Other·May 1, 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 a complaint and an entityreported incident. Complaint number: 506276 Entity-reported Incident number: 505457 Representing the Department: Health Facility Evaluator Nurse 36737. The investigation was limited to the specific complaint and entity reported incident investigated and does not represent the findings of a full inspection of the facility. No deficiencies were issued for the complaint number 5066276. One deficiency was issued for the entity reported incident number 505457.

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

F323 04/13/2017 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. 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: IO6311 Facility ID: CA020000274 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: _______________ 555313 (X3) DATE SURVEY COMPLETED 03/14/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE REHABILITATION CENTER OF OAKLAND 210 40th Street Way Oakland, CA 94611 (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, for one of two sampled residents (Resident 1) the facility failed to provide supervision to prevent accidents when Certified Nursing Assistant 1 left Resident 1 unattended during nursing care. This failure resulted in Resident 1 falling from bed and sustaining a broken left elbow. Findings: During observations on 10/12/16 from 11:15 a.m. to 4:30 p.m., Resident 1 was sleeping in the bed nearest to the door of a three bed room, her left arm was in a sling, she responded to touch and voice, and was unable to participate in interview. Review of the "Resident Admission Assessment," dated 9/13/16 indicated Resident 1 was admitted to the facility with diagnoses that included generalized muscle weakness, quadriplegia (paralysis), and a history of a broken right hip. The assessment also indicated Resident 1 required total assistance with bathing, dressing, hygiene, toileting, moving from bed to chair, walking, and had a history of falls. Resident 1 was able to follow instructions and make her needs known. Review of the "Skilled Nursing Notes," dated 9/24/16, indicated Resident 1 needed extensive assistance with bed mobility, transfer (assistance moving from bed to chair), and toileting. Review of the "Physical Restraint Device Assessment," dated 9/22/16, indicated Resident 1 also required the use of two hand rails to assist with turning and moving while in FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IO6311 Facility ID: CA020000274 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: _______________ 555313 (X3) DATE SURVEY COMPLETED 03/14/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE REHABILITATION CENTER OF OAKLAND 210 40th Street Way Oakland, CA 94611 (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 bed. Review of the "Resident Care Plan Fall Risk Prevention and Management," dated 9/20/16, indicated Resident 1 was at risk for fall and had limited mobility. The goal of care was to provide a safe environment that minimized complications associated with falls. The care plan also indicated the facility was to "...provide an environment that supports minimized hazards over which the facility had control..." and to "...orient Resident 1 to the environment each time changes were made...." During an interview on 10/12/16 at 2:45 p.m., Licensed Vocational Nurse (LVN) stated on 9/28/16 at 9:30 a.m., she asked Certified Nursing Assistant (CNA) 1 to get Resident 1 ready for wound care. LVN 1 stated she asked CNA 1 to turn Resident 1 on her right side, hold her in that position, and to stay with Resident 1 to assist LVN 1. LVN 1 stated that at 9:55 a.m., CNA 1 informed her that Resident 1 was ready (for care). LVN 1 stated CNA 1 was standing behind Resident 1 at the side of bed holding her in position for care. LVN 1 stated she was standing at the door to Resident 1's room when she heard a loud noise; she looked up and saw Resident 1 was on the floor in an "awkward" position. LVN 1 stated CNA 1 was standing at the foot of Resident 1's bed. LVN 1 also stated CNA 1 told her that she turned around to help another resident in the room. During a telephone interview 11/10/16 at 1:30 p.m. CNA 1 said on 9/28/16 at about 9:30 a.m. she was bathing Resident 1. CNA 1 stated LVN 1 asked her to get the resident ready for wound care and have her on her right side. CNA 1 stated she told LVN 1 she was ready, "a few minutes before 10 a.m." CNA 1 stated she had Resident 1 positioned on her right side, facing the door, both side rails were up, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IO6311 Facility ID: CA020000274 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: _______________ 555313 (X3) DATE SURVEY COMPLETED 03/14/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE REHABILITATION CENTER OF OAKLAND 210 40th Street Way Oakland, CA 94611 (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 Resident 1 was holding onto the side rail closest to the door, and the bed was in highest position. CNA 1 stated "I was behind her holding and supporting her, and waiting for the wound nurse. CNA 1 stated "suddenly, another resident called me, and I said to 'hold on'." CNA 1 stated the other resident said 'quick I need my clothes.'" CNA 1 stated she turned to the other resident for "just seconds," heard Resident 1 fall, and the wound nurse came in immediately. CNA 1 stated she went quickly to Resident 1 on the floor and asked her what happened. CNA 1 stated Resident 1 told her she moved her legs and fell over. Review of the "Post Fall Assessment," dated 9/28/16, indicated Resident 1 was not able to move her (left) arm without pain. Review of the "Nursing Notes and Situation Background Assessment Recommendation" (SBAR), dated 9/28/16, at 10:30 a.m., indicated a CNA (CNA 1) was assisting Resident 1 in bed "...when the roommate summoned her and asked for assist. CNA (CNA 1) left the resident (Resident 1) and went to roommate's bed resulting in resident (Resident 1) rolling off the edge of the bed and ending up on floor. Noted swelling to the (left) arm...." The SBAR also indicated the Nurse Practitioner was at the facility and ordered Resident 1 to be transported to the emergency room. Review of the "Emergency Room Notes," dated 9/28/16, Medical Doctor (MD) 1 indicated a left Humerus (bone in lower arm) fracture was treated with immobilization (long arm splint) and referred Resident 1 to orthopedic (bone) specialist. During clinical record review of the MD 2 orthopedic consult office visit dated 9/30/16 indicated Resident 1 had a left elbow fracture, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IO6311 Facility ID: CA020000274 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: _______________ 555313 (X3) DATE SURVEY COMPLETED 03/14/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE REHABILITATION CENTER OF OAKLAND 210 40th Street Way Oakland, CA 94611 (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 swelling through the hand, pain and difficulty with use of left arm. X-ray revealed a severely dislocated and unstable broken left elbow. During an interview on 10/12/16, at 12:45 p.m. the Director of Nursing (DON) stated he was present at the time of the fall, and CNA 1 used poor judgement when she left Resident 1 during care to answer a call from another resident in the same room. According to Hegner's "Nursing Assistant Basics," the ending procedure action to lower the bed to its lowest position "...ensures patient safely. Prevents falls, accidents, and injuries...." Review of the facility's policy and procedure titled "Fall Prevention and Management Program," dated 8/1/14 indicated "...Purpose To provide a safe environment that minimizes complications associated with falls..." and "...supports providing an environment free from the hazards over which the Facility has control...." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IO6311 Facility ID: CA020000274 If continuation sheet 5 of 5