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: CA00523163 Representing the Department: Health Facilities Evaluator Nurse: 36738 The inspection was limited to the specific entity reported incident investigated and does not represent the findings of a full inspection of the facility. The deficiencies at F223 and F226 were Immediate Jeopardy potentially affecting all the residents in the facility. Resident Census: 30

F223 SS=L FREE FROM ABUSE/INVOLUNTARY SECLUSION CFR(s): 483.12(a)(1)

F223 03/08/2017 483.12 The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident’s symptoms. 483.12(a) The facility mustLABORATORY 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: 2N9311 Facility ID: 02000065 If continuation sheet 1 of 11 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 02/21/2017 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 (a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion; This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to protect one Resident (Resident 1) from physical abuse when Certified Nursing Assistant (CNA) 1 CNA 1 struck Resident 1 in the head and back. These failed practices resulted in Resident 1 being "afraid to go to sleep when (CNA 1) was in the facility." This failed practice had the potential to expose the 30 residents residing in the facility to further abuse. On 2/21/17, at 7 p.m., Immediate Jeopardy (IJ) was called. The Administrator (ADM), the Director of Nursing (DON), and the Temporary Manager (TM) were verbally notified of the IJ regarding physical abuse of Resident 1 by CNA 1. The IJ was not lifted on 2/21/17, at 7:11 p.m. The Administrator was not able to provide an acceptable plan of correction to the Department. Findings: During an interview with Resident 1 on 2/21/17, at 12 p.m., Resident 1 stated Certified Nursing Assistant (CNA) 1 hit her twice. Resident 1 stated the first time CNA 1 hit her, he hit her on the back of the head. The second time, Resident 1 stated while pointing at her back, CNA 1 hit her on the back. Resident 1 stated, "It's scary, I'm afraid to go to sleep as long as he is here". FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2N9311 Facility ID: 02000065 If continuation sheet 2 of 11 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 02/21/2017 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 Review of the "Nurse's Notes," dated 2/20/17, at 11 a.m. indicated "was notified by social services to do an assessment of (Resident 1). Was told by Social Services (SS 1) that (Resident 1) had stated that she was hit by of of the CNAs..." Review of the "Nurse's Notes," dated 2/20/17, at 12:28 p.m., indicated Resident 1 stated "It's pain when it happens and he really used a heavy hand. I don't think he'll be back." The Nurse's Notes also indicated Resident 1 stated the man who used a heavy hand was wearing "red." During an interview with the Administrator (ADM) on 2/21/17, at 11:55 a.m., the ADM stated Resident 1 told him and the Temporary Manager (TM) that she was hit in the head and beaten up. The ADM stated the TM told him to send CNA 1 home. During a telephone interview with the TM, on 2/21/17, at 11 a.m., the TM stated that on 2/20/17, Resident 1 came to the DON's office and Resident 1 stated she had been hit in the back of the head and was afraid. The TM stated the resident identified CNA 1 as the man in red who hit her. The TM stated the ADM told her Resident 1 was confused, and he did not want to listen to Resident 1. During an interview with the TM on 2/21/17, at 6:35 p.m., The TM stated the ADM tried to remove Resident 1 from the DON's as she was trying to report being hit in the head. The TM stated the ADM did not want to send CNA 1 home because he did not know if CNA 1 did anything to Resident 1 and the facility needed CNA 1 to work or they would be short-handed (lacking the needed number of nursing staff). The TM stated she told the ADM to send CNA 1 home. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2N9311 Facility ID: 02000065 If continuation sheet 3 of 11 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 02/21/2017 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 Review of the facility's undated policy and procedure titled, "Abuse Prevention" indicated "...Abuse...will not be tolerated in this facility at any time. Every Resident has the right to be free from...physical abuse. Residents must not be subjected to abuse by anyone...Identification of Abuse: Observations, suspicious, or reporting of...bruises (of suspicious or unknown origin) will be investigated to rule out abuse." See F226 for additional information.

F226 DEVELOP/IMPLMENT ABUSE/NEGLECT, FORM CMS-2567(02-99) Previous Versions Obsolete

F226 Event ID: 2N9311 03/08/2017 Facility ID: 02000065 If continuation sheet 4 of 11 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 02/21/2017 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) SS=L ETC POLICIES CFR(s): 483.12(b)(1)-(3), 483.95(c)(1)-(3) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 483.12 (b) The facility must develop and implement written policies and procedures that: (1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, (2) Establish policies and procedures to investigate any such allegations, and (3) Include training as required at paragraph §483.95, 483.95 (c) Abuse, neglect, and exploitation. In addition to the freedom from abuse, neglect, and exploitation requirements in § 483.12, facilities must also provide training to their staff that at a minimum educates staff on(c)(1) Activities that constitute abuse, neglect, exploitation, and misappropriation of resident property as set forth at § 483.12. (c)(2) Procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property (c)(3) Dementia management and resident abuse prevention. This REQUIREMENT is not met as evidenced by: Based on interview and record review for two of three sampled residents (Resident 1 and 2) the facility failed to implement their policies and procedures for protection of residents and for the prevention, identification, investigation, and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2N9311 Facility ID: 02000065 If continuation sheet 5 of 11 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 02/21/2017 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 reporting of abuse. The Administrator (ADM), Licensed Vocational Nurse (LVN 1) and Certified Nursing Assistant (CNA 2) did not report or investigate Resident 1's allegation of abuse and an incident of suspicious red marks. The Activities Assistant (AA), LVN 1, and CNA 1 and 2 did not report Resident 2's allegation of being slapped or the two incidents of suspicious red marks and one incident of bruising. These failed practices resulted in one Resident (Resident 1) being hit in the head or the back on several occasions and feeling "...afraid to go to sleep..." when Certified Nursing Assistant (CNA 1) was working. Resident 2 receiving leg bruising and facial red marks on several occasions and screaming " ...he (CNA 1) hit me, I wanna die, and they wanna kill me...." These failed practices had the potential to expose the 30 residents residing in the facility to further abuse. On 2/21/17, at 7 p.m., Immediate Jeopardy (IJ) was called. The Administrator (ADM), the Director of Nursing (DON), the Temporary Manager (TM), and Licensed Vocational Nurse (LVN 2) were verbally notified of the IJ regarding the facility staffs' failures to report and investigate alleged Resident abuse. The IJ was not lifted on 2/21/17, at 7:11 p.m. The Administrator was not able to provide an acceptable plan of correction to the Department. Findings: 1. During an interview with the Administrator (ADM) on 2/21/17, at 11:55 a.m., the ADM stated Resident 1 told him and the Temporary Manager (TM) that she was hit in the head and beaten up. The ADM stated the TM told him FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2N9311 Facility ID: 02000065 If continuation sheet 6 of 11 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 02/21/2017 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 to send CNA 1 home. During a telephone interview with the TM, on 2/21/17, at 11 a.m., the TM stated that on 2/20/17, Resident 1 came to the DON's office and Resident 1 stated she had been hit in the back of the head and was afraid. The TM stated the resident identified CNA 1 as the man in red who hit her. The TM stated the ADM told her Resident 1 was confused, and he did not want to listen to Resident 1. During an interview with the TM on 2/21/17, at 6:35 p.m., The TM stated the ADM tried to remove Resident 1 from the DON's as she was trying to report being hit in the head. The TM stated the ADM did not want to send CNA 1 home because he did not know if CNA 1 did anything to Resident 1 and the facility needed CNA 1 to work or they would be short-handed (lacking the needed number of nursing staff). The TM stated she told the ADM to send CNA 1 home. During an interview with Resident 1 on 2/21/17, at 12 p.m., Resident 1 stated Certified Nursing Assistant (CNA) 1 hit her in the back of the head, and that had also done it before, while she was in her room with her roommate (Resident 2). Resident 1 pointed at her back with the back of her hand and stated CNA 1 "...hit me in the back the second time and ran out of the room, then he came back like nothing happened." Resident 1 continued and stated, "It's scary, I'm afraid to go to sleep as long as he is here". In an interview with Licensed Vocational Nurse (LVN) 1 on 2/21/17, at 12:23 p.m., LVN 1 stated she did not report to the Director of Nursing (DON) when Resident 1 had red marks on her face about two months ago. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2N9311 Facility ID: 02000065 If continuation sheet 7 of 11 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 02/21/2017 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 During an interview with LVN 1 on 2/21/17, at 3:30 p.m., LVN 1 stated that CNA 2 told her that when CNA 1 showered a resident, the resident would have red marks on their bodies. LVN 1 also stated that CNA 2 told her she had "said something before, but nothing is ever done." 2. During an interview with Certified Nursing Assistant (CNA 2) on 2/21/17, at 12:41 p.m., CNA 2 stated that whenever CNA 1 cared for a resident they end up with red marks on them. CNA 2 stated she and the Activities Assistant (AA) noticed Resident 2 had red cheeks about four or six months ago. CNA 2 also stated Resident 2 went into the activities room " ...and started screaming he (CNA 1) hit me, I wanna die, and they wanna kill me...." During an interview with AA on 2/21/17, at 1:30 p.m., the AA stated Resident 2's face was very red after her shower with CNA 1. The AA stated Resident 2 told her that someone beat her. The AA stated Resident 2 used her hands in a slapping motion at her face and said it burned. The AA stated she had seen Resident 2's face red a couple of times before. During an interview with LVN 1 on 2/21/17, at 12:23 p.m., LVN 1 stated that on 1/12/17, she noticed a red mark on Resident 2's cheek and that she did not report it to the DON. During an interview with LVN 1 on 2/21/17, at 3:30 p.m., LVN 1 stated that when she noticed the red mark on Resident 2's cheek (on 1/12/17), she told CNA 1 to write an "Incident Report". LVN 1 also stated she wrote up a "Change of Condition" regarding the new red marks on Resident 2's cheeks. Review of Resident 2's "Change of Condition Documentation and Notification," dated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2N9311 Facility ID: 02000065 If continuation sheet 8 of 11 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 02/21/2017 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 1/12/17, indicated "Situation...redness on right cheek....Assessment...redness noted to left cheek area noticed after shower by (CNA 1)...." Review of the "Incident Reports," for December 2016, January and February 2017, indicated there was no reported incident to investigate the cause of Resident 2's red marks on her cheek. 3. During an interview with Certified Nursing Assistant (CNA) 2 on 2/21/17, at 12:41 p.m., CNA 2 stated she changed Resident 2's wet undergarment and checked her skin, which was clear, but when Resident 2 returned from the shower with CNA 1, she had a bruise on her right thigh. CNA 2 stated she did not tell anyone, she " ...didn't say anything...I watched...because there was no witness." During an interview with Licensed Vocational Nurse (LVN) 1 on 2/21/17, at 3:30 p.m., LVN 1 stated that on 12/31/16, Resident 2 had a bluish mark on her left thigh "...It was a bruise." LVN 1 stated CNA 1 did not report to her the bruise on Resident 2's left thigh, she noticed it and instructed "CNA 1 to fill out an incident report." Review of the "Nurse's Notes," dated 12/31/16, at 2:40 p.m., indicated a "CNA reported during shower care, noted skin discoloration to left above knee, skin intact, slightly swollen, reddened. (Resident) complained of slightly pain upon touch...." Review of the "Incident Reports", for December 2016, January and February 2017, indicated there was no reported incident to investigate the cause of Resident 2's bruise on her thigh. During an interview with the DON on 2/21/17, at 1:11 p.m., the DON stated LVN 1 reported to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2N9311 Facility ID: 02000065 If continuation sheet 9 of 11 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 02/21/2017 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 him the bruise on Resident 2's thigh and there was no incident report. Review of the facility's staffing sheets for January 2017 indicated CNA 1 provided Resident care on: 1/1/17, 1/4/17, 1/5/17, 1/6/17, 1/7/17, 1/9/17, 1/10/17, 1/11/17,1/12/17, 1/13/17, 1/15/17, 1/16/17, 1/18/17, 1/19/17, 1/21/17, 1/22/17, 1/23/17, 1/24/17, 1/25/17, 1/28/17, 1/29/171/30/17, 1/31/17. Record Review of the facility's undated policy and procedure titled, "Abuse Prevention," indicated "...Identification of Abuse: 1. Observations, suspicious, or reporting of...bruises (of suspicious or unknown origin) will be investigated to rule out abuse. 2. Occurrences, patterns and trends will be assessed by Administrative Staff, Licensed Staff, Interdisciplinary Team to determine the corrective action based on the results of the investigation....G. Reporting...1. All mandated reporters are required by law to report incident of known or suspected abuse in two ways. a) By telephone immediately or as soon as practically possible, to the local law enforcement agency. b) By written report, Department of Social Services Form (SOC 341), 'Report of Suspected Dependent Adult Elder Abuse' sent within two (2) working days. 2. It is this facilities policy that any known or suspected abuse will be reported by completing an Incident and Injury Report. 3. First responder or first staff member informed will be responsible for informing immediate supervisor and initiating incident report. 4. Administrator or designee, and Director of Nursing must be notified as soon as possible but no later than 24 hours after the incident report. 9. Administrator/DON shall investigate all suspected or alleged abuse and report incident to the local ombudsman or the local law FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2N9311 Facility ID: 02000065 If continuation sheet 10 of 11 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 02/21/2017 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 enforcement agency. 10. Administrator shall report all incidents of alleged abuse or suspected abuse to (California Department of Public Health) CDPH within 24 hours....I. Administrative Procedure...2. Administrator or designee shall initiate and investigation immediately...." See F223 for additional information. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2N9311 Facility ID: 02000065 If continuation sheet 11 of 11