Other·March 22, 2017

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following represents the findings of the California Department of Public Health during the investigation of an entity-reported incident. Entity-reported incident number: CA00511482 Representing the Department: Health Facilities Evaluator Nurse: 32717 The inspection was limited to the specific entity-reported incident investigated and does not represent the findings of a full inspection of the facility. One deficiency was issued for the entityreported incident: CA00511482

F323 SS=G FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES CFR(s): 483.25(d)(1)(2)(n)(1)-(3)

F323 (d) Accidents. The facility must ensure that (1) The resident environment remains as free from accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. (n) - Bed Rails. The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B3I511 Facility ID: 02000065 If continuation sheet 1 of 4 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555914 (X3) DATE SURVEY COMPLETED 03/08/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WE CARE SKILLED NURSING FACILITY 21863 Vallejo Street Hayward, CA 94541 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (1) Assess the resident for risk of entrapment from bed rails prior to installation. (2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation. (3) Ensure that the bed’s dimensions are appropriate for the resident’s size and weight. This REQUIREMENT is not met as evidenced by: Based on interview and record review, for one of two sampled residents (Resident 1), the facility failed to supervise Resident 2 (who had a neurological disorder that exhibited itself as a lack of impulse control) to prevent harm to Resident 1 when Resident 2 hit Resident 1 on his face, chest, and back. This failed practice resulted in Resident 2 hitting Resident 1 who sustained a bloody nose and mouth that required treatment at the hospital. Findings: Review of the "Minimum Data Set" (MDS - a comprehensive assessment tool used to guide resident care), dated 10/26/16, indicated Resident 1 was admitted to the facility with multiple diagnoses and required extensive to total assistance of staff for dressing, personal hygiene, and bathing. Review of the MDS, dated 9/15/16, indicated Resident 2 had a neurological disorder in which nerve cells in certain parts of the brain waste away, or degenerate. The disorder exhibits itself as a person's lack of awareness of their own behaviors and abilities, a lack of impulse control that can result in outbursts or acting FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B3I511 Facility ID: 02000065 If continuation sheet 2 of 4 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555914 (X3) DATE SURVEY COMPLETED 03/08/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WE CARE SKILLED NURSING FACILITY 21863 Vallejo Street Hayward, CA 94541 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE without thinking, and the tendency to get stuck on a thought, behavior, or action. The MDS also indicated Resident 2 had combative behavior related to poor impulse control, physical abuse, biting, and kicking. Review of the "Combative Behavior Care Plan," dated 3/16/15, indicated Resident 2 had poor impulse control, anger, agitation, and biting, kicking, and hitting others. The care plan also indicated, to protect Resident 2 and others, the facility would monitor episodes of Resident 2's combative behavior and remove Resident 2 from the situation when combative. During a telephone interview with Licensed Vocational Nurse (LVN 1) on 3/3/17, at 9:48 a.m., LVN 1 stated Resident 1 and Resident 2 were roommates. LVN 1 stated on 11/16/16, at 7 a.m., she heard Resident 1 state "get off my bed." LVN 1 stated she went to check on both residents in their room and saw Resident 2 sitting on Resident 1's bed while Resident 1 was lying in bed. LVN 1 stated Resident 2 got up, left the room to go the bathroom across the hall and went back to his room. LVN 1 stated within minutes she heard a pounding noise that came from the Resident 1 and 2's room. LVN 1 went to check again and saw Resident 2 over Resident 1 hitting him everywhere. LVN 1 stated Resident 2 swung back at her when LVN 1 attempted to stop Resident 2. LVN 1 stated Resident 2 stopped hitting Resident 1, left the room, paced the hall, and then went back to the room and hit Resident 1. LVN 1 stated Resident 1 had multiple bruises on his face, chest, back, and was bleeding across the nose bridge. LVN 1 stated Resident 1 told her "he (Resident 2) hit me, he hit me." LVN 1 also stated Resident 1 was transferred to the hospital. LVN 1 further stated Resident 2 was known to be physically aggressive to different people on multiple occasions, but "you never FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B3I511 Facility ID: 02000065 If continuation sheet 3 of 4 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555914 (X3) DATE SURVEY COMPLETED 03/08/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WE CARE SKILLED NURSING FACILITY 21863 Vallejo Street Hayward, CA 94541 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE know what sets him off." Review of the "Nurse's Notes," dated 9/30/16, indicated that during the night shift, Resident 2 became agitated and grabbed the licensed nurse by the left shoulder, chased a CNA across the hallway toward a resident's room, and chased a different CNA out of the building. Resident 2 was sent to the hospital following this incident. The Nurse's Notes also indicated the Director of Nursing (DON) and Administrator (ADM) were notified and an incident report was completed. During a telephone interview with Certified Nursing Assistant (CNA 1) on 12/1/16, at 11 a.m., CNA 1 stated the incident on 11/16/16 was not the first one that involved Resident 2. CNA 1 stated over a month ago, Resident 2 attacked her and she had to lock herself in one of the resident rooms. CNA 1 stated Resident 2 chased another CNA out of the building. Review of the aftercare instructions from the hospital dated 11/16/16 showed Resident 1 had diagnoses that included contusions (a region of tissues where blood vessels have been ruptured) of nose and face. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B3I511 Facility ID: 02000065 If continuation sheet 4 of 4