Princeton Manor Healthcare Center, Llc

F 0600

the P&P Indicated, The Facility does not condone and form of resident abuse, neglect, misappropriation of resident property, exploitation, and/or mistreatment.

Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/20/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Princeton Manor Healthcare Center, LLC

2124 57th Avenue Oakland, CA 94621

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)

F 0689 Level of Harm - Actual harm Residents Affected - Few

During a telephone interview on 10/2/24 at 5:43 p.m. with CNA 5, CNA 5 stated he saw Resident 63 at 11:30 p.m. on the bed with his cap on. CNA 5 stated he then went to his position in the hallway. CNA 5 stated there was a resident from the back location walking around. CNA 5 stated LVN 8 asked him to take

the resident back to his room around 1:30 p.m. – 2 a.m. CNA 5 stated it took him maybe 20 minutes or less than 30 minutes to take that patient to his room. CNA 5 stated he came back around 2 a.m., and it occurred to him to check his residents. CNA 5 stated Resident 63 used to get up and wander around from 2 a.m. to 4 a.m. CNA 5 stated he looked in Resident 63's room and did not find him. He made LVN 8 aware, and they checked the bathroom and patio. He stated the other CNAs also searched for Resident 63. CNA 5 stated he did not know if Resident 63 had a wanderguard, and there was no sound of alarm during the night. He stated staff do not use the side door and the side door is always locked. CNA 5 stated resident 63 had history of elopement but not in the facility and this was his first time. CNA 5 stated the interventions the facility had in place for Resident 63 to prevent elopement were to just to be alert and to check on Resident 63 at least every two hours. CNA 5 stated only CNAs checked the residents, and the charge nurse sometimes reminded them about doing rounds. CNA 5 acknowledged they were supposed to check the resident at least every two hours, and he should have checked Resident 63 at 1:30 a.m. and anything could have happened within the 30 minutes of not checking Resident 63.

During a telephone interview on 10/2/25 at 6:55 p.m. CNA 5 (who was assigned to Resident 63 the night he eloped) stated that rounding every two hours was important to ensure the residents are okay, on their beds sleeping, and safe.

During the facility's Policy and Procedure (P&P) titled, Policy and Procedure Implementation Form – Person-Centered Care Planning, dated August 2017, the P&P indicated The facility must develop and implement a comprehensive person-centered care plan for each resident consistent with the resident rights that includes measurable objectives, and timeframes to meet a resident' s medical, nursing, mental, and psychological needs that are identified in the comprehensive assessment.

During a review of the care plan initiated on 6/13/25, Resident 63's care plan indicated, Risk for wandering/elopement identified, use of wanderguard with goals: The resident will not leave facility unattended, the resident's safety will be maintained, and the facility will not leave the facility unaccompanied. The care plan indicated the wanderguard on the right wrist. Resident 63's care plan did not include checking on the resident every 2 hours by facility staff.

During review of the facility's policy and procedure (P&P) titled, Wandering and Elopement revised 1/31/23,

the P&P indicated, The licensed nurse, in collaboration with the .(IDT), will assess residents.and upon identification of significant change in condition according to the to determine their risk of elopement.The resident's risk for elopement and preventative interventions will be documented.and will be reviewed and re-evaluated by the IDT.and upon change in condition.The IDT will develop a plan of care considering the individual risk factors for the resident.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet