Other·January 16, 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 entity reported incidents. Entity Reported Incident: CA00557916 Entity Reported Incident: CA00558901 Representing the Department: HFEN 38533 and 39074. No deficiencies were issued for entity reported incident CA00557916. One deficiency was issued for entity reported incident CA00558901.

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

F323 01/05/2018 (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. (1) Assess the resident for risk of entrapment 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: JS4J11 Facility ID: CA020000321 If continuation sheet 1 of 7 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: _______________ 056479 (X3) DATE SURVEY COMPLETED 12/22/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALAMEDA COUNTY MEDICAL CENTER D/P SNF 15400 Foothill Boulevard San Leandro, CA 94578 (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 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 observation, interview and record review, for one of four sampled residents (Resident 1) the facility failed to provide supervision to prevent accidents when: 1. Certified Nursing Assistant (CNA) 1 left Resident 1 unsupervised in front of the facility and Resident 1 eloped (left the facility's property without permission), and; 2. the facility did not monitor the functionality of Resident 1's individual WanderGuard (a system that tracks the person using a wrist or ankle band and automatically locks doors or alarms if the person moves outside a defined area) device or the functionality of the WanderGuard door monitors (three of 12 door monitors did not sound an alarm). These failures had the potential to result in serious injuries or harm for the six residents in the facility with WanderGuards. It was determined to constitute an Immediate Jeopardy (IJ) situation. The Administrator (ADM), Chief Administrative Officer (CAO) and Director of Nursing (DON) were verbally notified of the Immediate Jeopardy (IJ) on 11/1/17, at 5:16 p.m. The facility failed to provide adequate monitoring for Resident 1 who wore an individual WanderGuard device and the facility did not FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JS4J11 Facility ID: CA020000321 If continuation sheet 2 of 7 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: _______________ 056479 (X3) DATE SURVEY COMPLETED 12/22/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALAMEDA COUNTY MEDICAL CENTER D/P SNF 15400 Foothill Boulevard San Leandro, CA 94578 (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 have fully functioning WanderGuard system. Through interviews with the staff members and record reviews of the facility's in-service records, the facility showed they initiated the plan of action through in-services of employees regarding WanderGuard placement and monitoring. The facility repaired the nonfunctioning WanderGuard door monitors at the three exit doors. The IJ was abated on 11/1/17 at 7:23 p.m. Findings: 1. Review of the Resident Face Sheet indicated Resident 1 was admitted to the facility on 8/11/17. Review of Resident 1's Minimum Data Set (MDS - an assessment tool used to guide care), dated 8/17/17, indicated Resident 1 was able to recall and repeat words and knew the correct year and month. Resident 1's MDS also indicated he required supervision (oversight, encouragement, or cueing) with locomotion (movement) on and off the unit. Further review of Resident 1's MDS indicated he had active diagnoses that included dementia (progressive memory loss). During an interview with CNA 1 on 10/31/17, at 12:34 p.m., CNA 1 stated that on 10/29/17, she was not aware Resident 1 was off the unit until she transported another resident outside to smoke and noticed Resident 1 was outside smoking in front of the building. CNA 1 stated Resident 1 had an individual WanderGuard on his wrist. CNA 1 stated she asked Resident 1 if he wanted to come upstairs for lunch, and he said no. CNA 1 stated the second time she went outside to check on Resident 1, he was not there and CNA 1 stated she then notified Registered Nurse (RN) 1. CNA 1 stated she FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JS4J11 Facility ID: CA020000321 If continuation sheet 3 of 7 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: _______________ 056479 (X3) DATE SURVEY COMPLETED 12/22/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALAMEDA COUNTY MEDICAL CENTER D/P SNF 15400 Foothill Boulevard San Leandro, CA 94578 (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 and RN 1 looked for Resident 1 inside and outside the facility but did not find him. During an interview with CNA 1 on 11/1/17, at 2:45 p.m., CNA 1 stated she was aware Resident 1 required supervision. CNA 1 stated she should have reported Resident 1 being outside to the charge nurse when she first noticed him outside. Review of Resident 1's Care Plan, dated 8/14/17, indicated Resident 1 had impaired mobility and was to ambulate (walk) with general supervision on the nursing unit with a WanderGuard. Resident 1's Care Plan, dated 8/17/17, indicated he was to wear a WanderGuard while on the unit, and was to be supervised if he left the unit. Resident 1's Care Plan, dated 8/24/17, indicated he had confusion and wandering behaviors and staff were to act quickly when the WanderGuard alarm was activated and to redirect or reorient Resident 1. During an interview with Registered Nurse (RN) 1 on 10/31/17, at 12:13 p.m., RN 1 stated that on 10/29/17, at 1:40 p.m., Certified Nurse Assistant (CNA) 1 informed her Resident 1 was not in the outside smoking area when she went to look for him at 1:30 p.m. RN 1 stated CNA 1 also told her she (CNA 1) last saw Resident 1 at 12:30 p.m. in the smoking area. RN 1 stated she and CNA 1 looked inside and outside the facility, but did not find Resident 1. During an interview with the Charge Nurse (CN) on 11/1/17, at 1:51 p.m., the CN stated Resident 1 should have been supervised by a staff member when Resident 1 was off the unit. The CN stated the staff should know residents with individual WanderGuards need supervision. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JS4J11 Facility ID: CA020000321 If continuation sheet 4 of 7 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: _______________ 056479 (X3) DATE SURVEY COMPLETED 12/22/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALAMEDA COUNTY MEDICAL CENTER D/P SNF 15400 Foothill Boulevard San Leandro, CA 94578 (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 the facility's investigation summary, dated 11/2/17, indicated CNA 1 attempted to redirect Resident 1 back to the unit, but Resident 1 wanted to stay outside. The investigation summary also indicated CNA 1 stated she left Resident 1 outside, and Resident 1 left the campus. Review of Resident 1's Clinical Notes (Notes), dated 10/29/17, at 2:12 p.m., indicated CNA 1 last saw Resident 1 (on 10/29/17) at 12:15 p.m. in the smoking area in front of the facility. 2. In an observation 11/1/17, at 12:15 p.m., the ADM, DON, and the Nurse Manager (NM) tested an individual WanderGuard device at exit doors with WanderGuard door monitors. During testing at the following dates and times, the WanderGuard alarm was not activated at the following locations with WanderGuard door monitors: 1. 11/1/17, at 12:18 p.m. - First floor exit door between units B1 and B2; 2. 11/1/17, at 12:22 p.m. - First floor exit door 200, and; 3. 11/1/17, at 12:32 p.m. - Second floor exit door 300. During an interview with the DON and ADM on 11/1/17, at 12:40 p.m., the DON and ADM stated the WanderGuard device should have activated the sensor alarm at all the exit doors with WanderGuard door monitors. During an interview with the DON and ADM on 11/1/17/17, at 11:57 a.m., the DON stated the facility did not have a standardized method of monitoring the WanderGuard alarm system (individual monitoring devices or the door monitors). The ADM stated she thought the facility's engineering team monitored the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JS4J11 Facility ID: CA020000321 If continuation sheet 5 of 7 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: _______________ 056479 (X3) DATE SURVEY COMPLETED 12/22/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALAMEDA COUNTY MEDICAL CENTER D/P SNF 15400 Foothill Boulevard San Leandro, CA 94578 (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 WanderGuard alarm system. The ADM further stated the facility did not have a policy and procedure for the WanderGuard alarm system. Review of the WanderGuard system device manufacturer's instructions indicated "...Band attachment instructions...Make daily inspections to confirm the band is in place and is not damaged in any way...Testing the signaling device...test each signaling device before using...test the device daily and record the results in the resident's records...Testing without a signaling device tester 1. Move the signaling device within (three feet) of a properly operating door monitor. 2. Open the door or activate the passive infrared (PIR) device. The alarm will sound if the signaling device is functioning properly. 3. Move signaling device away from the monitored area and reset alarm...." During an interview with Engineering Services Manager (ESM) on 11/1/17 at 1:32 p.m., EMS stated the WanderGuard system was monitored and tested once a year. EMS stated the WanderGuard sensor (door monitor) at exit door 200 was painted over and that was the cause of the malfunction for exit door 200. EMS stated his department does not keep up with the day to day maintenance of the WanderGuards. During an interview with ESM on 11/1/17, at 2:26 p.m., the ESM stated the facility did not have a portable device to check the function of the WanderGuard alarm system. The ESM stated he did not have a log of when the WanderGuard alarm system was checked. Review of a facility email document titled, WanderGuard Install Update, dated 11/1/17, indicated the facility's WanderGuard system was last completed and tested (the vendor FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JS4J11 Facility ID: CA020000321 If continuation sheet 6 of 7 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: _______________ 056479 (X3) DATE SURVEY COMPLETED 12/22/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALAMEDA COUNTY MEDICAL CENTER D/P SNF 15400 Foothill Boulevard San Leandro, CA 94578 (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 physically demonstrated to the facility the completed work with functional tests of each operating device) on 7/2/17. During an interview with the Charge Nurse (CN) on 11/1/17, at 1:40 p.m., the CN stated the facility does not have a process in place for monitoring the WanderGuard alarm system. The CN was not able to show documentation that Resident 1's individual WanderGuard was monitored. During an interview with DON and Chief Administrative Officer (CAO) on 11/1/17, at 2:53 p.m., the DON and CAO stated they did not know how long the WanderGuard system had not been functioning properly. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JS4J11 Facility ID: CA020000321 If continuation sheet 7 of 7