San Leandro Healthcare Center

In the surveyor’s words

From the most serious findings on record at San Leandro Healthcare Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF800Nov 17, 2022

  Based on observation, interview and record review, the facility failed to ensure 37 out of 37 residents with regular diet received enough protein on a regular basis. This practice failure had a potential of malnutrition and protein deficiency for 37 residents on regular diet who were residing at the facility. Findings: During a concurrent observation and interview on 11/15/22 at 11:30 a.m., in the kitchen with Dietary Manager (DM), staff prepared dishes to serve residents with regular diet, fish was measured by the facility's scale and the weight of the fish was 2.1 oz (ounce, measurement) instead of 3 oz for regular diet. DM stated it was important to follow the protein measurements in the recipes because residents could have malnutrition or lose weight. […]

• No harm, potential for more than minimal, patternF847Nov 7, 2024

  Based on observation, interview, and record review, the facility failed to verify that residents understood binding arbitration agreements (a formal method of dispute resolution where a third party makes a decision instead of the dispute going to court) and/or that they were aware they could rescind the agreement within 30 days for 3 of 3 sampled residents (Resident 18, Resident 13, and Resident 49). This failure had the potential for residents to enter into an agreement without understanding their rights. […]

• No harm, potential for more than minimal, patternF848Nov 7, 2024

  Based on observation, interview, and record review, the facility failed to provide a binding arbitration agreement (a formal method of dispute resolution where a third party makes a decision instead of the dispute going to court) that met the regulations. This failure had the potential for residents to enter into an agreement that did not protect their rights. Findings: During a review of the arbitration agreement made between the facility and three randomly selected residents (Resident 18, Resident 13, and Resident 49), the arbitration agreement for all three residents did not provide for the selection of a neutral arbitrator agreed upon by both parties and/or provide for the selection of a venue that is convenient to both parties. […]

• No harm, potential for more than minimal, patternF558Nov 17, 2022

  Based on observation, interview and record review, the facility failed to ensure two of two sample selected non-English speaking residents (Resident 108 and 110) had an appropriate communication system in place when Residents 108 and 110 did not have a written translation of vital information (communication board) at the bed side. This failed practice resulted in Residents 108 and 110 not being able to communicate effectively with staff and to express their needs. Findings: A review of Resident 108's Admission Record indicated Resident 108 was admitted to the facility with diagnosis of Hepatic encephalopathy (syndrome of impaired brain function occurring in patients with advanced liver diseases). […]

• No harm, potential for more than minimal, patternF695Nov 17, 2022

  Based on observation, interview and record review, the facility failed to follow its policies and procedures for oxygen administration and ensure oxygen supplies were maintained according to the operator's manual for three (Resident 39, 5, and 20) of four sampled residents receiving oxygen therapy, when staff did not document oxygen flow and rationale of Resident 39's oxygen therapy and Resident 39, 5, and 20's oxygen concentrator (an electronically operated device that separates oxygen from room air and provides high concentration of oxygen directly through a nasal cannula, a lightweight tube with one end split into two prongs which are placed in the nostrils and from which a mixture of air and oxygen flows) filter was covered with a thick layer of gray, fluffy matter. […]