Other·March 14, 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 as a result of an investigation for two facility reported incidents. The inspection was limited to the specific facility reported incidents investigated and does not represent a full inspection of the facility. Facility Reported Incident: CA00561993 Facility Reported Incident: CA00569625 Representing the Department: Health Facilities Evaluator Nurse 36087 One deficiency was issued for the Facility Reported Incident CA00561993. See (F689) No deficiency was issued for the Facility Reported Incident CA00569625.

F689 SS=J Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) 02/20/2018 §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. 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: ZPZT11 Facility ID: CA020000124 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: _______________ 555358 (X3) DATE SURVEY COMPLETED 02/01/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRUITVALE HEALTHCARE CENTER 3020 East 15th Street Oakland, CA 94601 (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 REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure residents were provided the supervision to prevent them from wandering outside of the facility for one of 17 residents (Resident 1) and three of three randomly sampled residents (Resident 2, 3 and 4). The facility did not monitor the elopement alarm device functionality of Roam Alert (a system that tracks the person using a wrist or ankle bracelet which automatically alarms if the person moves outside a defined area) monitoring system for one of five door monitor (main door). Resident 1 left the facility undetected. Resident was found three miles away from the facility and was returned to the facility by the police after more than 24 hours later. This failure resulted in delay in identification of the system malfunction and potentially placed 17 of 17 residents in the facility with Roam Alert monitoring device (sensing tags) in serious harm. It was determined to constitute an Immediate Jeopardy (IJ) situation. The Administrator (ADM) and the Director of Nursing (DON) were verbally notified of the IJ on 1/29/18 at 12:31 p.m. The facility failed to ensure a fully functioning Roam Alert system was maintained. Through observations and interviews with the staff members and record reviews of the facility's in-service records, the facility showed they initiated the plan of action through inservices of employees regarding Roam Alert monitoring. The facility repaired the nonfunctioning Roam Alert door monitor at the front door. The IJ was lifted on 1/29/18 at 3:10 p.m. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZPZT11 Facility ID: CA020000124 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: _______________ 555358 (X3) DATE SURVEY COMPLETED 02/01/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRUITVALE HEALTHCARE CENTER 3020 East 15th Street Oakland, CA 94601 (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 Findings: Review of Resident 1's undated Face Sheet indicated he was admitted to the facility on 10/30/17 with diagnoses that included disorientation, dementia (a decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities) and a history of falling. Review of the Resident Progress Notes dated 11/17/17 indicated Resident 1 was last seen by the Certified Nursing Assistant 1 (CNA 1) around 8:10 a.m. and was identified to be missing at 8:30 a.m. Review of Resident 1's Progress Note dated 11/18/7 11 a.m., indicated "Resident returned to the facility accompanied by Police...found him in the [street of Oakland] near a store...Resident then claimed while while in the room that he fell while he was in the street and c/o [complained of] both knee pain...also c/o pain on his left fingers...Resident stated "I slept in the street it was too cold..." Review of the Minimum Data Set dated 11/12/17, indicated Resident 1 had a Brief Mental Interview Score (BIMS, an assessment intended to determine the resident's attention, orientation and ability to register and recall new information) of nine (moderately impaired). Further review indicated Resident 1 required oversight supervision when ambulating in and out of the unit. Review of Resident 1's Elopement Risk Assessment dated 10/30/17 indicated Resident 1 was at risk for elopement. Review of Resident 1's care plan "At risk for Elopement & [and] wandering out of facility" dated 10/30/17, indicated an approach that FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZPZT11 Facility ID: CA020000124 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: _______________ 555358 (X3) DATE SURVEY COMPLETED 02/01/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRUITVALE HEALTHCARE CENTER 3020 East 15th Street Oakland, CA 94601 (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 wearing a Wanderguard bracelet and to check the alarm for functioning. Review of Resident 1's Physician's Order dated 10/30/17 indicated "Wanderguard to be worn at all times..." During an interview with CNA 1 on 1/29/18 at 10:03 a.m., CNA 1 stated she was the CNA for Resident 1 on 11/17/18. CNA 1 further stated she did not hear any door alarm on 1/17/18, when Resident 1 eloped from the facility. During an observation on 1/29/18 at 10:20 a.m. Resident 2 was in a wheelchair wearing a Roam Alert sensing bracelet on the right wrist. The DON pushed Resident 2's wheelchair through the front door and the alarm sensor did not sound. During a second observation on 1/29/18 at 10:25 a.m. Resident 3 was ambulatory and was wearing a Roam Alert sensing bracelet on the left wrist. The DON and Resident 3 walked out of the front door and the alarm sensor did not sound. During a third observation on 1/29/18 at 10:50 a.m. Resident 4 was in a wheelchair wearing a Roam Alert sensing bracelet on the left wrist. The DON pushed Resident 4's wheelchair through the front door and the alarm sensor did not sound. During an interview on 1/29/18 at 10:50 a.m., the DON and ADM stated the Roam Alert sensing bracelet should have activated the sensor of the Roam Alert system on the front door and all protected exit doors with the Roam Alert door monitors. During an interview with the Maintenance Director (MD) on 1/29/18 at 11:15 a.m. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZPZT11 Facility ID: CA020000124 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: _______________ 555358 (X3) DATE SURVEY COMPLETED 02/01/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRUITVALE HEALTHCARE CENTER 3020 East 15th Street Oakland, CA 94601 (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 regarding door monitoring testing, MD stated his responsibility was to check the Roam Alert system once a week, usually every Friday. MD stated that he failed to perform the monitor check on 1/26/18. MD stated he does not have any documentation to indicate that monitoring was being conducted and further stated that he was not in compliance with the facility's policy to test and inspect each door monitor daily. In a follow up interview on 1/29/18 at 11:50 a.m., the ADM stated that the vendor did not regularly come to service unless the facility called them to come. He further stated that MD was responsible for monitoring the door alarm system and ensured it was in good working condition. Review of the facility's policy and procedure "Wander/Elopement Alarm System Testing" dated 4/2001 indicated, "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 preventive 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: ZPZT11 Facility ID: CA020000124 If continuation sheet 5 of 5