Health inspection·March 18, 2024

F 0624 Prepare residents for a safe transfer or discharge from the nursing home. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure to discharge on e of three sample selected residents (Resident 1) safely to an appropriate place, when the facility discharged Resident 1 to an independent living facility while Resident 1 needed a higher level of care. Residents Affected - Few This deficient practice resulted in Resident 1 eloping (leaving a facility when doing so may present an imminent threat to the patient's health or safety) from the independent living facility and found by police wandering the streets resulting in hospitalization. Finding: A review of Resident 1's Face Sheet indicated, Resident 1 was admitted to the facility with multiple diagnoses including schizophrenia (a mental condition which makes it difficult to think clearly, have normal emotional responses, act normally in social situations, and tell the difference between what is real and what is not real), seizures (episodes of uncontrolled and abnormal firing of brain cells that can cause physical changes in attention or behavior such as uncontrollable shaking with rapid and rhythmic body movements), major depression and dementia (a loss of brain function that occurs with certain diseases, affecting one or more brain functions such as memory, thinking, language, judgment, or behavior). During a concurrent interview and record review on 2/15/24 at 11:14 a.m. with Social Worker (SW), SW reviewed the Social Services Notes and stated Resident 1 needed a higher level of care and that was a mistake to discharge Resident 1 to an independent living facility. During an interview on 2/15/24 at 11:30 a.m. with Medical Doctor (MD), MD stated Resident 1 needed supervision and should be discharged to a facility with a higher level of care than an independent living facility. A review of Resident 1's Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan), section C0700, dated 1/27/24, the MDS indicated Resident 1 had short term and long-term memory problems. A review of Resident 1's Care Plan for discharge, initiated 9/28/23, indicated .Goal, will be discharge to appropriate placement which will meet individualized care needs . A review of Resident 1's MD Progress Note, dated 12/17/2023, indicated . patient continued to be aggressive and violent, wanting to leave Against Medical Advice (AMA), patient doesn't have capacity due to dementia . (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 3 Event ID: 555418 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 555418 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Francis Healthcare Center 718 Bartlett Ave Hayward, CA 94541 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)