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 . (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: 056052 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 056052 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eden Healthcare Center 27350 Tampa Avenue Hayward, CA 94544 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)