Health inspection·December 3, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, interview and record review, the facility failed to ensure 90 of 90 sampled residents were prevented from unauthorized visitor entry or resident exit from the facility when facility staff failed to close the alarmed emergency exit back door and arm the emergency exit alarm for 35 minutes during the evening shift. This failure had the potential to result in unauthorized visitor entry and/or unwitnessed resident elopements potentially resulting in resident injury. Findings: During an observation of the alarmed emergency exit back door on 10/17/24, at 1:00 p.m., the alarmed emergency exit back door was opened; there was no audible alarm. The door led to an access ramp with direct access to public streets. The access ramp was closed with an unlocked metal latch. During a continuous observation of the alarmed emergency exit back door on 10/18/24, at 6:40 p.m., the door was opened from 6:40 p.m. to 7:15 p.m.; there was no alarm audible. During a concurrent observation and interview on 12/3/24, at 11:05 a.m., with Certified Nursing Assistant 1 (CNA 1), an alarmed emergency exit door near the nurses' station was inspected. CNA 1 stated the facility emergency exit doors were never locked, but all the emergency exit doors have an alarm to alert staff when the door was opened. CNA 1 stated the alarms could be heard anywhere in the facility. During a concurrent observation and interview on 12/3/24, at 1:15 p.m., with the Director of Nursing (DON) and Housekeeping Supervisor (HS), the alarmed emergency exit back door was inspected. There were two signs affixed to the door. The first sign indicated, Please Keep Door Closed At All Times. The second sign indicated, Emergency Exit After 5:00 p.m. Keep Door Closed. The DON stated the door should always be closed. The HS stated when the door alarm was armed, an audible alarm would sound when the door was opened and would continue until staff reset the alarm. The DON and HS stated the alarm mechanism should be armed after 5:00 p.m. because the reduced staffing during the evening and night shift prevented continuous monitoring of the exit. The DON stated the purpose of the door alarm was to alert staff when the door was opened. The DON stated staff were expected to respond to the alarm when it sounded. During a review of facility policy and procedure (P&P) titled, Wandering & Elopement, Operational Manual Administrative Policies, dated 1/1/12, the P&P indicated facility staff must also act to ensure their health and safety .facility staff should check all doors to ensure they close properly Page 1 of 2 055215 055215 12/03/2024 Oakland Healthcare & Wellness Center 3030 Webster Street Oakland, CA 94609

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few after each entry/exit .the maintenance department will check the alarm system regularly to ensure it is in good working order. During a record review of facility plan of correction (POC) for the 2022 recertification survey titled, Exit' are equipped with both door alarms .On 4/20/22 DON instructed all licensed nurses to keep door alarms engaged at all times. Nurses were already familiar with the use of the intuitive and well labeled door alarm system and were previously leaving them disengaged .maintenance supervisor or environmental supervisor will inspect all door alarms daily to ensure they are in the armed position by pressing the alarm test button .when a patient would trip the alarm, a nurse would be required to show up on scene to reset the alarm, thereby being present to intervene on the situation. Nurses would not fail to show up to the scene as the alarm is extremely loud and impossible not to hear in the facility. 055215 Page 2 of 2