Other·August 17, 2017

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 three entity reported incidents and two complaints. Entity Reported Incidents: CA00539698, CA00535020 and CA00535968 Complaints number: CA00541490 and CA00541477 Representing the Department: Health Facility Evaluator Nurse(s): 38533, 39074, 16684, 39197, and 38789 No deficiencies were issued for entity reported incidents CA00535020, CA00535968 and complaints CA00541490 and CA00541477. For entity reported incident CA00539698 one deficiency was issued.

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

F323 08/15/2017 (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 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: 38YG11 Facility ID: CA020000133 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: _______________ 555533 (X3) DATE SURVEY COMPLETED 07/10/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DRIFTWOOD HEALTHCARE CENTER - HAYWARD 19700 Hesperian Boulevard Hayward, CA 94541 (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 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 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 supervision to prevent an accident when Certified Nurse Assistant (CNA) 1, without assistance of a second staff person, transferred one of four sampled residents ( Resident 2 ) with a Hoyer lift (a mechanical device used to lift people) from his wheelchair to bed. The loop on the sling of the hoyer lift malfunctioned and Resident 2 slid unto the floor. This deficient practice resulted in Resident 2 sustaining a fractured (broken bone), left eighth rib, hitting his head and the left side of his torso (trunk of the body), pain and having to go to the emergency room for treatment. Findings: Review of the Resident Face Sheet indicated Resident 2 was initially admitted to the facility on 12/1/16 and was re-admitted on 1/3/17. Review of the admission Minimum Data Set (MDS, an assessment tool used to guide care) dated 1/10/17, indicated Resident 2's Brief FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 38YG11 Facility ID: CA020000133 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: _______________ 555533 (X3) DATE SURVEY COMPLETED 07/10/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DRIFTWOOD HEALTHCARE CENTER - HAYWARD 19700 Hesperian Boulevard Hayward, CA 94541 (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 interview for mental status was 14 (indicated he was able to recall events and knew the correct year and month). The MDS also indicated Resident 2 was totally dependent and required total assistance of two plus persons when transferring to and from bed to wheelchair. Further review of the MDS indicated Resident 2's active diagnoses included Muscle weakness. During an interview with Resident 2 on 7/5/17, at 1:05 p.m., Resident 2 stated the sling broke on the Hoyer lift when CNA 1 was transferring him from the wheelchair to the bed on 6/12/17. Resident 2 stated he fell and hit the left side of his head and the left side of his trunk on the footboard of his roommate's bed. Resident 2 stated he was hurting and asked to go to the hospital. During an interview with CNA 1 on 7/5/17, at 1:50 p.m., CNA 1 stated while transferring Resident 2 from the wheelchair to the bed on 6/12/17 one of the hooks on the sling came off the lift. When Resident 2 was lifted from the wheelchair, CNA 1 saw the sling come off the lift, and Resident 2 was leaning to the left. CNA 1 stated she moved Resident 2's wheelchair out of the way and the Hoyer lift was used to guide the sling down until Resident 2 reached the floor in a sitting position. CNA 1 stated she used the Hoyer lift without assistance. She stated she had been trained on how to use the lift before the incident, and she was aware two people were required when using the Hoyer lift. Review of the facility's investigation summary dated 6/16/17, indicated CNA 1 was operating the Hoyer lift, and the sling loop came off from the mechanical lift's hook during transfer. Further review indicated Resident 2 slid down and ended in a sitting position on the floor. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 38YG11 Facility ID: CA020000133 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: _______________ 555533 (X3) DATE SURVEY COMPLETED 07/10/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DRIFTWOOD HEALTHCARE CENTER - HAYWARD 19700 Hesperian Boulevard Hayward, CA 94541 (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 on 7/5/17 at 2:10 p.m. with Licensed Vocational Nurse (LVN) 3, he stated on 6/12/17, Resident 2 was on the floor in a sitting position when he entered the room after the fall. LVN 3 stated CNA1 told him Resident 2 had slid from the wheelchair to the floor. LVN 3 stated he assessed Resident 2 and with the help of facility staff, Resident 2 was transferred to bed using a sheet to lift him. LVN 3 stated Resident 2 complained of pain on his left side. He notified the physician, and Resident 2 was transferred to the acute hospital. Review of Resident 2's Observation Report dated 6/12/17 at 9:44 p.m., indicated Resident 2 was transferred to the acute hospital. Review of the acute hospital X-Ray report dated 6/13/17, indicated Resident 2 sustained a fracture to his left eighth rib. Review of Resident 2's care plan "Self care deficit", initiated on 12/2/16, indicated the staff should "Provide 2 person assist with Activities of daily living (ADL's) as needed." Review of Resident 2's Physical Therapist Progress Discharge Summary dated 2/23/17, indicated Resident 2 required the assistance of two or more helpers for transfer. Review of the facility's "Hoyer Lift/Mechanical Lift Procedures" training document for staff dated 6/14/17, indicated "Mechanical lifts require at a 2-person assist. Both caregivers will steady the resident as the lift is being moved. The second caregiver will guide the resident's body while the first caregiver moves the lift." Review of the facility's "Resident Transfer: Mechanical Lift" policy and procedure dated 8/15/2002, revealed "Mechanical lifts require at FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 38YG11 Facility ID: CA020000133 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: _______________ 555533 (X3) DATE SURVEY COMPLETED 07/10/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DRIFTWOOD HEALTHCARE CENTER - HAYWARD 19700 Hesperian Boulevard Hayward, CA 94541 (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 least a 2-person assist." Review of the "Manual/Electric Portable Patient Lift" manufacturer manual, under Transferring the Patient, indicated "The use of one assistant is based on the evaluation of a healthcare professional for each individual case...before moving the patient, check again to make sure that the sling is properly connected to the hooks of the swivel bar. If any attachments are are not properly in place...correct this problemotherwise, injury or damage may occur...". The manual further indicated, when transferring resident to a wheelchair, one assistant will be behind the chair and the other operating the patient lift, "This will maintain a good center of balance and prevent the chair from tipping forward." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 38YG11 Facility ID: CA020000133 If continuation sheet 5 of 5