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 reflects the findings of the California Department of Public Health during the investigation of one complaint CA00638487. Representing the Department of Public Health: HFEN 39555. The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. The Department issued one deficiency.

F626 SS=D Permitting Residents to Return to Facility CFR(s): 483.15(e)(1)(2)

F626 06/25/2019 §483.15(e)(1) Permitting residents to return to facility. A facility must establish and follow a written policy on permitting residents to return to the facility after they are hospitalized or placed on therapeutic leave. The policy must provide for the following. (i) A resident, whose hospitalization or therapeutic leave exceeds the bed-hold period under the State plan, returns to the facility to their previous room if available or immediately upon the first availability of a bed in a semiprivate room if the resident(A) Requires the services provided by the facility; and 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: RMC411 Facility ID: CA020000090 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: _______________ 056052 (X3) DATE SURVEY COMPLETED 06/04/2019 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 (B) Is eligible for Medicare skilled nursing facility services or Medicaid nursing facility services. (ii) If the facility that determines that a resident who was transferred with an expectation of returning to the facility, cannot return to the facility, the facility must comply with the requirements of paragraph (c) as they apply to discharges. §483.15(e)(2) Readmission to a composite distinct part. When the facility to which a resident returns is a composite distinct part (as defined in § 483.5), the resident must be permitted to return to an available bed in the particular location of the composite distinct part in which he or she resided previously. If a bed is not available in that location at the time of return, the resident must be given the option to return to that location upon the first availability of a bed there. This REQUIREMENT is not met as evidenced by: Based on interview and record review, facility failed to ensure one (Resident 1) of three sampled residents was allowed to return to the facility after admission to Acute Care Hospital (ACH). This failure had direct or immediate relationship to the health, safety, or security of Patient 1. Findings: According to the Face Sheet dated 5/21/2019, Resident 1, a male resident, was admitted to the facility on 3/27/19 with multiple diagnoses including dementia with behavioral disturbance (chronic disorder of the brain causing poor memory, personality changes and impaired FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RMC411 Facility ID: CA020000090 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: _______________ 056052 (X3) DATE SURVEY COMPLETED 06/04/2019 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 reasoning). In a telephone interview with Social Worker (SW1) from the hospital, on 5/21/19 at 11:50 a.m., SW1 stated that the facility refused to take Resident 1 back due to his behavior problems. Review of Progress Notes dated 5/17/19 indicated Resident 1 was sent to the hospital due to episodes of verbally and physically abusive behavior towards residents and staff. In an interview with facility's Administrator (ADM) on 5/21/19 at 1:27 p.m., ADM stated the hospital should find Resident 1 another facility that was more capable of managing his abusive behavior towards others. Review of the facility's Resident Roster dated 5/20/19 indicated facility had two unoccupied male beds. Review of the hospital's social service progress notes dated 5/20/19 indicated Resident 1 was medically ready to be discharged. Review of the hospital's inpatient physician note dated 5/21/19 showed Resident 1 had been calm, cooperative, and followed commands without signs of agitation over the past two days. In a telephone interview on 5/23/19 at 5:03 p.m., Director of Case Management (DCM) at the ACH stated Resident 1 was stable and was ready to be discharged but was still waiting for the facility to readmit him. Review of ACH Physician Orders dated 5/23/19 indicated Resident 1 was ready to be discharged back to the facility. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RMC411 Facility ID: CA020000090 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: _______________ 056052 (X3) DATE SURVEY COMPLETED 06/04/2019 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 In a telephone interview on 6/4/19 at 9:37 a.m., Director of Case Management (DCM) at the ACH stated Resident 1 was stable and was ready to be discharged but was still waiting for the facility to readmit him. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RMC411 Facility ID: CA020000090 If continuation sheet 4 of 4