Other·April 16, 2019

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 a complaint and a facility reported incident. Complaint number : CA00612205. Facility reported incident number: CA00612347. Representing the Department: Health Facilities Evaluator Nurse 33155. The inspection was limited to the specific complaint and facility reported incident investigated and does not represent the findings of a full inspection of the facility. One deficiency was issued for complaint number CA00612205 and facility reported incident number CA00612347.

F689 SS=G Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) 03/22/2019 §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. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record 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: GYK911 Facility ID: CA020000275 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: _______________ 056121 (X3) DATE SURVEY COMPLETED 02/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WASHINGTON CENTER 14766 Washington Avenue San Leandro, CA 94578 (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, the facility failed to ensure one of three sampled residents (Resident 1) was safely transferred from the bed to the wheelchair, when: 1. Certified Nursing Assistant (CNA 1) used a mechanical lift (a specialized piece of equipment used to lift and transfer a resident from one area/surface to another, to reposition or to lift a resident) without a second staff member to assist as required per facility policy. 2. CNA 1 did not use the appropriate size sling (a flexible canvas strengthened/supported with strap or belt used in the form of a loop attached to a mechanical lift to support or raise a weight to assist resident with changing of position or transfer from/to different surfaces) and did not perform sling inspection per manufacturer ' s recommendation. 3. The facility did not provide CNA 1 training in the use of mechanical lift per facility policy. During Resident 1 ' s transfer, the straps of the sling attached to the mechanical lift snapped and broke. Resident 1 fell onto the floor and sustained multiple rib fractures (broken bone) on her left side. Findings: Review of Progress Notes dated 11/15/18 indicated, at 10 a.m., Resident 1 was on the floor on her back near her bed. CNA 1 reported Resident 1 was being transferred from bed to wheelchair using a mechanical lift. The sling suddenly snapped and Resident 1 fell onto the floor. The note indicated, "Called 911 for immediate transfer to the hospital for further eval (evaluation) and management." Review of Resident 1's Emergency Department FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GYK911 Facility ID: CA020000275 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: _______________ 056121 (X3) DATE SURVEY COMPLETED 02/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WASHINGTON CENTER 14766 Washington Avenue San Leandro, CA 94578 (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 (ED) Physician Notes dated 11/15/18 indicated Resident 1 sustained multiple fractures of five of 12 ribs on the left side as a result of the fall. The Medical Decision Making section indicated "The complexity of data and the risk of complications for this case is high." Review of the Minimum Data Set (MDS, an assessment tool used to guide care) dated 11/1/18, indicated Resident 1 was cognitively intact and had diagnosis of Cerebrovascular Accident (stroke) and muscle weakness. Further review indicated Resident 1 require extensive assist from two persons for bed mobility and transfer between surfaces. During an interview with CNA 1 on 11/27/18 at 10:20 a.m., CNA 1 stated, on 11/15/18, she transferred Resident 1 from the bed to the wheelchair using a Tollos (mechanical lift) using a white colored sling. CNA 1 stated she started to lift Resident 1 from the bed with the mechanical lift when the straps, which were attached to the lift, the sling snapped and broke on the left side then on the right side and Resident 1 fell onto the floor on her left side. CNA 1 stated she was not sure if the white sling used during the transfer was the right sized sling for Resident 1. CNA 1 stated she did not check the sling for integrity prior to use, as the same sling was used in the previous day for Resident 1. CNA 1 stated she did not receive training in the use of mechanical lift. Review of Resident 1's "Lift Transfer Reposition (assessment)" dated 11/9/18 indicated Resident 1 required two staff for repositioning and transfer using a mechanical lift. Further review indicated Resident 1 had a body weight of 179.5 pounds. The Care Plan Section indicated two persons extensive assist should be provided during transfers with mechanical lift to decrease the risk for falls. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GYK911 Facility ID: CA020000275 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: _______________ 056121 (X3) DATE SURVEY COMPLETED 02/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WASHINGTON CENTER 14766 Washington Avenue San Leandro, CA 94578 (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 inspection of the Tollos sling tag with the Central Supply Staff (CSS 1) on 11/27/18 at 10:28 a.m., the Tollos sling tag indicated: the approximate weight guideline for white colored sling (designated as Extra Small) was between 49 to 74 lbs.; the approximate weight guideline for green colored sling (designated as Large) was between 175 to 249 lbs. During an interview with Director of Staff Development (DSD) on 2/11/19 at 3:15 p.m., DSD stated there were no staff in-service conducted from 2017 until 11/15/18. DSD acknowledged there was no record of inservice on the use of mechanical lift for CNA 1. During an interview with the Director of Nursing (DON) on 11/27/18 at 11:30 am, the DON stated CNA 1 had worked in the facility for 8 months. The DON was not able to produce CNA 1 ' s in service training record on the use of mechanical lift for transferring residents. Review of an undated Manufacturer Owner ' s Manual provided by the facility indicated, "Warning: Visibly inspect sling prior to each use to ensure sling is the correct type, size and design to handle lifting. Ensure the sling is not damaged, torn worn, discolored or past its useful life; ...that the sling ' s straps are correctly attached to the spreader bar, and that the sling is tested with resident in it at a few inches over bed or chair prior to actual transferring to proper operation...Warning: Untrained operators can cause injury or be injured. Permit only trained personnel to operate the lift. Improper operation can cause injury. Operate the lift only as described in this manual." Review of the facility's Policy and Procedure titled, "Safe Resident Handling/Transfer FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GYK911 Facility ID: CA020000275 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: _______________ 056121 (X3) DATE SURVEY COMPLETED 02/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WASHINGTON CENTER 14766 Washington Avenue San Leandro, CA 94578 (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 Equipment" dated 5/15/17, indicated, "Patient will be assessed to determine the correct equipment to use. Staff will be trained in the use of each type of equipment ..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GYK911 Facility ID: CA020000275 If continuation sheet 5 of 5