Other·March 29, 2018

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 the investigation of complaint number: CA00540528 Representing the Department: Health Facilities Evalutor Nurse 36593. 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 complaint number : CA00540528.

F323 SS=G FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES CFR(s): 483.25(d)(1)(2)(n)(1)-(3)

F323 03/08/2018 (d) Accidents. The facility must ensure that (1) The resident environment remains as free from accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. (n) - Bed Rails. The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements. (1) Assess the resident for risk of entrapment 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: FUOJ11 Facility ID: CA020000090 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: _______________ 056052 (X3) DATE SURVEY COMPLETED 02/09/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EDEN HEALTHCARE CENTER 27350 Tampa 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 from bed rails prior to installation. (2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation. (3) Ensure that the bed’s dimensions are appropriate for the resident’s size and weight. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to provide sufficient supervision for one (Resident 1) of three sampled residents when Resident 1 was left unattended outside the patio with a maximum temperature of 105 degrees Fahrenheit (°F, unit of measurement for temperature) This failure resulted in Resident 1 being found outside with a bloody nose and a body temperature of 101°F (normal body temperature is 97.8°F to 99.1°F), Resident 1 was sent to the emergency room for heat exhaustion (heat-related illness that can occur after exposure to high temperatures). Findings: Review of Resident Face Sheet dated 6/29/17 indicated facility admitted Resident 1 on 11/24/11 with diagnoses that included epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures), congestive heart failure (heart's inability to pump an adequate supply of blood), type 2 diabetes mellitus (disease that affect how the body uses blood sugar), and right and left leg above the knee amputation. Record review of the document titled, Minimum Data Set (MDS, an assessment tool), dated 12/25/16, indicated Resident 1 has poor FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: FUOJ11 Facility ID: CA020000090 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: _______________ 056052 (X3) DATE SURVEY COMPLETED 02/09/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EDEN HEALTHCARE CENTER 27350 Tampa 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 memory. During an interview with Resident 1's family member (FM 1) on 6/29/17 at 8:39 a.m., FM 1 stated it was a hot day on 6/18/17 and another family member visited Resident 1. Upon arrival in the facility the family member could not find Resident 1, they searched the facility and found Resident 1 in the smoking area where Resident 1 passed out. FM 1 further stated that Resident 1 was weak and was sent and treated in the hospital for extreme heat. In an interview with Licensed Vocational Nurse 1 (LVN 1) on 6/29/17 at 11:20 a.m., LVN 1 stated Resident 1's husband visited on 6/18/17 and could not find Resident 1. The facility staff searched and found Resident 1 outside in the smoking area, bleeding from nose and a little confused. In an interview with Activity Staff (AS) on 6/29/17 at 11:50 a.m., AS stated Resident 1 left the activity room at 11:30 a.m. after church service and was not aware where Resident 1 went. In an interview with Certified Nursing Assistant (CNA 1) on 6/29/17 at 12:10 p.m., CNA 1 stated on 6/18/17 during lunch time she was looking for Resident 1 to deliver the lunch tray. CNA 1 found Resident 1 outside in the smoking area and brought her to the room. Review of the Resident Progress Notes, dated 6/18/17, indicated Resident 1 went to the smoking area for smoking, CNA 1 helped to bring Resident 1 back in the room. Resident 1's vital sign were: Temperature= 101°F, Pulse=143 beats per minute (normal range is 60 to 100 beats per minute) and oxygen saturation of 84-88 (normal range is 94-100 %) percent. The note further indicated Resident 1 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: FUOJ11 Facility ID: CA020000090 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: _______________ 056052 (X3) DATE SURVEY COMPLETED 02/09/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EDEN HEALTHCARE CENTER 27350 Tampa 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 "...is very hot. Bleeding from nose...looks pale & [and] weakness [sic]". Record review of the document titled, Emergency Depart. Discharge Instructions, dated 6/18/17, showed Resident 1's final diagnosis was acute heat exhaustion. It further indicated "This is heat-related caused by loss of water and electrolytes from the body. It causes excess sweating, extreme fatigue, weakness, dizziness, nausea, vomiting and headache" In an interview with the Administrator (ADM) on 6/29/17 at 11:15 a.m., ADM stated facility was aware of the Heat Advisory-All Facilities Letter (AFL, letter from the Licensing and Certification Program to health facilities that are licensed or certified by L&C. The information contained in the AFL may include changes in requirements in healthcare, enforcement, new technologies, scope of practice, or general information that affects the health facility) dated 6/16/17. Review of the All Facilities Letter (AFL) summary date June 16, 2017 indicated "The hottest temperatures are expected Saturday, June 17 through Wednesday, June 21, with many locations experiencing three digit temperatures, up to 110 degrees...Facilities must remember that the elderly and other health-compromised individuals are more susceptible to extreme temperatures and dehydration...CDPH [California Department of Public Health] recommends facilities implement the following measures to keep residents and clients comfortable during extreme hot weather...Stay indoors and out of sun during the hottest parts of the day..." According to the AccuWeather forecast for June 18, 2018 at Hayward California, it FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: FUOJ11 Facility ID: CA020000090 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: _______________ 056052 (X3) DATE SURVEY COMPLETED 02/09/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EDEN HEALTHCARE CENTER 27350 Tampa 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 indicated the actual temperature reached as high as 105°F on 6/18/17. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: FUOJ11 Facility ID: CA020000090 If continuation sheet 5 of 5