Health inspection·September 12, 2023

F 0624 Prepare residents for a safe transfer or discharge from the nursing home. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of three discharged residents (Resident 1) had a safe and appropriate discharge location based on his medical needs when Resident 1 who was legally blind was discharged to an independent living facility where resident sustained falls. Residents Affected - Few This failure placed Resident 1 at risk for adverse health outcomes that had the potential to cause serious complications and psychosocial harm. Findings: During a review of Resident 1's admission record, printed on 9/12/23, the admission record indicated Resident 1 was originally admitted to the facility on [DATE] and has a medical diagnosis including history of cerebral infarction (a condition which occurs when the blood supply to part of the brain is interrupted or reduced, preventing brain tissue from getting oxygen and nutrients) without residual deficits, generalized muscle weakness and need for assistance with personal care. During a record review of Resident 1's Minimum Data Set (MDS, a resident assessment tool used to guide care) dated 12/27/22, the MDS assessment section B indicated Resident 1's vision was severely impaired. MDS section G also indicated that Resident 1 needed staff assistance for toilet use, transfers, personal hygiene, dressing and bathing. The MDS assessment section C indicated Resident 1's Brief Interview of Mental Status (BIMS- an assessment for mental status) score was 14 out of 15 which indicated intact mental status. During a review of Resident 1's Care Plan, printed on 9/12/23, the care plan indicated Resident 1 has self-care performance deficit related to impaired balance, limited mobility and being legally blind. The care plan interventions included assistance from staff for showering, dressing, mobility, personal hygiene, toileting, and transfers. During an interview on 9/11/23 at 1:30 pm., with Resident representative (RP), RP stated, when she visited the facility with her father prior to discharge, she was not aware that the facility was an independent living facility and thought it was assisted living facility. RP also stated they only found out that the facility was independent living facility after the discharge. RP stated after the discharge Resident 1 fell a couple of times at the independent living facility and they had to call 911 for help. During a concurrent interview and record review on 9/12/23 at 11:24 a.m., Resident 1's Interdisciplinary discharge summary was reviewed. The Interdisciplinary discharge summary section G1 indicated that Resident 1 was discharged to an assisted living facility. Social Worker (SW) stated Resident 1 Page 1 of 2 056345 056345 09/12/2023 San Leandro Healthcare Center 368 Juana Avenue San Leandro, CA 94577

F 0624 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few was discharged to a Board and Care facility and not assisted living facility. SW stated resident 1 and resident representative visited the facility prior to discharge to confirm to discharge the resident. SW stated the facility was referred from a placement agency and no one from the facility visited or verified if it was a board and care facility other than verbal confirmation from the owner of the facility. During an interview on 9/12/23 at 12:18 pm., with owner of the independent living facility, the owner stated the facility is a licensed independent living facility in which residents needed to provide for their own care. Owner also stated they accepted Resident 1 because they were provided information that the resident was independent with most of his ADL and care and only needed some assistance with care. Owner also stated they can help with medications and food but Resident 1 needed constant supervision and assistance with ADL all the time which they could not provide, and the facility was not a right fit for the resident's needs. During an interview on 9/12/23 at 12:38 p.m. with SW, SW stated it was the facilities responsibility to ensure Resident 1 was discharged to a safe place. SW also stated they did not know that Resident 1 was discharged to an independent living facility. SW also stated it was important to make sure it was the right place for Resident 1 to ensure if the residents medical care needs and accessibility would be met. 056345 Page 2 of 2