Other·March 4, 2020

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 facility-reported incident. Facility-reported incident number: CA00630570. Representing the Department: HFEN 40762. The inspection was limited to the specific facility-reported incident investigated and does not represent the findings of a full inspection of the facility. One deficiency was issued for facility-reported incident number CA00630570.

F805 SS=G Food in Form to Meet Individual Needs CFR(s): 483.60(d)(3)

F805 03/31/2020 §483.60(d) Food and drink Each resident receives and the facility provides§483.60(d)(3) Food prepared in a form designed to meet individual needs. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to serve food in the prescribed form for one of three sampled residents (Resident 1). Resident 1, who had dysphagia (inability to swallow whole food) and had a physician order for mechanically altered diet (a diet specifically prepared to alter the texture or consistency of food to facilitate oral intake), 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: 4CXP11 Facility ID: CA020000116 If continuation sheet 1 of 6 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: _______________ 055239 (X3) DATE SURVEY COMPLETED 12/11/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EAST BAY POST-ACUTE 20259 Lake Chabot Road Castro Valley, CA 94546 (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 was served two hot dogs and chips. The dietary staff did not follow the physician's order of mechanically altered diet and the nursing staff did not review the meal tray before serving the hotdog and chips. Resident 1 ate the hot dog and choked. Resident 1 was sent to an acute hospital and died. Findings: During a review of Resident 1's Admission Minimum Data Sheet (MDS - a comprehensive assessment tool for residents of long-term care facilities), dated 1/4/19, indicated Resident 1 had multiple medical diagnoses including attention and concentration deficit following a stroke, and difficulty swallowing. The MDS also indicated Resident 1 needed limited assistance of one staff member with eating and receives a mechanically altered diet. Review of a Nutrition care plan, dated 12/28/18, indicated Resident 1 was at risk for altered nutritional status and requires mechanically altered diet related to chewing or swallowing problem. The approaches included: 1. Diet as ordered. 2. Honor resident food preferences within diet parameter. 3. Monitor for ability to tolerate diet texture as indicated. The physician's order, dated 12/28/18, indicated Resident 1 was to receive a mechanical soft diet (a diet designed for people who have trouble chewing and swallowing, requiring food to be chopped or ground). Review of the speech therapy notes, dated 12/31/18, indicated Resident 1 had chewing and swallowing difficulties and pocketing of food in the right side of his mouth while eating. The recommendation section indicated "Diet FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4CXP11 Facility ID: CA020000116 If continuation sheet 2 of 6 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: _______________ 055239 (X3) DATE SURVEY COMPLETED 12/11/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EAST BAY POST-ACUTE 20259 Lake Chabot Road Castro Valley, CA 94546 (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 Recs [recommendations]- solids= mechanicaly soft texture." During an interview with Speech Therapist (ST) on 4/9/19, at 4:30 p.m., ST stated Resident 1 had Wernicke's aphasia (difficulty understanding written and spoken language). ST stated on 3/21/19, Resident 1 used a communication book, which included pictures of alternative food options to request for a hot dog. ST stated at the time, the facility did not have a form to inform dietary of the residents' alternative food choice. ST provided a note to dietary staff regarding Resident 1's alternative food request. Review of the form titled "Diet Trials Requested by Speech Therapist," dated 3/21 (without a year), the form showed a request to serve Resident 1 two dogs, potato chips, ranch and mustard. The entry on the form to indicate mechanically altered diet texture was not marked. During an interview with the Cook on 4/9/19, at 4:20 p.m., the Cook stated, ST came to the dietary staff with a slip requesting an alternate of hot dog and chips and the slip did not say ground. The Cook further stated she was not aware Resident 1 had mechanical soft diet order and she should have verified the diet texture, but she did not look at the diet card. Cook stated a regular hot dog was served to Resident 1. During an interview with the Registered Dietician (RD) on 4/9/19, at 4:05 p.m. RD stated the dietary department prints tray ticket out and the dietary assistant along with RD highlights the resident diet, likes, and dislike. RD stated the food alternates are added on the tray ticket and checked against print out when received. RD stated "That did not happen in FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4CXP11 Facility ID: CA020000116 If continuation sheet 3 of 6 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: _______________ 055239 (X3) DATE SURVEY COMPLETED 12/11/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EAST BAY POST-ACUTE 20259 Lake Chabot Road Castro Valley, CA 94546 (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 this case" because the ST slip was used as the tray ticket for the meal tray. RD stated, "All staff are trained to check the diet order." During an interview with Certified Nurse Assistant (CNA) 1 on 4/9/19, at 4:55 p.m., CNA 1 stated the staff serving trays usually check for the diets indicated on the tray ticket against the food being served to the residents. CNA 1 stated the meal trays were not checked on the day of the incident (3/21/19). CNA 1 stated Resident 1 began coughing and she called for help and attempted to do Heimlich maneuver (first aide procedure used for choking). Licensed Vocational Nurse (LVN) 1, came immediately and helped. LVN 1 attempted Heimlich maneuver which did not work and then tried suctioning. After LVN 1's attempt, Restorative Nurse Assistant (RNA) 1, performed the Heimlich maneuver and one bite size of the hot dog came out. LVN 1 had Resident 1 taken back to his room and 911 was called. During a second telephone interview with CNA 1 on 7/31/19, at 4 p.m., CNA 1 stated Resident 1 ate by himself, and (on 3/21/19) CNA 1 was feeding another resident about one table away with his back turned to Resident 1. Resident 1 then started to choke about 5:30 p.m. when Resident 1 had eaten half of his food. Review of the progress note, dated 3/21/19, at 6:25 p.m. indicated Resident 1 left the facility at 6:10 p.m. accompanied by five paramedics to an acute hospital. Review of the Emergency Medical Services (EMS) Field Notes, dated 3/21/19, indicated Resident 1 was found to have no heart beat upon paramedic's arrival in the facility. Resident 1 received initial Cardiopulmonary Resuscitation (CPR) at 5:53 p.m. Attempts at FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4CXP11 Facility ID: CA020000116 If continuation sheet 4 of 6 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: _______________ 055239 (X3) DATE SURVEY COMPLETED 12/11/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EAST BAY POST-ACUTE 20259 Lake Chabot Road Castro Valley, CA 94546 (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 resuscitation continued until arrival at the hospital. Review of the acute hospital Emergency Department (ED) Record, dated 3/21/19, indicated Resident 1 arrived in the emergency department at 6:26 p.m. without a heartbeat. Attempts to resuscitate were unsuccessful and resident death was pronounced at 6:30 p.m. During an interview with Director of Nursing (DON) on 4/9/19, at 2:20 p.m., DON stated all staff were trained to check dietary cards for diet order when serving trays. DON stated if anything appears to be wrong with the diet or tray, staff were supposed to report the concern to the dietary staff before serving the food. During an interview with LVN 1 on 4/9/19, at 4:45 p.m., LVN 1 stated the CNA told her the tray ticket was not checked against the meal tray on the day of the incident. LVN 1 was in the hallway and heard someone coughing and CNA 1 was calling for help. LVN 1 initiated Heimlich maneuver without success then, attempted to suction without success. RNA 1 then performed Heimlich maneuver successfully. Resident 1 had only taken one bite of the hot dog and one bite came out of his mouth. LVN 1 stated she administered oxygen to Resident 1 and took Resident 1 back to his room and another nurse called 911. LVN 1 stated Resident 1 pulse was noted as being present and slow and Fire and Paramedics arrived and Resident 1 was transferred to the hospital. During a second interview with LVN 1 on 7/17/19, at 12:45 p.m., LVN 1 stated it was the licensed nurses' responsibility to check the meal trays before being served to the residents. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4CXP11 Facility ID: CA020000116 If continuation sheet 5 of 6 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: _______________ 055239 (X3) DATE SURVEY COMPLETED 12/11/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EAST BAY POST-ACUTE 20259 Lake Chabot Road Castro Valley, CA 94546 (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 the facility policy on Mechanical Soft Diet Description indicated "...Foods that are difficult to chew are replaced with foods that have been altered into a form that can be easily chewed ...Foods that may need to be modified include meat, poultry, raw vegetables, and other fibrous foods...." Review of the facility policy and procedure titled, "Food and Nutrition Services," dated 10/17, indicated Food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident...." Review of the facility policy and procedure titled, "Tray Identification," dated 4/7 indicated, "1...the Food Services Department will use appropriate identification...to identify the various diets...Nursing staff will check random food tray for the correct diet before serving the residents...If there is an error, the Nursing staff will notify the Dietary Department immediately so that the appropriate food tray can be served." Review of the "Alameda County Coroner's Report," dated 3/22/19, indicated "...Autopsy Findings I. Asphyxia (a condition arising when the body is deprived of oxygen causing unconsciousness or death) A. Obstruction of upper airway by hot dog...Cause of death: Asphyxia due to obstruction of airway...Neck...The hyoid bone (tongue bone) and larynx (voice box) are intact but the posterior oral cavity and upper pharynx (part of the throat) is obstructed with 4x2x2.5cm hot dog...." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4CXP11 Facility ID: CA020000116 If continuation sheet 6 of 6