Other·January 10, 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 a Facility Reported Incident. Intake number: CA00602770 Representing the Department: Health Facilities Evaluator Nurse 38534. The inspection was limited to the specific FRI investigated and does not represent the findings of a full inspection of the agency. One deficiency was issued to intake number: CA00602770.

F689 SS=G Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) 12/19/2018 §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 observation, interview, and record review, the facility failed to ensure resident received adequate supervision to prevent accidents for one of three sample residents (Resident 1) when Resident 1 was left in the bathroom without staff supervision, fell to the floor, and obtained multiple bruises and a Left hand fracture (broken bone). 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: VCJK11 Facility ID: CA020000037 If continuation sheet 1 of 3 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: _______________ 056463 (X3) DATE SURVEY COMPLETED 11/28/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EMMANUEL POST ACUTE CARE - HAYWARD 26660 Patrick Avenue Hayward, CA 94544 (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 Findings: Review of Resident 1's Admission Record indicated, Resident 1 was admitted to the facility 11/28/14 with multiple diagnoses included muscle weakness, osteoporosis (a medical condition in which the bones become brittle and fragile from loss of tissue) and dementia ( loss of cognitive functioningthinking, remembering, and reasoning-and behavioral abilities). During an observation on 9/19/18 at 10:30 a.m., Resident 1 was in her room, Resident 1 had multiple bruises on her face and a splint (a cast like devise supporting and immobilizing a broken bone) on her left hand. During an interview on 10/9/18 at 11:50 a.m., Certified Nurse Assistant (CNA) 1 stated that on the day of the accident, she took Resident 1 to the bathroom, put her on the toilet, went back to her bed to turn off the alarm then, went back to the restroom and saw Resident 1 on the floor. CNA 1 also stated that she knew Resident 1 needed assistance during the bathroom activities. CNA 1 stated she should not have left Resident 1 alone in the restroom. During an interview with Licensed Vocational Nurse 1 (LVN 1) on 10/8/18 at 10:45 a.m., LVN 1 stated Resident 1 required supervision from the CNA's during activities of daily living. Review of Resident 1's MDS (Minimum Data Set) section G0110 (I) and G0300 (D), dated 6/8/18 indicated Resident 1 needed limited assistant with physical assist from the staff for toilet using. Review of section C0500, BIMS (Brief Interview for Mental Status) showed: 06 (which meant severely impaired cognition). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VCJK11 Facility ID: CA020000037 If continuation sheet 2 of 3 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: _______________ 056463 (X3) DATE SURVEY COMPLETED 11/28/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EMMANUEL POST ACUTE CARE - HAYWARD 26660 Patrick Avenue Hayward, CA 94544 (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 Review of Resident 1's fall risk evaluation dated 3/8/18 indicated, Resident 1 had history of falls, balance problem, decrease muscular coordination and high risk for potential falls. During a review of Resident 1's falls care plan, dated 3/19/18 indicated, Resident 1 was at risk for falls, impaired balance and needs assistance due to the confusion. Goal was "The resident will not sustain serious injury through the review date...The resident will be free of minor injury through the review date." Review of a progress notes dated 9/4/18 by Licensed Vocational Nurse 1 (LVN 1) indicated Resident 1 hit her head on the floor as witnessed by a CNA. Upon assessment, LVN 1 noted a raised area on the forehead measuring eight centimeters and Resident 1 complained of 10 out of 10 pain (worst pain possible on a scale of one to ten) on the left arm. Further review indicated Resident 1 was transported to the acute hospital. Review of the hospital document titled "progress notes" dated 9/6/18 indicated Resident 1's bones below the Left thumb and index finger were fractured. During an interview with Physical Therapist Supervisor (PTS) 1 on 9/19/18 at 11:00 a.m., PTS stated Resident 1 needed supervision from the staff for activities of daily living, also Resident 1 had the tendency to move from the toilet by herself because of dementia, PTS 1 also stated, supervision means constant supervision and not just checking on residents. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VCJK11 Facility ID: CA020000037 If continuation sheet 3 of 3