Health inspection·July 12, 2023

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Based on interview and record review, for one of two sampled residents (Resident 2), the facility failed to ensure Resident 2 was free from physical abuse when Resident 1 hit Resident 2's shoulder while in front of the nurse's station. This failure had the potential to result in Resident 2's emotional distress. Findings: Review of Resident 1's admission Record indicated Resident 1 was admitted to the facility with diagnoses that included Alzheimer's dementia (inability to remember, think, and use good judgement/decision-making) and major depressive disorder During a concurrent interview and record review with Social Services Director (SSD), on 5/25/23 at 11:42 a.m., SSD stated, Resident 1 had been on melatonin (a sleep aid) which did not offer much help in reducing behavior. SSD stated Resident 1 had delusions (false beliefs) that some people wanted to inflict harm. Review of Resident 1's behavior care plan dated 4/7/23 indicated Resident 1 had a behavior of screaming when approached. The care plan indicated multiple interventions that included administering medications as ordered, assisting Resident 1 to develop more appropriate methods of coping and providing positive interaction. Review of Resident 1's Progress Notes indicated the following incidents: - On 4/6/23, Resident 1 was in the dining room, yelling and screaming for help. As staff approached to offer help, Resident 1 screamed louder and was agitated and became aggressive. - On 4/16/23, Resident 1 was fully confused, screaming, hit Licensed Vocational Nurse (LVN) 1 twice, after alleging another resident's room belonged to her. - On 4/16/23, Resident 1 did not sleep the entire evening shift, was hostile, intrusive, and interfered with the care of other residents. Resident 1 did not respond to re-direction. - On 4/21/23. Resident 1 was Screaming and yelling at the top of her lungs, and redirections, distractions and assistance was not working, resident was inconsolable, grabbing other residents' wheelchairs. Page 1 of 4 055338 055338 07/12/2023 Sage Post Acute 1832 B Street Hayward, CA 94541

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few - On 4/21/23, during dinner in social dining room, Resident 1 was very disruptive and intrusive to other residents, grabbing food items from their trays, yelling in the other residents' faces, making them uncomfortable. Resident 1 did not respond to redirection and continually wandered between tables and Made the room [intolerable] for others to enjoy their dinner. - On 4/25/23, Resident 1 was in the alternate dining room with other residents, had a couple episodes of angry outburst towards staff and other residents in the dining room. -On 4/27/23, Resident 1 was screaming and yelling at staff. During an interview and concurrent review of Resident 1's behavior care plan with SSD on 7/12/23 at 11:05 a.m., SSD stated the behavior care plan was not revised after multiple incidents of negative behavior. During a concurrent interview and review of Resident 1's Progress Notes dated 4/29/23, with LVN 1 on 5/25/23 at 12:21 p.m., LVN 1 stated, on 4/29/23, Resident 1 and Resident 2 were at the nurse's station when LVN 1 saw Resident 1 push Resident 2's wheelchair out of the nurse's station and hit Resident 2 on the right shoulder. LVN 1 stated she tried to intervene and stop Resident 1 from further hitting Resident 2 but was also hit by Resident 1 in the process. Further review of Resident 1's Progress Notes dated 4/29/23 at 5:36 p.m., during dinner in the social dining room, Resident 1 continued to speak loudly with false accusations to everyone. Resident 1 could not be redirected and had mood changes from being pleasant to being very angry. During an interview with Resident 2 on 5/25/23 at 1 p.m., Resident 2 stated, while seated in a wheelchair at the nurse's station, Resident 1 approached from the back and hit Resident 2's right shoulder three times. 055338 Page 2 of 4 055338 07/12/2023 Sage Post Acute 1832 B Street Hayward, CA 94541

F 0745 Provide medically-related social services to help each resident achieve the highest possible quality of life. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, for one of two sampled residents (Resident 1), the facility failed to provide a psychological evaluation as ordered by the physician. Residents Affected - Few This failure delayed the management of disruptive, aggressive behavior towards other residents in the facility. Findings: Review of Resident 1's admission Record indicated Resident 1 was admitted to the facility with diagnoses that included Alzheimer's dementia (inability to remember, think and use good judgement/decision-making) and major depressive disorder with an onset date of 4/27/23. During a concurrent interview and record review with Social Services Director (SSD), on 5/25/23 at 11:42 a.m., SSD stated, Resident 1 had been on melatonin (a sleep aid) which did not offer much help in reducing Resident 1's behavior. SSD also stated Resident 1 had delusions (false beliefs) that some people wanted to inflict harm. Review of Resident 1's behavior care plan initiated 4/7/23 indicated Resident 1 had a behavior of screaming when approached related to dementia. The care plan identified interventions that included monitoring behavior episodes and intervene as necessary, offering tasks to divert attention, discussing behavior and inappropriateness of negative behaviors, educating caregivers on successful coping. Review of Resident 1's Progress Notes indicated the following incidents: - On 4/6/23, Resident 1 was in the dining room, yelling and screaming for help. As staff approached to offer help, Resident 1 screamed louder, was agitated and aggressive. - On 4/16/23, Resident 1 was fully confused, screaming, hit Licensed Vocational Nurse (LVN) 1 twice, after alleging another resident's room belonged to her. - On 4/16/23, Resident 1 did not sleep the entire evening shift, was hostile, intrusive,and interfered with the care of other residents. Resident 1 did not respond to re-direction. - On 4/21/23. Resident 1 was Screaming and yelling at the top of her lungs, redirections, distractions and assistance was not working, resident was inconsolable, grabbing other residents' wheelchairs. - On 4/21/23, during dinner in social dining room, Resident 1 was very disruptive and intrusive to other residents, grabbing food items from their trays, yelling in the other residents' faces, making them uncomfortable. Resident 1 did not respond to redirection and continually wandered between tables and Made the room [intolerable] for others to enjoy their dinner. - On 4/25/23, Resident 1 was in the alternate dining room with other residents, had a couple episodes of angry outburst towards staff and other residents in the dining room. Review of Resident 1's Physician's Orders dated 4/24/23 indicated Resident 1 to have a 055338 Page 3 of 4 055338 07/12/2023 Sage Post Acute 1832 B Street Hayward, CA 94541

F 0745 psychological evaluation completed. Level of Harm - Minimal harm or potential for actual harm During a telephone interview with SSD, on 7/5/23 at 3:23 p.m., SSD stated the former Director of Nursing (DON) did not call the facility's psychologist to schedule an evaluation. SSD further stated the physician's order for a psychological evaluation was not done. Residents Affected - Few During a follow-up interview with SSD, on 7/12/23 at 11:05 a.m., SSD stated, the nursing department should have carried out the order and SSD could have assisted if they needed help. 055338 Page 4 of 4