Health inspection·October 17, 2019

F 0685 Assist a resident in gaining access to vision and hearing services. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the skilled nursing facility did not provide the necessary care to to maintain a resident's ability to effectively communicate with staff for one of 19 sampled residents (Resident 68). Facility staff did not address Resident 68's hearing loss. Residents Affected - Few This failure resulted in Resident 68 expressing feelings of frustration. Findings: A record review on 10/15/19 of the document Resident Face Sheet, showed the facility admitted Resident 68 on 9/20/19. Diagnoses included kidney failure and lung disease. A review of the document MDS 3.0 (resident assessment), dated 9/27/19, showed Resident 68 understood what others said to him and had, Minimal Difficulty hearing with Difficulty in some environments (e.g., when person speaks softly or setting is noisy. In an interview on 10/14/19 at 8:40 a.m., Resident 68 stated he could not understand this surveyor's question because he could not hear. Resident 68 stated he did not have a hearing aide, could Sometimes understand what staff were saying to him. He stated he was Frustrated and would like to get a hearing aide At some point. In an interview on 10/15/19 at 12:50 p.m., Certified Nursing Assistant 1 (CNA 1) confirmed Resident 68 had a difficult time hearing and she needed to Speak louder to him. In an interview on 10/15/19 at 1:02 p.m., the facility's Social Services Director (SSD) confirmed Resident 68 had difficulty hearing. The SSD stated when a resident had anything other than adequate hearing documented on the resident assessment form, they needed to be placed on the audiologist (hearing specialist) referral list so the hearing loss can be addressed. The SSD stated Resident 68's name had not been placed on the list. A review of the document Referral to Outside Agencies, dated 6/2008, showed it was the facility's policy to, Establish guidelines for making referrals to outside agencies that will meet the psychosocial and/or concrete needs of a resident . Referrals can be made by the, Social Service Director, licensed nurse, or a member of the IDT (Interdisciplinary Team) based on a resident's individualized, specific needs identified through interviews, evaluations, and assessments. 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: 056447 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 056447 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/17/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hayward Hills Health Care Center 1768 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)