Health inspection·August 26, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on interview and record review, the facility failed to ensure adequate supervision of two of three sampled residents (Resident 1 and Resident 2). Residents Affected - Few The facility failed to ensure the two residents who were roomed together and had the same surname were properly identified by facility staff before initiating a transfer for dialysis treatment. The facility failed to ensure staff properly identified Resident 1 so Resident 1 could be sent for dialysis treatment (a treatment for kidney failure to remove waste products and excess fluids by external filtration of blood). These failures resulted in Resident 2 being unnecessarily transported to the dialysis center, and a one-hour delay in pick-up for Resident 1's dialysis treatment. For Resident 1, the one-hour delay in pick-up for dialysis had the potential to result in shortened or unavailable dialysis treatment. For Resident 2, the unnecessary trip caused emotional distress. Findings: A review of Resident 1's admission Record, undated, indicated Resident 1 was admitted to the facility with multiple diagnoses including end stage renal disease (a permanent condition where the kidneys are no longer able to function and filter waste from the blood. This leads to a buildup of toxins in the body that can be life-threatening if not treated with dialysis or a kidney transplant). The admission Record indicated Resident 1 had a family member as the responsible party. A review of Resident 1's physician Order Summary Report, dated active orders 8/19/24, indicated an order with start date 8/14/24, for a dialysis schedule three times a week on Tuesday, Thursday and Saturday. The order indicated Resident 1 should be picked up for dialysis between 7:20 a.m. and 7:50 a.m.; dialysis treatment time from 8:15 a.m. to 12:15 p.m.; return to facility 12:15 p.m. to 12:45 p.m. During an interview on 8/26/24 at 11:52 a.m. with the Director of Nursing (DON), the DON stated when Resident 1 was admitted the only bed available was in the same room as Resident 2. The DON stated both Resident 1 and Resident 2 had the same surname. During an interview on 8/26/24, at 12:33, with the Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 2 was sent to dialysis instead of Resident 1 on 8/17/24. LVN 1 stated the transport crew arrived to take Resident 1 to dialysis while LVN 1 was reporting off to the oncoming shift. LVN 1 stated LVN 1 had showed the transport crew Resident 1's room location but did not go into the room to identify Resident 1 to the transport crew. (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: 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 08/26/2024 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)