Other·June 13, 2019

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 a complaint. Complaint number: CA00633682. Representing the Department: Health Facilities Evaluator Nurse: 32717. The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. One deficiency was issued for complaint number CA00633682.

F689 SS=G Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) 05/23/2019 §483.25(d) Accidents. The facility must ensure that §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents. This REQUIREMENT is not met as evidenced by: Based on interview, and record review, for one of three (Resident 1) sampled residents, the facility failed to ensure safety when Certified Nursing Assistant (CNA) 1 assisted Resident 1 to the bathroom without the physical assistance of a second staff member. 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: 5UFL11 Facility ID: CA020000038 If continuation sheet 1 of 3 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: _______________ 056457 (X3) DATE SURVEY COMPLETED 05/20/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GREENRIDGE POST-ACUTE 2150 Pyramid Drive El Sobrante, CA 94803 (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 This failure resulted in Resident 1 falling on the bathroom floor and sustaining femoral neck (part of the hip joint) fracture. Findings: Review of Resident 1's Admission Record indicated Resident 1 was admitted to the facility on 11/06/16 with diagnoses that included hemiplegia affecting the right dominant side (weakness of the right side of the body) and aphasia (loss of ability to understand or express speech, usually caused by brain damage). Review of Resident 1's Minimum Data Set (MDS - a resident assessment tool used to guide care), dated 1/29/19, indicated Resident 1 required two persons physical assist when using the toilet room and with transfers on/off toilet. The MDS also indicated Resident 1 had short term memory loss and required the extensive help from staff with two persons assist when transferring to and from the toilet. During a telephone interview with CNA 1 on 4/30/19, at 2:13 p.m., CNA 1 stated, on 4/7/19 in the afternoon, she took Resident 1 to the bathroom. CNA 1 stated Resident 1 held the grab bar with one hand. CNA 1 stated while Resident 1 was in a standing position and about to transfer from the shower chair to the wheelchair, Resident 1 became stiff, her hand lost grip of the grab bar and she began to fall. CNA 1 stated she could not hold Resident 1's weight and could not stop her from falling. CNA 1 stated Resident 1 fell on the bathroom floor and landing on her right hip. CNA 1 stated she knew Resident 1 required two persons assist with toilet transfers but at the time, no one was available to help as everybody was busy. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5UFL11 Facility ID: CA020000038 If continuation sheet 2 of 3 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: _______________ 056457 (X3) DATE SURVEY COMPLETED 05/20/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GREENRIDGE POST-ACUTE 2150 Pyramid Drive El Sobrante, CA 94803 (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 During an interview with Registered Nurse (RN) 1 on 4/26/19, at 2:24 p.m., RN 1 stated that on 4/8/19 (the day after Resident 1's fall incident), a staff member reported that Resident 1 appeared to be in severe pain on the right leg. RN 1 stated X-rays were done and found that Resident 1 had fractured right hip. RN 1 stated Resident 1 needed assist from two staff for transfers (movement from one surface to another like wheelchair to shower chair or bed). RN 1 stated Resident 1's care plan also indicated two person transfers because, although sometimes Resident 1 was able to help when moving from bed to wheelchair or back, one would never know when Resident 1 was able to help or not. Review of Resident 1's Nurses Notes, dated 4/8/19, indicated Resident 1 complained of pain (rated as 7 out of 10, with 0 being no pain and 10 being the worst pain) when her right leg was touched or moved. The notes indicated X-rays were done. Review of Resident 1's Radiology Report, dated 4/9/19, indicated right femoral neck fracture. Review of Resident 1's Progress Notes, dated and signed 4/12/19, by Resident 1's attending physician at the facility indicated "Patient had a fall in the [facility] after toileting and was sent to [acute hospital] after X-ray result showed femoral neck fracture. On 4/9/19, [Resident 1] underwent right hip hemiarthroplasty (surgical procedure that involves replacing half of the hip joint)." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5UFL11 Facility ID: CA020000038 If continuation sheet 3 of 3