Other·January 11, 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 represents the findings of the California Department of Public Health during the investigation of a complaint and an entity reported incidents (ERI). Complaint Number: CA00470391 Entity Reported Incident Number: CA00471257 and CA00470038 Representing the Department: Health Facilities Evaluator Nurse: 33650 The inspection was limited to the specific entity reported incident investigated and does not represent the findings of a full inspection of the facility. There was one deficiency issued as a result of the investigation.

F323 SS=G FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES CFR(s): 483.25(h)

F323 03/16/2016 The facility must ensure that the resident environment remains as free of accident hazards as is possible; and 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 provide a safe environment free of accident hazards for one 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: SPP211 Facility ID: CA020000115 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: _______________ 055215 (X3) DATE SURVEY COMPLETED 02/26/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OAKLAND HEALTHCARE & WELLNESS CENTER 3030 Webster Street Oakland, CA 94609 (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 (1) of three sampled residents, when a housekeeper (HK 1) opened a metal gate, adjacent to an outdoor smoking area, and lifted the 1-7/8 inch by 2-3/8 inch steel box track bar from the ground to move supplies down a ramp leading to the garage. HK 1 failed to use another employee to assist in closing the gate as he moved the supplies to the garage. Resident 1 was in the smoking area sitting in his wheelchair and gained access to the ramp through the open, unattended gate. He rolled down to the bottom and hit a concrete wall. This accident resulted in Resident 1 sustaining multiple injuries that included broken bones in his face and abrasions (scraping of the skin) on his left knee and forehead. Findings: The facility reported that Resident 1 sustained a nasal bone fracture due to an inability to stop his wheel chair from going down a ramp at 2:40 p.m. on 12/22/15. According to Resident 1's "Face Sheet" dated 7/9/14, he had diagnoses that included general muscle weakness and dementia (disorder that affect the brains intellectual functioning that interferes with normal activities). Review of the undated "Transfer Summary" signed by the medical doctor on 12/23/15 at 3:27 p.m., revealed Resident 1 was admitted to the acute care hospital trauma service following "a fall from a wheelchair into a glass door," and had injuries that included a nasal fracture, right zygomatic (bone that forms the prominent part of the cheek and outer side of the eye socket) fracture, left knee abrasion and forehead abrasion. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SPP211 Facility ID: CA020000115 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: _______________ 055215 (X3) DATE SURVEY COMPLETED 02/26/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OAKLAND HEALTHCARE & WELLNESS CENTER 3030 Webster Street Oakland, CA 94609 (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 During an observation of the smoking area on 1/6/16 at 8 a.m., the smoking area was located in an alley at side the building beside the garage entry way. The garage entry had a metal gate that blocked the entry way and a 23/8 inch high steel track bar on the ground. It led to a descending walkway with a concrete wall at the end of the walkway and a door at right wall that led to the garage. During an interview with Housekeeping 1 (HK 1) on 1/6/16 at 10:15 a.m., HK 1 stated on 12/22/15 he was moving supplies from the ground floor to the garage using a pallet jack (a tool used to lift and move pallets which are low portable platforms on which goods are placed for storage). HK 1 saw Resident 1 in the smoking area and he moved Resident 1 close to the building door so he could pass with the pallet jack. HK 1 proceeded to open the metal gate and removed a metal bar on the ground to access the descending walkway leading to the garage. HK 1 left the gate open and did not replace the steel track bar on the ground. Approximately five minutes later, HK 1 heard a noise and immediately checked the walkway. He saw Resident 1's face with blood against the concrete wall while sitting in his wheelchair. He said the metal bar should have been put back before leaving and not left open and unattended. During an interview with the House Keeping Supervisor (HK SUP) on 1/6/16 at 10:40 a.m., HK SUP stated the metal gate should always be closed and there should be two persons when moving supplies to the garage, one person pushes the pallet jack and the other to close the gate. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SPP211 Facility ID: CA020000115 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: _______________ 055215 (X3) DATE SURVEY COMPLETED 02/26/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OAKLAND HEALTHCARE & WELLNESS CENTER 3030 Webster Street Oakland, CA 94609 (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 During an interview with the facility's Administrator on 2/3/16 at 10:50 a.m., she stated the metal gate was built several years ago for safety and security purposes. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SPP211 Facility ID: CA020000115 If continuation sheet 4 of 4