Health inspection·April 10, 2024

F 0584 Level of Harm - Minimal harm or potential for actual harm Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on interview and record review, the facility failed to provide a safe and clean environment for two of six sampled residents (Resident 1 and Resident 6) when: Residents Affected - Few 1. Resident 4 went into Resident 1's room and urinated on the curtain next to Resident 1's bed; and 2. Resident 4 went into Resident 6's room and urinated on the floor. These failures resulted in Resident 1 and Resident 6 experiencing emotional distress, feeling mad, and being upset. Findings: 1. A review of Resident 4's clinical record indicated Resident 4 was admitted October of 2023 and had diagnoses that included mood disorder (marked disruptions in emotions) and dementia (impairment of the ability to remember, think, or make decisions that interferes with everyday activities). A review of Resident 4's Minimum Data Set (MDS- an assessment tool used to guide care) Cognitive Patterns, dated 1/18/24, indicated Resident 4 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 2 out of 15 which indicated Resident 4 had severely impaired cognition. A review of Resident 4's progress notes, dated 12/27/23, indicated, Received report that resident [Resident 4] continue to go into other residents' rooms due to psychotic disorder [a mental disorder characterized by a disconnection from reality]. Resident [Resident 4] not only urinates but having bowel movement to undesignated areas . A review of Resident 1's clinical record indicated Resident 1 was admitted July of 2023 and had diagnoses that included delirium (an altered state of consciousness, characterized by episodes of confusion), and need for assistance with personal care. A review of Resident 1's MDS Cognitive Patterns, dated 1/27/24, indicated Resident 1 had a BIMS score of 13 out of 15 which indicated Resident 1 had intact cognition. During an interview on 4/10/24 at 10:56 a.m. with Resident 1, in Resident 1's room, Resident 1 stated Resident 4 went into her room on the first week of January and urinated on the curtain next to her bed. Resident 1 further stated, .I was mad a lot and also was upset because that guy [Resident 4] just comes here and pees . Page 1 of 2 056052 056052 04/10/2024 Eden Healthcare Center 27350 Tampa Avenue Hayward, CA 94544

F 0584 Level of Harm - Minimal harm or potential for actual harm During an interview on 4/10/24 at 11:45 a.m. with Certified Nurse Assistant (CNA) 2, CNA 2 stated, .He [Resident 4] will go around to other [resident's] rooms. I'm concerned with other residents .Yes, I see him [Resident 4] pee in the hallway and sometimes in other [resident's] room .That's what he [Resident 4] does .Once he [Resident 4] gets up, he [Resident 4] goes around to other rooms, touches their [other residents'] things, and pees on things in there [other resident's room] or on the floor . Residents Affected - Few During an interview on 4/10/24 at 12:18 a.m. with CNA 3, CNA 3 stated Resident 4 had a behavior of going into other resident's room and sometimes would urinate in other resident's rooms. CNA 3 further stated, .I think he needs more .supervision .for safety of them [other residents] . A review of Resident 1's active care plan, undated, indicated, The resident [Resident 1] has a psychosocial wellbeing problem or potential . 2. A review of Resident 6's clinical record indicated Resident 6 was admitted July of 2023 and had diagnoses that included schizoaffective disorder (a mental health condition that includes combination of cycles of severe symptoms of a false belief of external reality, a sensory perception of something that isn't there, depressed episodes, and/or manic periods of high energy), and transient (temporary) alteration of awareness. A review of Resident 6's MDS Cognitive Patterns, dated 3/28/24, indicated Resident 6 had a BIMS score of 10 out of 15 which indicated Resident 6 had moderately impaired cognition. During an observation on 4/10/24 at 12:22 p.m. in Resident 6's room, Resident 4 was observed entering Resident 6's room without permission. CNA 3 followed Resident 4 in the room and redirected/reoriented Resident 4 to go out of the room. During an interview on 4/10/24 at 12:25 p.m. with Resident 6, in Resident 6's room, Resident 6 stated Resident 4 would just go in her room sometimes and Resident 4 had urinated on the floor in her room before. Resident 6 further stated, .I was mad because it is not right . A review of Resident 6's active care plan, undated, indicated, The resident [Resident 6] has a psychosocial wellbeing problem potential [related to] SCHIZOAFFECTIVE DISORDER. During an interview on 4/10/24 at 2:27 p.m. with the administrator (ADM), the ADM stated he would expect that resident's rights for safe and clean environment should always be upheld. A review of the facility's policy and procedure titled, Residents Rights, dated 6/1/23, indicated, 8. Safe environment. The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. 056052 Page 2 of 2