Other·June 25, 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 reflects the findings of the California Department of Public Health during an abbreviated survey for the investigation of facility reported incident CA00635860. Representing the Department of Public Health: HFEN, 39939. The inspection was limited to the specific facility reported incident investigated and does not represent the findings of a full inspection of the facility.

F689 SS=J Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) 06/20/2019 §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 observation, interview, and record review, the facility failed to ensure four out of four sampled residents (Residents 1,2,3,4) were provided the supervision through the functionality of the "Wander Management 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: M4ZF11 Facility ID: CA020000047 If continuation sheet 1 of 5 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: _______________ 056447 (X3) DATE SURVEY COMPLETED 06/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAYWARD HILLS HEALTH CARE CENTER 1768 B Street Hayward, CA 94541 (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 System" (a system that tracks a person using a wrist or ankle bracelet which automatically alarms if the person moves outside a defined area) for one of seven doors (Door 8) in the residents' direct proximity (closeness) that opened to the outside. Resident 1 left the facility undetected on 4/29/19 and was found in the bushes in front of the facility parking lot. Resident 1 was returned to the facility by a family representative at 1 a.m. on 4/30/19. This failure resulted in the delay in identification of the system malfunction and exposed four of four residents in the facility with wander management monitoring device (sensing tags) to risk of serious harm. It was determined to constitute an Immediate Jeopardy (IJ) situation. The Administrator was verbally notified of the IJ on 5/9/19 at 8:04 p.m. The facility failed to ensure a fully functioning Wander guard alert system was maintained. Through observations and interviews with the staff members and record reviews of the facility's training records, the facility showed they initiated the plan of action through training of employees regarding Wander guard alert system monitoring. The facility replaced the nonfunctioning Wander guard alert door monitor at Door 8. The IJ was lifted on 5/9/19 at 10:30 p.m.. Findings: Review of Resident 1's undated "Face Sheet" showed Resident 1 was admitted to the facility on 3/14/19. Review of "Minimal Data Set" (MDS- an assessment tool used to guide care) dated 3/21/19 showed Resident 1 with diagnosis that FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: M4ZF11 Facility ID: CA020000047 If continuation sheet 2 of 5 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: _______________ 056447 (X3) DATE SURVEY COMPLETED 06/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAYWARD HILLS HEALTH CARE CENTER 1768 B Street Hayward, CA 94541 (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 included Dementia (loss of memory), unspecified psychosis (mental disorder where thought and emotions are impaired), personal history of traumatic brain injury. Further review of the MDS showed Resident 1 had severely impaired cognition and that Resident 1 required supervision when ambulating (walking) in corridor. Review of the "Elopement Risk Assessment" dated 3/23/19 showed Resident 1 was at risk for elopement. Review of Resident 1's care plan for "At risk for elopement and wandering out of facility" dated 3/23/19 showed an approach that included wearing a Wander guard bracelet and to check the alarm for functioning. Review of the "Physician's Order Report" dated 3/23/19 showed "Wander guard bracelet on left wrist for elopement precautions. Monitor for proper placement and battery function every shift." Review of Resident 1's "Progress notes" dated 4/29/19 9:00 p.m., showed Resident 1 was on 15 minutes' watch, Registered Nurse (RN 1) was not able to "locate Resident 1's whereabouts at 8:30 p.m.." Review of Resident 1's "Progress notes" dated 4/30/19 1:00 a.m., showed Resident 1 returned to the facility accompanied by "family representative ... found him walking around the bushes in the parking lot." Resident 1 kept stating "he needs to clean the bushes and weeds... I am cold but I will see you tomorrow. I need to work now." During an interview with RN 1 on 5/9/19 at 8:14 p.m., RN 1 stated she was the nurse in charge for Resident 1 on 5/9/19. RN 1 further stated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: M4ZF11 Facility ID: CA020000047 If continuation sheet 3 of 5 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: _______________ 056447 (X3) DATE SURVEY COMPLETED 06/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAYWARD HILLS HEALTH CARE CENTER 1768 B Street Hayward, CA 94541 (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 the staff did not hear any door alarms on 4/29/19 when Resident 1 eloped from the facility. During an interview with Certified Nursing Assistant (CNA 1) on 5/9/19 at 9:29 p.m., CNA 1 stated Resident 1 was "shivering" when the staff brought him inside around 1:00 a.m. on 4/30/19. Review of "AccuWeather Forecast" for facility's location on 4/29/19 and 4/30/19 showed the low (nighttime) temperature range was between "50 and 48 degrees Fahrenheit." During an observation accompanied by facility's Supplies Director (SD 1) on 5/9/19 at 5:88 p.m., SD 1 used a brand new Wander guard bracelet labeled 'do not use after 5/24/20' to go through Door 8 and the Wander guard alarm sensor did not sound. SD 1 indicated Door 8 had another back up alarm system as well, but that did not sound either. SD 1 further showed Door 8 opens in the back patio, which had another door, which was unlocked as well. Back Patio door had a way out to get to the front parking lot. During a second observation on 5/9/19 at 6:10 p.m., SD 1 held the same type of Wander Guard bracelet that was worn by Resident 1 and walked out of Door 8. The Wander Guard alarm sensor and back up alarm did not sound. SD 1 stated, "the Maintenance Director (MD 1) is responsible for checking the Wander guard system. Door 8 was used a lot by the employees, and they had to make sure the back up alarm was armed, otherwise it wouldn't go off." During an interview with Licensed Vocational Nurse (LVN 1) on 5/9/19 at 6:40 p.m., LVN 1 stated, "I check the wander guard system at FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: M4ZF11 Facility ID: CA020000047 If continuation sheet 4 of 5 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: _______________ 056447 (X3) DATE SURVEY COMPLETED 06/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAYWARD HILLS HEALTH CARE CENTER 1768 B Street Hayward, CA 94541 (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 beginning and end of my shift. I did not check Door 8 today when I started my shift." During an observation and concurrent interview with MD 1 on 5/9/19 at 6:58 p.m., MD 1 used a different Wander Guard bracelet labeled 'do not use after 6/28/19' and "Wander Guard system Tester" to go through Door 8, and the Wander alarm sensor did not sound. MD 1 stated his responsibility was to check the Wander Guard Alert system during weekdays. MD 1 stated he failed to perform the monitor check on 5/9/19. MD 1 stated he did not have documentation to indicate that monitoring was conducted on 5/9/19. Review of the facility's policy and procedure "Wander/Elopement Alarm System Testing" dated 4/2001 showed,"Regular testing of door monitors and signaling devices in the alarm system verifies the integrity of the system...Regular testing is essential...This is a function of the preventative maintenance program and regular testing is essential to resident safety...Door Monitor Test 1. Inspect and test each door monitor daily..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: M4ZF11 Facility ID: CA020000047 If continuation sheet 5 of 5