Other·October 4, 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 represents the findings of the California Department of Public Health during the investigation of a Complaint and Facility Reported Incident (FRI). Complaint number: CA00599197 FRI number: CA00598014 Representing the Department: Health Facilities Evaluator Nurse: 38534. The inspection was limited to the specific complaint and FRI investigated and does not represent the findings of a full inspection of the agency. One deficiency was issued for Complaint number: CA00599197 and FRI number: CA00598014.

F689 SS=D Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) 09/26/2018 §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 facility failed to ensure resident received adequate supervision to prevent accidents for one of two residents (Resident 1) when 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: 1J8D11 Facility ID: CA020000092 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: _______________ 055775 (X3) DATE SURVEY COMPLETED 09/04/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ORINDA CARE CENTER, LLC 11 Altarinda Road Orinda, CA 94563 (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 was left in a wheelchair outside a dialysis (the process of removing excess water, solutes and toxins from the blood) center while unattended. As a result, Resident 1 slid out of the wheelchair, fell on her face. Resident 1 obtained skin injuries and femoral (thigh bone) fracture. Findings: Review of the Face Sheet indicated Resident 1 was admitted to the facility on 6/20/17 with multiple diagnoses that included muscle weakness, unspecified convulsions (condition where body muscles contract and relax rapidly and repeatedly, resulting in an uncontrolled shaking of the body), hemiplegia (paralysis of one side of the body) affecting left nondominant side and end stage kidney disease (ESRD, condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life). Review of Resident 1's Minimum Data Set (MDS, an assessment tool used to guide care) dated 8/3/18 indicated Resident 1 was cognitively intact and required two person physical assist with transfer. The MDS Section G0400 "Functional Limitation in Range of Motion" (code for limitation that interfered with daily functions or placed resident at risk for in jury) indicated Resident 1 had impairment on one side of the upper extremity and both sides on the lower extremities. Review of Resident 1's medical documents "Fall Risk Assessment" dated on 7/29/18 indicated Resident 1 had poor judgement and safety awareness, balance problem, decreased muscular coordination, and jerking or unstable when making turns. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1J8D11 Facility ID: CA020000092 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: _______________ 055775 (X3) DATE SURVEY COMPLETED 09/04/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ORINDA CARE CENTER, LLC 11 Altarinda Road Orinda, CA 94563 (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 Review of Resident 1's care plan titled "Resident Care Plan-Fall Risk" dated 2/1/18 indicated Resident 1 was at risk for fall due to impaired vision, impaired function, decrease strength, endurance, weakness, unsteady balance/gait and poor trunk control/balance deficit. The approaches and plan included frequent visual monitoring and whereabouts of the resident and wheelchair for transport with staff assistance. During an interview with Resident 1 on 8/9/18 at 2:10 p.m., Resident 1 stated on 7/30/18 after the dialysis treatment, Facility Driver 1 (FD 1) wheeled her outside the center's building and parked the wheelchair without pulling the breaks. FD 1 walked away and left Resident 1 alone to help Resident 2 to the van. The wheelchair started to wheel itself and that she had no safety belt at that time of the incident and she fell out of the wheelchair. Resident 1 further stated that at that time, she had too much pain and was upset that she was left alone because the driver was helping another resident. Resident 1 further stated she was still upset about the way she was handled. During an interview with Resident 2 on 8/9/18 at 2:30 p.m., Resident 2 stated Facility Driver 1 (FD 1) pushed his wheelchair towards the van and left Resident 1 outside in front of the dialysis center's door, then they heard Resident 1 screaming, FD 1 went back to Resident 1 and saw her on the floor and someone called 911. Resident 2 further stated FD 1 was around ten feet away from Resident 1 when the incident happened. Review of the Hospitalist Discharge Summary dated 8/5/18 indicated Resident 1's principal discharge diagnosis was Femur Fracture. The skin assessment indicated "Abrasion forehead, ecchymosis [a discoloration of the skin FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1J8D11 Facility ID: CA020000092 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: _______________ 055775 (X3) DATE SURVEY COMPLETED 09/04/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ORINDA CARE CENTER, LLC 11 Altarinda Road Orinda, CA 94563 (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 resulting from bleeding underneath] face..." Review of the Narrative Course section indicated "Patient was mobilizing via wheelchair after dialysis this afternoon when she fell forward striking her knees first been reported onto the pavement...Underwent radiographic studies given reports of knee pain...findings of age-indeterminate nondisplaced slightly impacted fracture of the distal left femoral metaphysis [narrow portion of a long bone]..." During an interview with FD 1 on 8/15/18 at 1:39 p.m., FD 1 stated on 7/30/18 he took Resident 2 outside the dialysis center and parked Resident 2 outside the center. FD 1 went inside to get Resident 1 and left Resident 2 outside unattended. FD 1 then took Resident 1 from the center and wheeled her outside and parked Resident 1 in front of the dialysis center. FD 1 proceeded to bring Resident 2 to the van and left Resident 1 by herself outside the dialysis center, he looked back and saw Resident 1 on the floor and the dialysis centers' staff called 911. FD 1 stated it would be safer and secured if one resident was transferred at a time. Review of the facility policy "Falls and fall Risk, Managing" dated December 2007, indicated "based on previous evaluation and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling". FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1J8D11 Facility ID: CA020000092 If continuation sheet 4 of 4