the area that included providing treatment as ordered.During a review of Resident 2's Order Summary Report (OSR) dated 1/29/26, the OSR indicated a physician's order to apply moisture barrier cream on the buttocks and coccyx pressure ulcer every shift and as needed.During a concurrent telephone interview and review of Resident 2's Weekly Assessment dated 11/12/25, on 1/29/26 at 10:07 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated he did not do treatments during the night shift.

He also stated when he assessed Resident 2's pressure ulcer on 11/12/25, there was a small open area on

the coccyx, but LVN 1 did not measure as he just made a quick look at it. During another concurrent telephone interview and review of Resident 2's Weekly Assessment dated 11/19/25, on 1/29/25 at 10:41 a.m. with LVN 2, LVN 2 stated she completed the weekly assessment dated [DATE REDACTED] and wrote there was a stage 2 pressure ulcer on the coccyx but did not measure it because it has already healed. LVN 2 stated

she only wrote that a pressure ulcer was there as reminder that there once was a pressure ulcer on Resident 2's coccyx.During a review of the facility's policy and procedure (P&P) titled Pressure Ulcers, undated, the P&P indicated multiple factors in management of pressure ulcers that included wound assessment. The P&P indicated to monitor wound status with each dressing change documenting wound assessment parameters using quantitative instrument such as Bates-[NAME] Wound Assessment Tool (BWAT, a more detailed wound assessment tool that evaluates multiple characteristics that included wound size and depth and condition of wound edges and surrounding skin).

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

01/29/2026

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)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and record review, for one of two sampled residents (Resident 2), the facility failed to ensure medical records were accurately documented.This failure had the potential to result in gaps in communication and uncoordinated care.During a review of Resident 2's admission Record (AR) printed 1/29/26, the AR indicated Resident 2 was admitted to the facility in on 11/3/25 with diagnoses that included type 2 diabetes mellitus (high blood sugar resulting from insulin resistance or insufficient insulin production), chronic kidney disease (a long-term condition characterized by a gradual loss of kidney function over months or years), and left hemiplegia (paralysis that affects only one side of the body).During

a review of Resident 2's Weekly Pressure Ulcer Injury Record (WPUIR) dated 11/3/25, the WPUIR indicated Resident 2 had a Stage II pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, pressure ulcer is damage to skin and underlying tissue caused by prolonged pressure or friction, commonly occurring over bony prominences like the heels, tailbone, or hips)

on the coccyx (tailbone) that measured 1 x 0.3 cm. The WPUIR is a clinical tool for monitoring the healing progress and effectiveness of treatment for pressure ulcers, documenting stage, size, wound bed tissue type, and surrounding skin color.During a concurrent telephone interview and review of Resident 2's Weekly Assessment dated 11/12/25, on 1/29/26 at 10:07 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated he did not perform treatments during the night shift. He also stated when he assessed Resident 2's pressure ulcer on 11/12/25, there was a small open area on the coccyx, but LVN 1 did not measure as he just made a quick and superficial look at it. During a review of Resident 2's Treatment Administration

Record (TAR) for November 2025, the TAR indicated the following treatment orders: to coccyx pressure ulcer, wash with soap and water, pat dry, apply moisture barrier cream and keep open to air every shift and as needed. to moisture-associated skin damage on the coccyx, right and left perineum, wash with soap and water, pat dry, apply moisture barrier cream every shift and as needed.The TAR indicated LVN 1 signed off seven out of 20 scheduled NOC shift treatments for Resident 2.During another concurrent telephone

interview and review of Resident 2's Weekly Assessment dated 11/19/25, on 1/29/25 at 10:41 a.m. with LVN 2, LVN 2 stated she completed the weekly assessment dated [DATE REDACTED] and wrote there was a stage 2 pressure ulcer on the coccyx but did not measure it because it has already healed. LVN 2 stated she only wrote that a pressure ulcer was there as reminder that there once was a pressure ulcer on Resident 2's coccyx.During a review of the facility's policy and procedure (P&P) titled Weekly Nurses Progress Notes, undated, the P&P indicated the Weekly Nurses Progress Notes is part of the resident's medical record. It will summarize the resident's condition during the week, based upon the nurse's assessment, and reflect

the nurse's assessment at the time of the documentation.

Event ID:

Facility ID:

If continuation sheet