Other·March 23, 2018

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 two complaints. Complaint number: CA00573427 Complaint number: CA00573488 Representing the Department, Health Facilities Evaluator Nurse: 36891 The inspection was limited to the specific complaints investigated and does not represent the findings of a full inspection of the facility. For complaint number: CA00573427, one deficiency was cited. For complaint number: CA00573488, no deficiencies were cited.

F689 SS=G Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) §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, the 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: RMVI11 Facility ID: CA020000081 If continuation sheet 1 of 4 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: _______________ 055085 (X3) DATE SURVEY COMPLETED 02/28/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MORAGA POST ACUTE 348 Rheem Boulevard Moraga, CA 94556 (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 facility failed to provide supervision to prevent an accident for one (Resident 1) of four sampled residents. For Resident 1, Certified Nurse Assistant 1(CNA 1), single-handedly transferred him using a Hoyer lift (a mechanical device used to lift people) from his bed to his wheelchair; hoisting him up by herself, causing Resident 1 to fall onto the floor head first. This deficient practice resulted in Resident 1 sustaining a contusion (bruise) and hematoma (a blood-filled raised bruise) to the left side of his head, warranting a transfer to the emergency room for evaluation and treatment. Findings: Review of the "Resident Face Sheet" indicated Resident 1 was admitted on 12/22/16 with multiple diagnoses including Multiple Sclerosis (a disabling disease of the brain and spinal cord (central nervous system) and Quadriplegia (a complete loss of function of both the arms and legs). Review of the admission Minimum Data Set (MDS - an assessment tool used to guide care) dated 12/28/17, indicated Resident 1 was unable to complete a Brief Interview for Mental Status. The MDS also indicated Resident 1 was totally dependent for transfers and required the assistance of two or more persons when transferring to and from bed to his wheelchair. In a telephone interview with Certified Nursing Assistant 1 (CNA 1) on 2/13/18 at 11:45 a.m., CNA 1 stated she transferred Resident 1 by herself using the EZ lift Hoyer (mechanical lift) from the bed to the wheelchair at 10:30 a.m. on 2/3/18. CNA 1 stated she called for help, but staff were busy assisting other residents. CNA 1 stated, while waiting for help she hoisted FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RMVI11 Facility ID: CA020000081 If continuation sheet 2 of 4 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: _______________ 055085 (X3) DATE SURVEY COMPLETED 02/28/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MORAGA POST ACUTE 348 Rheem Boulevard Moraga, CA 94556 (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 Resident 1 up by herself to try to position Resident 1 in front of the wheelchair. CNA 1 stated that she called for assistance from staff again, then she saw Resident 1 starting to fall head first. CNA 1 stated she tried to catch Resident 1, but was not able to because he was heavy. CNA 1 stated she was supposed to transfer Resident 1 with another person. Review of the Emergency Department's (ED) Triage Notes, dated 2/3/18 at 11:56 a.m. showed, "Hematoma & superficial abrasion (scraping of tissue/skin) to left frontal skull." Review of the ED physician's notes, dated 2/3/18 at 12:35 p.m., showed, "Diagnosis: Blunt head trauma". Further review of the ED discharge instructions by the ED physician on 2/3/18 at 1:59 p.m., indicated that, "Patient requires two person assist with Hoyer lift". Review of the facility's undated policy and procedure titled, "Lifting and Transferring of Residents", showed, "Residents are lifted and transferred safely in all instances. Mechanical lift procedures are used on any resident unable to independently pivot or transfer. The designated method of lifting and transferring of a resident is indicated in the Plan of Care and MDS. Adjustments are made to the Plan of Care as needed". Review of the facility's undated policy and procedure, titled, "Mechanical Lift", revealed, "At least two people are present while resident is being transferred with the mechanical lift". FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RMVI11 Facility ID: CA020000081 If continuation sheet 3 of 4 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: _______________ 055085 (X3) DATE SURVEY COMPLETED 02/28/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MORAGA POST ACUTE 348 Rheem Boulevard Moraga, CA 94556 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) FORM CMS-2567(02-99) Previous Versions Obsolete ID PREFIX TAG Event ID: RMVI11 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) Facility ID: CA020000081 (X5) COMPLETE DATE If continuation sheet 4 of 4