Health inspection·October 10, 2019

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, for one of 25 (Resident 5) sampled residents, the facility failed to inform and provide information to the residents and/or the resident representatives, the option to formulate an advance directive (a legal document in which a person specifies what actions should be taken for their health if they are no longer able to make a decision for themselves because of illness or incapacity). This failure had the potential to result in delay of the treatment directions to healthcare providers regarding Resident 5's medical care. Findings: Review of the Resident Face Sheet, printed 10/8/19, indicated Resident 5 was readmitted to the facility on [DATE]. During a review of the medical record for Resident 5, the Physician Orders for Life-Sustaining Treatment (POLST) form, signed 11/4/18, indicated Section D - Information and Signatures regarding Advance Directives was left unanswered. Review of Resident 5's significant change in status Minimum Data Set (MDS - an assessment tool used to direct care), dated 6/26/19, indicated the advance directive section was not completed. Review of a document titled Social Services Assessment, dated 11/7/18, indicated Resident 5 did not have an advance directive. During a concurrent interview and record review with the Social Services Director (SSD) on 10/08/19 at 11:55 a.m., she showed that the advance directive question had been marked no on the Social Services Assessment document dated 11/7/18. SSD stated although she marked Resident 5 did not have an advance directive, she did not document that she had informed Resident 5 and his resident representative (RR) of the pros and cons of an advance directive. SSD was unable to show documentation that Resident 5 and his RR were offered an opportunity to develop one. SSD was not able to show documentation in the Interdisciplinary Team notes that the advance directive had been discussed with Resident 5 and his RR. Review of facility's policy and procedure titled Advanced Healthcare Directives, revised 2/2017, indicated, .I. Upon admission, admission Staff or designee will inform the resident of his/her right to execute an Advance Healthcare Directive. X. Inquiries concerning Advance Directives are referred to the Director of Social Services/Designee 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 3 Event ID: 055874 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 10/10/2019 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)