San Leandro Healthcare Center

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and record review, for one of two sampled residents (Resident 1), the facility failed to ensure Resident 1 was treated with respect and dignity when Certified Nursing Assistant (CNA) 1 loudly argued with Resident 1.This failure had resulted in Resident 1's emotional distress. During a review of Resident 1's admission Record (AR) dated 11/18/25, the AR indicated Resident 1 was admitted to the facility in August 2025 with diagnoses that included major depressive disorder (a mental health condition causing persistent sadness, hopelessness, and loss of interest in activities, significantly impacting daily life) and post-traumatic stress disorder (a mental health condition that can develop after experiencing or witnessing

a traumatic event, such as combat, assault, or a natural disaster).During a review of Resident 1's Minimum Data Set (MDS, an assessment tool used to direct resident care) assessment dated [DATE REDACTED], the MDS indicated a Brief Interview for Mental Status (BIMS, a scoring system used to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information) score of 15.

A BIMS score of 13-15 is an indication of intact cognitive status.During a telephone interview on 11/19/25 at 11:45 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated hearing loud arguing around midnight

on 9/17/25. LVN 1 stated she separated Resident 1 and CNA 1, who were arguing. Resident 1 said he requested CNA 1 to unlock the bathroom door, but CNA 1 did not assist. LVN 1 stated both Resident 1 and CNA 1 became somewhat aggressive, and she heard CNA 1 tell Resident 1 to go to his room and return to sleep in a loud manner. However, Resident 1 calmed down after being separated.During a telephone

interview on 11/18/25 at 3:36 p.m. with CNA 1, CNA 1 repeatedly stated during the interview that Resident 1 refused to listen after CNA 1 explained that the bathroom door was not locked.During a review of Resident 1's Interdisciplinary Team (IDT, a group composed of individuals from different departments of the facility) Note dated 9/17/25, the IDT Note indicated Resident 1 had a verbal altercation with CNA 1, resulting in Resident 1 feeling threatened and unable to sleep through the night.During a review of the facility's policy and procedure (P&P) titled Dignity last revised February 2021, the P&P indicated that each resident shall be cared for in a manner that promotes feelings of self-worth and self-esteem and sense of well-being. Staff are required to always speak to residents respectfully.

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

Event ID:

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

11/26/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

San Leandro Healthcare Center

368 Juana Avenue San Leandro, CA 94577

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 0553 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

Allow resident to participate in the development and implementation of his or her person-centered plan of care. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and record review, for one of two sampled residents (Resident 2), the facility failed to ensure Resident 2 was afforded the right to participate in the care planning process when care conference meeting was not scheduled despite repeated requests from Resident 2's representative.This failure had the potential to result in Resident 2 being uninformed about treatment objectives and care plan.During a review of Resident 2's admission Record (AR), the AR indicated Resident 2 was admitted to the facility in March 2025 with diagnoses that included cognitive communication deficit (a difficulty with communication caused by impairments in cognitive functions like memory, attention, and problem-solving, rather than by problems with speech or language), age-related cognitive decline (a natural slowdown in thinking and memory that occurs with aging), and epilepsy (a brain disorder characterized by recurrent seizures, which are temporary disruptions in brain activity). The AR also indicated Resident Representative (RR) 1 was responsible for Resident 2's care.During a concurrent interview and review of Resident 2's Social Service Notes on 11/18/25 at 10:47 a.m. with Social Worker (SW), SW stated Long Term Care Ombudsman (LTCO) 1 requested a care plan meeting with RR 1 and Resident 2 via email. SW stated the meeting was initially scheduled for 10/28/25 at 10 am but was postponed to 11/3/25 because Resident 2 was hospitalized from [DATE REDACTED] to 10/30/25. Although Resident 2 returned to the facility on [DATE REDACTED] and RR 1 informed SW of Resident 2's return on 11/1/25, no confirmation or discussion about the rescheduled care plan meeting occurred. Resident 2 remained in the facility from 10/30/25 until being taken to the hospital again on 11/12/25, without a care plan meeting being held. There was no documentation of any coordination for setting up the meeting in the clinical record.During a telephone interview on 11/19/25 at 10:14 a.m. with LTCO, LTCO stated sending SW an email to request a care plan meeting with RR 1 and Resident 2. LTCO stated SW did not reply until the morning of 10/30/25, informing LTCO that Resident 2 was still in the hospital. LTCO stated reaching out again on 11/3/25 to ask if any care plan meetings had been scheduled.

LTCO stated on 11/17/25, RR 1 informed LTCO that no meeting had been scheduled. LTCO stated the facility was trying to discharge Resident 2 and RR 1 wanted updates on the discharge plan and process.

During a follow-up interview on 11/18/25 at 12:33 p.m. with SW, SW stated the receptionist on duty will call

the resident's family to arrange a care plan meeting upon admission. SW could not show any documentation in the clinical record of any scheduled care plan meeting in the clinical record.During an

interview on 11/19/25 at 10:42 a.m. with Receptionist (REC) 1, REC 1 stated, initial care conferences are scheduled by the receptionist on duty for newly admitted residents. For Resident 2, who was not a newly admitted resident, and was only returning from the hospital, it was the responsibility of SW to schedule the subsequent care conference meeting.During a review of the facility's policy and procedure (P&P) titled Resident Participation-Assessment/Care Plans last revised February 2021, the P&P indicated: The residents and any legal representative are encouraged to attend and participate in the development of the person-centered care plan . The resident and the resident's representative's right to participate includes the right to request meetings . The facility provides sufficient notice in advance of the meeting.

Event ID:

Facility ID:

If continuation sheet