Other·March 24, 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 a complaint. Complaint number: 521108 Representing the Department: Health Facilities Evaluator Nurses: 32717, 36738, and 33375. The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. The deficiency at F223 was Immediate Jeoplardy 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 03/12/2017 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. 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: W00P11 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 02/17/2017 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 483.12(a) The facility must(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 observation, interview, and record review, the facility failed to provide goods and services for nine of nine sampled Residents (Residents 1,2,3,4,5,6,7,8, and 9) that were necessary to attain or maintain physical, mental, and psychosocial wellbeing. The facility did not pay wages to facility staff, or make payments to food, medical supply vendors, and utilities. These failed practices resulted in nine Residents (Residents 1, 2, 3, 4, 5, 6, 7, 8, and 9) not receiving basic nursing care and all residents were served food from the emergency food supplies. Staff told Resident 4 they were too busy to get her out of bed. Prescribed physical therapy (PT) services were not provided for three Residents (Residents 1, 2, and 3). There was a shortage of medical supplies, such as diabetic (when the body can't use sugar normally) blood sugar testing supplies, for eight residents (Residents 2, 3, 4, 5, 6, 7, 8, and 9). These failed practices had the potential to result in substandard quality of care which affected the 30 residents residing in the facility. On 2/17/17, at 10:15 a.m., Immediate Jeopardy (IJ) was called. The Administrator (ADM) and the Director of Nursing (DON) were verbally notified of the IJ regarding the loss of nursing staff, the non-provision of PT services, and shortages of food and supplies for the residents. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: W00P11 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 02/17/2017 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 The IJ was not lifted on 2/17/17 at 11:30 a.m. The Administrator was not able to provide an acceptable plan of correction to the Department. Findings: During an observation and concurrent interview with Resident 4 on 2/16/17, at 11:27 a.m., Resident 4 was lying in bed. Resident 4 stated she wanted to get up into her wheelchair, but staff had told her they were too busy. Resident 4 stated she'd feel better if she was up. During an interview with LVN 3 on 2/13/17, at 1:20 p.m., with LVN 2 on 2/14/17, at 3 p.m., with CNA 3 on 2/16/17 at 12:10 p.m., and with CNA 4 on 2/16/17, at 11:35 a.m., LVN 3, LVN 2, and CNA 3 each stated they often worked short of nursing staff (lacking the usual or necessary number of nursing staff). During an interview with the ADM on 2/17/17, at 7:38 a.m., the ADM stated when the facility was short of nursing staff, he and the DON worked as nurses and the facility also used registry (an employment agency that provides nurses to work in temporary positions). The ADM stated the regular night shift nurse left around late November 2016. The ADM stated the facility used registry staff for the night shift almost every night in January 2017. Review of the facility staffing assignment sheets, dated 1/1/17 through 1/31/17, showed: a. During the day shifts, the facility was short nursing staff 6.4% of the time in January when one CNA was absent of 1/22/17 one 1/23/17; b. During the Afternoon shifts, the facility was short nursing staff 3.2% of the time in January when one CNA was absent on 1/28/17. The January 2017 staffing assignment sheets also showed the facility used registry staff 29% FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: W00P11 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 02/17/2017 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 of the time on day shift, 41.9% of the time on the afternoon shift, and 90% of the time on the night shift. Review of the facility staffing assignment sheet, dated 2/1/17 through 2/16/17, showed: a. During the day shifts, the facility was short nursing staff 6% of the time in February when one LVN and two CNAs were absent on 2/14/17; b. During the afternoon shifts, the facility was short nursing staff 6% of the time in February when one CNA was absent on 2/14/17; c. During the nights shifts, the facility was short nursing staff 12.5% of the time in February when one CNA was absent on 2/4/17 and 2/11/17. The February 2017 staffing assignment sheets also showed the facility used registry nursing staff 25% of the time on day shift, 37.5% of the time on the afternoon shifts, and 75% of the time on the night shift. During an interview with LVN 4 on 2/16/17, at 3 p.m., LVN 4 stated "...we just provide adequate care...using registry is not as good...they do not know the residents..." During an interview with LVN 3 on 2/16/17, at 12:50 p.m., LVN 3 stated "...staff is not motivated and don't want to provide care. Some things are not done for the residents according to their schedules...showers, treatments, and diapers (incontinent undergarments) are not being done as often as they should be done because we are short staffed...care isn't going to get done or not done as good...." During an interview with CNA 4 on 2/16/17, at 1:10 p.m., CNA 4 stated "...Residents are not getting the care needed. We aren't trying to neglect (the residents), but attitudes are bad, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: W00P11 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 02/17/2017 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 so our care might not be as good...not enough manpower for priority needs...(like) prevent(ing) (residents) from falling...." During an interview with the Social Services Director (SSD) on 2/6/17 at 11:25 a.m., she stated the paychecks that were due on 1/25/17 would not be available until the 1/31/17. The SSD stated the facility staff had not been paid to date. A facility memo, dated 1/25/17, showed the following message "...The company is fully aware of the delayed in cashing some of employee's paychecks dated 1/10/2017 for (the facility)...The employees who have been affected will be paid $290.00 per work week or $58.00 per day (based on a 5 days of work schedule). We are anticipating to distribute the paycheck date 1/25/17 on or before 1/31/17 and the same rule mentioned above will apply for the delay in cashing their paychecks." During an interview with the Administrator (ADM) on 2/6/17, at 12:48 p.m., the ADM stated the facility owners had issues with the Labor Department and the Internal Revenue Service (IRS) and hence, are in financial difficulty. The ADM stated facility employees were getting late payments and some have not been showing up for work. During an interview with the ADM on 2/8/17, at 9:25 a.m., the ADM stated the facility owners told him paychecks would be delayed and there was an IRS levy (collection of taxes by force) issued against the corporate office. During an interview with the Payroll and Medical Records Director (PMD) on 2/6/17 at 11:30 a.m., the PMD stated the delays in issuance of paychecks started July 2016 but got worse starting in December 2016. During FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: W00P11 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 02/17/2017 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 an interview with Certified Nursing Assistant (CNA) 1 on 2/6/17, at 11:57 a.m. and with CNA 2 on 2/6/17, at 12:10 p.m., CNA 1 and 2 both stated facility staff had to try to cash their paychecks as early as possible before funds ran out. During an interview with CNA 3 on 2/16/17, at 12:10 p.m., with the Maintenance Supervisor (MS) on 2/16/17, at 12:20 p.m., and with LVN 3 on 2/16/17, at 12:50 p.m., and with CNA 2 on 2/16/17, at 1:10 p.m., each stated they were not getting paid. During an interview with CNA 4 on 2/16/17, at 11:35 a.m., CNA 4 stated she had "no (pay) checks since January. Some of the staff calls in sick, and they (the facility) ask us to work over time." During interviews on 2/16/17 at 12:50 p.m., LVN 3, with CNA 2 on 2/16/17, at 1:10 p.m., LVN 3 and CNA 2 each stated they call in sick sometimes because they were not getting paid. During an interview with LVN 1 on 2/17/17, at 7:05 a.m., LVN 1 stated since she started working at the facility in August 2016, her pay had been delayed every time. LVN 1 stated this month they told her she would not be paid for the 2/10/17 payday until 2/22/17. During an interview with LVN 3 on 2/13/17, at 1:20 p.m., with LVN 1 on 2/13/17, at 2:50 p.m., and with LVN 4 on 2/16/17, at 3 p.m., LVN 3 and LVN 4 each stated they have either already had, or were considering, resigning from working at the facility full-time and either working only part-time at the facility or getting a new job. During an interview with the ADM on 2/8/17, at FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: W00P11 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 02/17/2017 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 1:20 p.m., the ADM stated the Dietary Manager resigned and the facility did not have a Dietary Manager. During an interview with the DON on 2/17/17, at 7:33 a.m., the DON stated in January two CNAs resigned and two LVNs dropped from full-time to part-time status because of the pay issues. Review of the facility document titled, "Employee Status," last updated 2/17/17, showed the following employee status changes: a. LVN 4 had dropped from full-time to parttime status as of 1/1/17; b. LVN 5 had dropped from full-time to parttime status as of 2/1/17; c. CNA 5 had resigned as 1/22/17, and; d. CNA 6 had resigned as of 1/26/17. During an interview with CNA 1 on 2/8/17, at 12 p.m., CNA 1 stated the facility had problems with food orders last month (January 2017) and the facility did not receive food deliveries. During a telephone interview with the food supply vendor representative on 2/15/17, at 9:34 a.m., the representative said the facility was behind in payments and the food vendor stopped delivering food to facility. During an interview with the ADM on 2/17/17, at 7:15 a.m., the ADM stated the food vendor put a hold on the facility's account last month and the corporate office bought food from grocery stores instead. During an interview on 2/16/17 at 12:30 p.m., Dietary Staff (DS) stated the facility ran out of some food last month (January) and used the facility's emergency food supplies. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: W00P11 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 02/17/2017 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 the ADM on 2/13/17 at 1 and 1:28 p.m., the ADM stated the facility did not have PT services since 1/20/17. The ADM stated the facility had three residents with PT orders. During an interview with the DON on 2/14/17, at 1 p.m., the DON said the facility was still negotiating for a Physical Therapy company to come in. Review of the "Record of Admission," dated 11/7/16, showed Resident 1 had multiple diagnoses that included a stroke (sudden death of brain cells due to lack of oxygen caused by a blood clot in or rupture of an artery in the brain resulting in the sudden loss of speech, weakness, or paralysis of one side of the body). Review of the "Minimum Data Set," (MDS - a resident assessment tool used to guide care), dated 8/8/16, showed Resident 1 was cognitively intact (had the ability to think, reason, and remember clearly). The MDS also showed Resident 1 used a wheelchair and was dependent on one or two staff for bed mobility, transfers (to and from bed to wheelchair), dressing, and personal hygiene. Record Review of Resident 1's medical chart showed the doctor ordered PT on 1/3/17 five times a week for four weeks and skilled Occupational Therapy (OT) to increase bed mobility and transfer ability from bed to wheelchair. During an observation and concurrent interview with Resident 1 on 2/14/17, at 12:50 p.m., Resident 1 was lying in bed and eating lunch. Resident 1 stated he had made good progress in PT, until PT quit. Resident 1 also stated he needed PT to help him improve on doing things FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: W00P11 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 02/17/2017 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 for himself. Resident 1 further stated he would like to go to an assisted living facility, but he needed PT to help him become independent. Review of the "Record of Admission," dated 1/4/17, showed Resident 2 had multiple diagnoses that included a broken hip and stroke. Review of the MDS, dated 1/11/17, showed Resident 2 was moderatly cognitively intact (had some diffieculty with being able to think, reason, and remember clearly). The MDS also showed Resident 2 used a wheelchair and a walker and required the assistance of one to two staff for bed mobility, transfers, dressing, and personal hygiene. Review of Resident 2's medical chart showed Resudent 2 had doctor's order for PT on 1/5/17 for five times a week for four weeks for therapeutic activities, therapeutic procedures, gait training, caregiver training for difficulty walking. During an observation on 2/14/17 at 12:50 p.m., Resident 2 was in bed awake and alert but did not communicate. Review of Resident 3's medical chart showed Resident 3 had a diagnoses that included generalized muscle weakness and difficulty walking. Review of the "Physician's Orders," dated 1/2/17 showed Resident 3 had an order for the continuation of PT five times a week for four weeks for therapeutic activities, therapeutic procedures, gait training, caregiver training for difficulty walking. A review of the "Order Acknowledgement," dated 2/6/17, from the medical supplier showed FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: W00P11 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 02/17/2017 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 an order for items such as incontinent undergarments, exam gloves, dressing supplies, lancets, syringes, nutritional supplement drinks, and masks. During a telephone interview with the medical supply vendor representative on 2/15/17, at 9:44 a.m., the representative stated they withheld the last shipment (dated 2/6/17) to the facility due to nonpayment and the facility's account was suspended. During an interview with the ADM on 2/16/17, at 10:45 a.m., the ADM stated the medical supply company did not deliver the facility's last order (dated 2/6/17). During an observation in the presence of the DON on 2/17/17, at 10:50 a.m., there were a total of 126 lancets (definition) and 231 teststrips (definition) in Medication Carts 1 and 2. The DON stated there were no other diabetic testing supplies in the facility. Review of the "Physician's Orders," dated 2/1/17, indicated the following residents had a physician's order for a finger stick blood sugar test [FSBS - a procedure in which a finger is pricked with a lancet (a pricking needle) to obtain a small quantity of capillary blood for testing]: a. Resident 2 - FSBS one time per day; b. Resident 3 - FSBS four times per day; c. Resident 4 - FSBS five times per day; d. Resident 5 - FSBS four times per day; e. Resident 6 - FSBS four times per day; f. Resident 7 - FSBS one time per day; g. Resident 8 - FSBS one time per day, and h. Resident 9 - FSBS twice per day. Combined, Residents 2, 3, 4, 5, 6, 7, 8, 9, and 9 required 22 blood glucose test strips (test strips - a key component in the FSBS testing process) and 22 lancets each per day. Since FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: W00P11 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 02/17/2017 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 there were 231 test strips and the Residents needed 22 test strips per day, the facility had enough test strip supplies for 10.5 days. Since there were 126 lancets, and the Residents needed 22 lancets per day, the facility had enough lancets to last 5.7 days. After 5.7 days, the facility would not be able to perform the prescribed FSBS tests for Residents 2, 3, 4, 5, 6, 7, 8, and 9. During an interview with the Maintenance Supervisor (MS) on 2/16/17, at 12:20 p.m., the MS stated "...we are ok today with supplies today, but will run out soon...very stressful...I don't know what we'll do." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: W00P11 Facility ID: 02000065 If continuation sheet 11 of 11