Other·June 6, 2019

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following represents the findings of the California Department of Public Health during the investigation of an entity reported incident. Entity reported incident number: CA00624624. Representing the California Department of Public Health: Health Facilities Evaluator Nurse: 39512. The inspection was limited to the specific entity reported incident investigated and does not represent the findings of a full inspection of the facility. One deficiency was issued for the entity reported incident: CA00624624.

F689 SS=G Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) 06/03/2019 §483.25(d) Accidents. The facility must ensure that §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was not left alone while LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5HNW11 Facility ID: CA020000020 If continuation sheet 1 of 4 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055885 (X3) DATE SURVEY COMPLETED 05/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE COUNTRY DRIVE POST ACUTE 2500 Country Drive Fremont, CA 94536 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE standing to prevent a fall from occurring when Certified Nursing Assistant (CNA) 1 left Resident 1 unattended in his bathroom to retrieve his wheelchair from his room. This failure resulted in Resident 1 falling off the shower chair and sustained several injuries that included facial fractures (broken bones), and a spinal injury. Findings: A review of the admission record for Resident 1 indicated he was admitted to the facility on 1/26/19 with multiple diagnoses including syncope (temporary loss of consciousness) and collapse, muscle weakness, difficulty walking and Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). A review of Resident 1's Admission Minimum Data Set (MDS-an assessment tool) dated 2/2/19 showed Resident 1 had a history of falls. The MDS showed Resident 1 was, "not steady, only able to stabilize with staff assistance" when moving from seated to standing position. The MDS also showed Resident 1 required extensive assistance (staff needed to provide weight-bearing support) and one person physical assist during transfers from chair to wheelchair or bed, walking in room and toilet use. A review of the Fall Risk Assessment dated 2/3/19 indicated Resident 1 scored 20, which placed him in the high risk category for falls. During an interview on 2/28/19 at 10:25 a.m. in Resident 1's room, CNA 1 stated on the morning of 2/12/19 Resident 1 was seated on a shower chair in his bathroom over the toilet. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5HNW11 Facility ID: CA020000020 If continuation sheet 2 of 4 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055885 (X3) DATE SURVEY COMPLETED 05/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE COUNTRY DRIVE POST ACUTE 2500 Country Drive Fremont, CA 94536 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE CNA 1 stated she told Resident 1 to "wait there." CNA 1 described how she went out of the bathroom briefly to retrieve Resident 1's wheelchair, which was in Resident 1's room near the entrance door to his room. CNA 1 stated she heard a loud thud, and she ran into the bathroom and found Resident 1 face down on the floor. CNA 1 stated, "it happened so quick," and that there were no witnesses to the fall. CNA 1 stated she had to take her eyes off of Resident 1 to go retrieve his wheelchair out of Resident 1's room to bring it into the bathroom, and that she could not see Resident 1 while she did that. A review of Resident 1's care plan initiated on 1/26/19 indicated, "The resident is high risk for falls related to gait/balance problems..." Interventions include, "Do not leave patient unattended...Remind staff not to leave resident unattended when doing activities of daily living (ADL's)." Review of the Change of Condition Evaluation form dated 2/12/19 at 4:11 p.m., showed Resident 1 had a "witnessed" fall in the bathroom. Resident 1 obtained a forehead injury and was sent to the hospital. Review of the "ED [Emergency Department] Physician Notes" dated 2/12/19 indicated Resident 1 was noted with approximately four centimeters of laceration over the left eyebrow and fracture of the left eye socket bone, broken swollen and bloody nose. Further review of the notes indicated Resident 1 obtained a neck injury with widening between cervical spine number 5 and 6 vertebrae (small bones that form the spine). A review of the facility's undated "Falls Prevention Strategies and Interventions" list, showed interventions that included: Adequate FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5HNW11 Facility ID: CA020000020 If continuation sheet 3 of 4 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055885 (X3) DATE SURVEY COMPLETED 05/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE COUNTRY DRIVE POST ACUTE 2500 Country Drive Fremont, CA 94536 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE staff supervision and keeping resident in sight or close by for interaction. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5HNW11 Facility ID: CA020000020 If continuation sheet 4 of 4