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. (continued on next page) 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 Page 1 of 4 Event ID: 055338 Printed: 05/15/2026 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 055338 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sage Post Acute 1832 B Street Hayward, CA 94541 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)