Health inspection·November 29, 2018

F 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, for two of 21 sampled residents, the facility failed to implement their Pain Management policy and procedure when Residents 6 and 243 experienced pain and Licensed Vocational Nurse (LVN) 1 did not assess the Residents for pain using the zero to 10 pain scale (zero being no pain and 10 being the worst pain). Residents Affected - Few This failure had the potential to result in Resident 6 and Resident 243's pain to be incompletely relieved or managed. Findings: 1. Review of Resident 6's Facesheet, printed 11/28/18, indicated Resident 6 was admitted to the facility with diagnoses that included rheumatoid arthritis (a chronic inflammatory disorder in which the body's immune system attacks its own tissue, including joints, causing pain and swelling). Review of Resident 6's Minimum Data Set (MDS - a resident assessment too used to guide care), dated 12/1/17, indicated Resident 6 was able to identify the correct day, month, year, and could recall words presented to her. Resident 6 had clear speech and could express ideas and wants and had clear comprehension of verbal content. Review of Resident 6's Pain Re-Assessment, dated 11/25/18, indicated Resident 6 was at risk for pain due to a diagnosis of Rheumatoid Arthritis. Review of Resident 6's Care Plan for Pain, dated 12/1/18, indicated Resident 6 was at risk for pain due to kidney disease and arthritis. Interventions included pain medication and Hot packs as needed to bilateral knees for pain. During an observation and concurrent interview on 11/28/18, at 9:05 a.m., Licensed Vocational (LVN) 1 asked Resident 6 if she was in pain. Resident 6 stated she was very stiff. LVN 1 told Resident 1 she would go and get Resident 6's pain medication. LVN 1 did not ask Resident 6 to rate her pain on a scale of 0 to 10, where the stiffness was, or what measures either relieved the discomfort or made it worse. In an interview on 11/28/18, at 9:55 a.m., LVN 1 stated she did not know why Resident 6 was stiff. LVN 1 stated this would have been helpful information to obtain as this would allow staff to reposition her and try to find ways to make Resident 6 more comfortable. 2. Review of Resident 243's Facesheet, printed 11/28/18, indicated the Resident 243 was admitted to the facility with diagnoses that included muscle weakness and peripheral neuropathy (weakness, numbness, and pain from nerve damage, usually in the hands and feet). Review of Resident 243's Pain Re-Assessment, dated 11/28/18, indicated Resident 243 had back pain which was rated between 5 and 7 on the pain scale of 0 to 10. Non-medication interventions being used included Relaxation and repositioning. Review of Resident 243's Care Plan Pain, dated 11/15/18, indicated Resident 243 was at risk for pain due to neuropathy, back pain and kidney failure. Interventions included medication administration as well as repositioning, distraction, quiet environment and dimmed lights. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055874 If continuation sheet Page 2 of 4 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 055874 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hayward Healthcare & Wellness Center 1805 West Street Hayward, CA 94545 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)

F 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident 243's Minimum Data Set (MDS - a resident assessment too used to guide care), dated 11/21/18, indicated Resident 243 had clear speech, was able to express his ideas and wants and understood what others said to him. In an observation and concurrent interview on 11/28/18, at 8:40 a.m., LVN 1 asked Resident 243 if he had pain. Resident 243 told LVN 1 Yes, he had pain. LVN 1 then turned to retrieve the pain medication from the medication cart. LVN 1 stated she did not know where Resident 243's pain was located, the intensity (on a scale of 0-10), or what made the pain worse or better. In an interview on 11/29/18, at 12:30 p.m., the Director of Nursing (DON) stated licensed nursing staff were to ask if the resident has pain, where the pain is located, where the pain is on the pain scale, what brings the pain on and what makes the pain better. The DON stated these questions needed to be asked in order to address the pain correctly and identify any possible triggers. Review of the facility's policy and procedure titled Pain Management dated November 2016, indicated .Pain Management .D. The Licensed Nurse will assess the resident for pain and document results on the (Medication Administration Record) each shift using the 0-10 pain scale .F. Nursing Staff will implement timely interventions to reduce an increase in severity of pain .J. Nursing Staff will also utilize non-pharmacological interventions to address possible issues contributing to pain FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055874 If continuation sheet Page 3 of 4 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 055874 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hayward Healthcare & Wellness Center 1805 West Street Hayward, CA 94545 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)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, for one of 21 sampled residents (Resident 69), the facility failed to implement their Dressings - Application to ensure cleanliness policy and procedure when Licensed Vocational Nurse (LVN) 2 did not re-clean Resident 69's sacral (lower back) pressure injury Residents Affected - Few (localized damage to the skin and/or underlying soft tissue usually over a bony prominence) after Resident 69 rolled onto the open wound during a dressing change. This failure had the potential to result in infection. Findings: Review of Resident 69's Facesheet, printed 11/28/18, indicated Resident 69 was admitted to the facility with diagnoses that included muscle weakness. Review of Resident 69's Physician's Telephone Orders, dated 10/31/18, indicated Resident 69 had a sacral pressure injury that required cleaning and dressing changes, daily and as needed, by the facility's licensed nurses. Review of Resident 69's Care Plan, Pressure Injury, dated 9/16/18, indicated Resident 69's pressure injury was to be free of signs and symptoms of infection. In an observation on 11/29/18, at 10:04 a.m., Resident 69 was assisted into his bed and laid on his left side so LVN 2 could clean his sacral pressure injury and change the dressing. Resident 69's buttocks were on a blue pad (chux - blue absorbent pad commonly used for resident's who may have occasional leakage of bowel or bladder). LVN 2 removed Resident 69's old sacral dressing and cleaned the sacral pressure injury with the normal saline. Resident 69 stated he was uncomfortable being on his side and rolled back onto his back and onto the chux. LVN 2 then assisted Resident 69 back onto his left side. LVN 2 applied the new clean dressing and medication to Resident 69's sacral injury. LVN 2 did not re-clean Resident 69's sacral pressure injury with normal saline after the contact with the incontinent pad. In a concurrent interview, LVN 2 stated she should have re-cleaned Resident 69's sacral (injury) wound before applying the medication and dressing. In an interview at 12:40 p.m., the facility's Director of Nursing (DON) stated the sacral dressing change is a Clean procedure. If the resident rolled back over onto the incontinent pad which had been there for an unknown number of hours, staff should have re-cleaned the wound to diminish the chance of infection. Review of the facility's policy and procedure titled Dressings - Application, dated 1/1/12, indicated the purpose was to .ensure cleanliness and prevent infection by protecting the skin's surface and to promote resident comfort and wound healing FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055874 If continuation sheet Page 4 of 4