Other·December 12, 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 a standard abbreviated survey regarding investigation of entity reported incidents conducted on 12/7/18. For Entity Reported Incident CA00610366 regarding Accidents, a federal deficiency was identified (see F689). A Class B citation was also issued. Inspection was limited to the specific entity reported incidents investigated and does not represent the findings of a full inspection of the facility. Representing the California Department of Public Health: 34383, Health Facilities Evaluator Nurse.

F689 SS=G Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) 12/13/2018 §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 observation, interview, and record 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: 7OBK11 Facility ID: CA070000064 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: _______________ 055211 (X3) DATE SURVEY COMPLETED 12/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE IDYLWOOD CARE CENTER 1002 W Fremont Ave Sunnyvale, CA 94087 (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, the facility failed to follow the operating manual regarding a wheelchair lift (platform lift was a fully powered device designed to raise a wheelchair and its occupant in order to overcome a step) used in the facility's van for one of three sampled residents (Resident 1). This failure resulted in Resident 1 sustaining a laceration (a deep cut), nail damage, and a fracture of the left big toe. Findings: Review of Resident 1's clinical record indicated he was admitted 2/4/15 with diagnoses including diabetes (increase blood sugar), peripheral vascular disease (blood circulation disorder), and below knee amputation (surgical removal of the leg below the knee) on the right leg. Review of Resident 1's Minimum Data Set (MDS, an assessment tool) dated 8/8/18 indicated Resident 1 was cognitively intact (no memory problem), required assistance for transfer, bed mobility, locomotion off unit (walk in the corridor), toileting, and personal hygiene. Review of Resident 1's progress note dated 10/31/18, indicated Resident 1, who used a wheelchair went with the facility's van to his appointment on 10/31/18 at the acute hospital accompanied by the restorative nursing assistant A (RNA A). After the appointment Resident 1 sat in his wheelchair and was placed on the lift's ramp of the van with his feet facing towards the door of the van. When the driver lifted the ramp up, Resident 1's left foot was caught between the floor of the van's door entrance and the wheelchair lift. Review of the Resident 1's Situation, Background, Assessment, and Recommendation (SBAR, a technique that can FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7OBK11 Facility ID: CA070000064 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: _______________ 055211 (X3) DATE SURVEY COMPLETED 12/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE IDYLWOOD CARE CENTER 1002 W Fremont Ave Sunnyvale, CA 94087 (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 be used to facilitate prompt and appropriate communication) dated 10/31/18 indicated on 10/31/18, Resident 1's left big toe was swollen with bluish discoloration on the nail, minimal bleeding, skin tear, and nail avulsion (the excision of the body of the nail plate from its primary attachments). Resident 1 was transferred to the acute hospital. Review of the Resident 1's discharge instructions from the acute hospital on 10/31/18 indicated a laceration, nail damage, nail avulsion, and closed displaced fracture of the left great toe. During an observation and concurrent interview with Resident 1 on 11/7/18 at 1:45 p.m., Resident sat on his bed with a white dressing around his left foot. Resident 1 stated he had an appointment on 10/31/18 at the acute hospital, upon returning to the facility, he was lifted on the ramp up to the facility van and his left big toe was squeezed between the floor of the van and the wheelchair lift. Resident 1 stated it was so painful and happened too fast. He stated he was facing towards the door of the van when he entered the wheelchair lift and caught his big toe in between the floor of the van and the wheelchair lift. During an interview with the RNA A on 11/15/18 at 2:35 p.m., she stated she accompanied Resident 1 to his appointment on 10/31/18 and it was the facility driver (FD) who pushed Resident 1 on the wheelchair lift. RNA A confirmed Resident 1 was facing towards the door of the van when Resident 1 entered the wheelchair lift and his left big toe was caught in between the plates. She stated Resident 1 was wearing a sock and was not wearing a shoe on his left foot. During an interview with the FD on 11/15/18 at FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7OBK11 Facility ID: CA070000064 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: _______________ 055211 (X3) DATE SURVEY COMPLETED 12/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE IDYLWOOD CARE CENTER 1002 W Fremont Ave Sunnyvale, CA 94087 (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 3:30 p.m., he stated he pushed Resident 1, who was faced towards the door of the van, and when he turned the wheelchair lift on, Resident 1's left big toe was caught in between the two plates. FD stated he was trained by the previous facility driver in 2014 to place a resident facing towards the door of the van when a resident would enter the wheelchair lift. FD acknowledged he never read the operation manual for the wheelchair lift. During an interview with the maintenance supervisor (MS) on 11/15/18 at 3:00 p.m., he stated he helped the FD when transporting the residents to their appointments. MS stated he was not sure who trained FD how to use the wheelchair lift. There was no evidence of an inservice or training was provided to FD regarding the proper use of the wheelchair lift. MS also stated when taking residents to their appointments, residents were always facing towards the door of the van when they entered the wheelchair lift. During an interview and concurrent record review with the administrator (ADM) on 11/15/18 at 3:50 p.m., she acknowledged Resident 1 was facing towards the door of the van when Resident 1's left big toe was caught between the floor of the van and the wheelchair lift. ADM confirmed the operation manual for the use of the wheelchair lift indicated a resident should be faced outward to prevent a feet being caught between the facility's van and the wheelchair lift. She acknowledged Resident 1 should have been faced outward during his incident. The ADM also stated FD should have read the operation manual for the use of the wheelchair lift, so he would have been aware how to prevent accidents. Review of the, "Operator Manual for Personal Use Wheelchair Lift" dated 9/2001, indicated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7OBK11 Facility ID: CA070000064 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: _______________ 055211 (X3) DATE SURVEY COMPLETED 12/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE IDYLWOOD CARE CENTER 1002 W Fremont Ave Sunnyvale, CA 94087 (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 under "General Safety Precaution to read and thoroughly understand operating instructions before attempting to operate." "Wheelchair occupant should face outward when entering and exiting the vehicle". Carefully place wheelchair centrally on platform, and facing outward. Review of the facility's policy 9/2013, "Transporting Resident to Appointment", indicated the residents will be transported to appointments at an off site (different location) location in a safe manner. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7OBK11 Facility ID: CA070000064 If continuation sheet 5 of 5