Health inspection·March 27, 2024

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1) received showers per shower schedule. Resident 1 received only one shower in more than two weeks long stay at the facility. Residents Affected - Few This failure placed Resident 1 at risk for lack of cleanliness and comfort. Findings: During a review of Resident 1 ' s admission Record, printed on 3/27/24, the admission Record indicated Resident 1 was admitted to the facility on [DATE] and discharged from the facility on 2/09/24. During a record review of Resident 1 ' s Minimum Data Set (MDS, a resident assessment tool used to guide care) dated 2/13/24, the MDS assessment Section GG - Functional Abilities and Goals showed Resident 1 needed a setup or clean-up assistance (the helper assists prior to or following the activity) for shower. During a review of Resident 1 ' s Activities of Daily Living (ADL) Care plan dated 3/27/24, the care plan showed Resident 1 had an ADL self-care performance deficit and was at high risk for decline in functional limitations and contractures; and the facility was to keep Resident 1 clean, dry and well-groomed. During an interview on 3/27/24 at 12:28 p.m., Licensed Vocational Nurse (LVN 1) stated providing showers to residents and documenting their refusal of showers was only Certified Nursing Assistants (CNA) ' s responsibility. LVN 1 stated CNAs would notify her residents ' refusal of care only if they needed her help convincing the resident to take shower. During an interview on 3/27/24 at 12:41 p.m. with Certified Nurse Assistant (CNA 2), CNA 2 stated when a resident refused a shower, she would inform the nurse, document resident ' s refusal on the shower sheets and in residents ' electronic health record. CNA 2 stated providing showers to residents was important to prevent skin issues and infection; and for them to smell good. During an interview on 3/27/24 at 2:14 p.m., with the Director of Nursing (DON), DON stated when a resident refuses a shower, the CNAs should notify the nurses and they must document it in their nurse ' s progress notes. DON also stated the nurses should inform the resident ' s responsible party and their attending physician if the resident keeps refusing to receive showers. During a concurrent interview and record review on 3/27/24 at 2:50 p.m., with DON, Resident 1 ' s (continued on next page) 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. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 555341 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555341 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canyon Creek Post-Acute 22103 Redwood Road Castro Valley, CA 94546 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)