Health inspection·July 16, 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 one of three sampled residents (Resident 1) with impaired mental status received adequate supervision to prevent accident hazards when Resident 1 left the facility and was found and brought to the police station by a concerned citizen. This failure resulted in Resident 1's elopement (elopement is when a patient or resident who is incapable of adequately protecting themselves, departs the health care facility unsupervised and undetected) and had the potential for Resident 1 to be dehydrated, injured, or struck by a motor vehicle. Findings: During a review of Resident 1's Annual Minimum Data Set (MDS - Resident assessment and care guide tool), dated 4/20/24, the MDS indicated Resident 1's Basic Interview of Mental status (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.) score was 04 and indicated poorly impaired mental status. The MDS indicated Resident 1 was unable to recall the correct year, month and day of the week. The MDS indicated Resident 1 used a manual wheelchair for mobility. The MDS indicated Resident 1 responded only to simple and direct communication. The MDS further indicated Resident 1 had diagnosis of Non-Alzheimer's Dementia (a group of diseases characterized by progressive deficits in behavior, executive function or language). During a review of Resident 1's progress notes, dated 5/30/24, the progress notes indicated on 5/29/24 at 8:10 p.m., Resident 1 eloped from the facility and the police were notified. The progress notes indicated the police dispatcher mentioned Resident 1 was brought to the police station by a concerned citizen. The progress notes further indicated Resident 1's Family Member (FM1) brought Resident 1 back to the facility. During a concurrent observation and interview, on 6/13/24, at 11:20 a.m., with the Administrator (Admin), Resident 1's room observed with two sliding doors that exited directly into the car parking lot. An exit alarm was observed located on top of the exit sliding doors. The Admin stated the sliding door exit alarm next to Resident 1's bed was found to be loosely connected and not working when Resident 1 eloped from the facility. During a concurrent observation and interview, on 6/13/24, at 11:30 a.m., Resident 1 was observed sitting in a wheelchair in the activity room, verbally responsive with incomprehensible sounds. (continued on next page) 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. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 055338 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055338 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sage Post Acute 1832 B Street Hayward, CA 94541 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)