Other·November 15, 2017

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during the investigation of one compliant and one entity reported incident. Complaint Number: CA00548743 Entity reported incident: CA00550053 Representing the Department: HEFN 37005 This inspection was limited to the specific complaint/entity reported incidents investigated and does not represent the findings of a full inspection of the facility. One deficiency was written as a result of complaint CA00548743 and the entity reported incident CA00550053.

F323 SS=G FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES CFR(s): 483.25(d)(1)(2)(n)(1)-(3)

F323 10/27/2017 (d) Accidents. The facility must ensure that (1) The resident environment remains as free from accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. (n) - Bed Rails. The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: F4S411 Facility ID: CA020000030 If continuation sheet 1 of 5 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056359 (X3) DATE SURVEY COMPLETED 09/27/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SAN PABLO HEALTHCARE & WELLNESS CENTER 13328 San Pablo Avenue San Pablo, CA 94806 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (1) Assess the resident for risk of entrapment from bed rails prior to installation. (2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation. (3) Ensure that the bed’s dimensions are appropriate for the resident’s size and weight. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to provide supervision to assure a safe transfer with two staff for one (Resident 1) of four sampled residents. As a result Resident 1 fell on 8/11/17 and sustained a severely fractured hip which was not recognized for three days. Findings: Review of the clinical record indicated Resident 1 was admitted on 3/20/13 with diagnoses including stroke (interruption of blood flow to brain causing loss of function controlled by that part of the brain); left sided paralysis (loss of ability to move or to feel); contractures (shortening and tightening of muscles and tendons) of left hand, left elbow and knee; muscle weakness and Alzheimer's disease (progressive disease that destroys memory and other mental functions). A review of the Minimum Data Set Assessment (an assessment tool to guide care), dated 3/17/17, indicted Functional Status During Transfer (how resident moves between surfaces including to or from bed, chair, wheelchair): Assistance needed was, "Total dependence-full staff performance every time during entire 7-day period." The Support FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: F4S411 Facility ID: CA020000030 If continuation sheet 2 of 5 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056359 (X3) DATE SURVEY COMPLETED 09/27/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SAN PABLO HEALTHCARE & WELLNESS CENTER 13328 San Pablo Avenue San Pablo, CA 94806 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE provided for transfer was assessed as, "Two plus persons physical assist." That meant that Resident 1 needed at least two staff members to transfer her from the bed to the wheelchair. Review of the Fall Risk Assessment, date 6/19/17, Resident 1's rating for fall risk was "15." On the Total Score line at the bottom of the form was written, "A total score of 10 or above represents HIGH RISK." A review of the care plan, revised on 3/16/17, indicated Resident 1's Problem/Need list included, "At risk for fall, limited mobility, poor balance, lack of awareness, forgets to call/wait for assistance ... and had a history of falls." The Approaches (interventions) listed were: "Provide an environment that supports minimized hazards over which the Facility has control, call light within reach, remind resident to use call light, bed in the low position (whole bed lowered)." During an interview on 8/29/17 at 11:10 a.m., Certified Nurse Assistant (CNA) 1 stated (when the fall happened), "Basically, I had got her dressed. Resident was supposed to be transferred to a chair. It was a two person transfer. As I went to go pull the wheelchair close to the bed for her to get her up, as I went to grab the wheelchair, she (Resident 1) was sitting on the side of the bed. To my knowledge, I thought she could hold herself up on bed. I guess not. I tried to catch her. I definitely approached her from the back. When I ran she was already pretty much was on the ground. It was something that happened fast. It was an instant type thing. I remember holding her from her back under her arm. I knew I needed to leave her there. The other CNA (CNA 2) went to get help. She came after the fall. She (Resident 1) seemed as though she could hold herself up. I thought I could take a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: F4S411 Facility ID: CA020000030 If continuation sheet 3 of 5 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056359 (X3) DATE SURVEY COMPLETED 09/27/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SAN PABLO HEALTHCARE & WELLNESS CENTER 13328 San Pablo Avenue San Pablo, CA 94806 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE few steps and grab the chair. I had worked with the resident before and was able to transfer the resident." CNA 1 stated, Resident 1,Cried a little bit. She did not yell. She was "grabbing onto her leg or thigh." She always cried and complained. It seemed she was saying she was in pain. CNA 1 stated, "I was told to make her feel as comfortable as possible in the chair and put her in the day room after the incident." During an interview on 8/29/17 at 3:30 p.m., with Licensed Vocational Nurse (LVN) 1, who was the charge nurse on the day of Resident 1's accident, LVN 1 stated, "It always takes one person to get her (Resident 1) out of bed, or they would ask the RNA (Restorative Nurse Assistant) to do it." During an interview on 8/30/17 at 3:15 p.m., the Assistant Director of Nursing (ADON) stated we should have assessed in more detail, where the pain was coming from. When I assessed her, the CNA did not report to me that she said, "pain." The fall happened on Friday. It was on Monday that she was really complaining of pain. The hip was tender and there was some heat. A review of the SBAR Communication form, dated 8/14/17, indicated Resident 1 had, "Left hip pain and swelling and left cheek discoloration. Rt (resident) complains of pain when moved." An x-ray was done on 8/15/17 at the facility. The x-ray results showed Resident 1 had a severely comminuted (multiple fragments) fracture of the left hip. On 8/15/17 at 2:30 p.m. Resident 1 was sent to an acute hospital for treatment. The ED (Emergency Department) Provider Notes indicated Resident 1 had a fractured FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: F4S411 Facility ID: CA020000030 If continuation sheet 4 of 5 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056359 (X3) DATE SURVEY COMPLETED 09/27/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SAN PABLO HEALTHCARE & WELLNESS CENTER 13328 San Pablo Avenue San Pablo, CA 94806 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE right hip, abrasions (top layer of skin damaged from friction) of both lower legs, bruising on the right leg and delirium (decline from a previous baseline state of mental function), probably from pneumonia. On 8/17/17 surgery was done to repair the fracture. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: F4S411 Facility ID: CA020000030 If continuation sheet 5 of 5