Other·June 10, 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 represents the findings of California Department of Public Health during an investigation of a facility reported incident. The investigation was limited to the specific facility reported incident investigated and does not represent a full inspection of the facility. Facility Reported Incidents Number: CA00625626 Representing the California Department of Public Health: HFEN 40762 One deficiency was issued.

F689 SS=G Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) 05/21/2019 §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 interview and record review, the facility failed to provide supervision to prevent one of three residents (Resident 1) from falling. The failure to provide one-on-one supervision for Resident 1 after a shower resulted in Resident 1 attempting to stand without assistance to dress herself, falling out of an 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: XZEY11 Facility ID: CA020000276 If continuation sheet 1 of 4 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: _______________ 555341 (X3) DATE SURVEY COMPLETED 05/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON CREEK POST-ACUTE 22103 Redwood 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 unsecured shower chair (a wheeled chair used during showering), and sustaining a fractured shoulder. Findings: A review of the Minimum Data Set (MDS, an assessment tool used to guide resident care) dated 1/24/19, indicated the facility admitted Resident 1 in 2011 with diagnoses that included paralysis of one side of her body, and dementia (impaired thinking, reasoning, and memory skills). The MDS indicated Resident 1 had severe memory and thinking impairment, with a Brief Interview for Mental Status (BIMS, an assessment tool for a resident's orientation to time, and capacity to remember. The BIMS range is 0-15, with zero as the most impaired condition.) score of two. The MDS reflected Resident 1 was unsteady when transferring from one surface to another surface, and required extensive physical assistance from one person for such transfers. The MDS also indicated Resident 1 required physical assistance from one person for the activities of bathing and dressing. The MDS indicated Resident 1 used a wheelchair for movement within the unit, but required supervision by one person for the movement. A review of the care plan, "Fall Risk," initiated 10/23/15, revised 1/31/17, indicated Resident 1 had a history of falls, was unable to transfer without assistance, and had impaired safety awareness. The care plan interventions included, "Anticipate and meet the resident's needs. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance." A review of the facility form, "Incident/Accident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: XZEY11 Facility ID: CA020000276 If continuation sheet 2 of 4 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: _______________ 555341 (X3) DATE SURVEY COMPLETED 05/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON CREEK POST-ACUTE 22103 Redwood 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 Report," dated 2/15/19, showed Resident 1 had a fall on 2/15/19 at 9:20 a.m., witnessed by a certified nursing assistant. The report showed Resident 1 had no sign of injury or complaint of pain immediately after the event. During a telephone interview with Certified Nurse Assistant (CNA) on 3/13/19 at 11:25 a.m., CNA stated she had assisted Resident 1 with a shower, then transported Resident 1 back to her room in a shower chair. CNA stated Resident 1's clothes were on top of her bed, when CNA told Resident 1 she would be right back, and left the room to get Resident 1's regular wheel chair, located across the hall. CNA stated when she returned to the room, Resident 1 was attempting to stand up and was reaching for her clothes on the bed. CNA stated she asked Resident 1 to sit back down, and Resident 1 started to sit back down in the shower chair, but the chair moved, and Resident 1 slid off the seat onto the floor, hitting her arm on the side of the bed as she fell. CNA stated she called the licensed nurse for assistance while Resident 1 sat on the floor. During an interview with Registered Nurse (RN) on 3/5/19 at 11:45 a.m., RN stated she and Nursing Supervisor (NS) responded to CNA's call for assistance after Resident 1 fell. RN stated when she entered the room, Resident 1 was on the floor by a shower chair. RN stated she assessed Resident 1 before moving her off the floor, and saw no sign of injury. RN stated Resident 1 had no complaint of pain, or change in her ability to move her extremities. RN stated CNA and NS transferred Resident 1 to her wheel chair with a draw sheet (a sheet used to facilitate transfer and change in position). A review of a nurse progress note dated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: XZEY11 Facility ID: CA020000276 If continuation sheet 3 of 4 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: _______________ 555341 (X3) DATE SURVEY COMPLETED 05/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON CREEK POST-ACUTE 22103 Redwood 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 2/15/19 at 3:00 p.m., reflected Resident 1 had skin discoloration from under her arm to her breast. The note also reflected Resident 1 received acetaminophen (medication used for pain relief) for complaints of pain with arm movement on 2/15/19 at 6:10 p.m. A review of nurse progress notes showed Resident 1 complained of pain in her right underarm, and received acetaminophen on: 2/16/19 at 5:30 a.m., and 2/17/19 at 6:15 a.m. A review of the note dated 2/18/19 at 7:00 a.m., reflected RN notified the physician of Resident 1's right arm and shoulder discoloration and pain; the physician ordered X-ray studies of Resident 1's arm and shoulder. A progress note dated 2/18/19 at "around 7 p.m." showed the nurse notified the physician about the X-ray results; at 8:24 p.m. the physician ordered Resident 1 to the hospital for treatment. A review of the radiology, "Final Report," dated 2/18/19, showed Resident 1's upper arm was broken, with the bone ends still in proper anatomical position. Review of the Nurses Progress Note dated 2/19/18 at 3:00 a.m., indicated the hospital informed the facility that Resident 1 would return to the facility with a sling for the right arm to maintain bone alignment. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: XZEY11 Facility ID: CA020000276 If continuation sheet 4 of 4