Health inspection·February 5, 2024

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to provide activities of daily living (ADLS,Activities of daily living are those needed for self-care and mobility and include activities such as bathing, dressing, grooming, oral care, ambulation, toileting, eating, transferring, and communicating.) to one of three sampled residents (Resident 1), when Resident 1 did not receive schedules showers for nine weeks and fingernails were long with brown matter underneath the nail. Residents Affected - Few This failure placed Resident 1 feeling not cared for and neglected. Findings: During a review of Resident 1 ' s Face Sheet, dated October 2023, the Face sheet indicated Resident 1 was admitted to the facility in October 2023 with diagnoses to include left sided weakness. During a review of Resident 1 ' s Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan.), dated 1/6/24, the MDS indicated, Resident 1 ' s Brief Interview for Mental (BIMS, is a scoring system used to determine the resident ' s cognitive status in regard to attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.) was 15 out of 15. During a concurrent observation and interview on 1/17/24 at 9:26 a.m. in Resident 1 ' s room, Resident 1 was observed lying in bed. Resident 1 stated he liked showers but only had a shower two times since July 2023. Resident further stated he felt neglected. During a concurrent interview and record review on 1/17/24 at 10:30 a.m. with Certified Nursing Assistant (CNA), Resident 1 ' s January ' s electronic record for bathing was reviewed. CNA stated, Resident had shower on 1/14/24, then other days were all bed baths. CNA further stated, she was familiar with Resident 1 ' s care and had rejected care including showers before. CNA also stated, CNAs would notify charge nurse for refused care. During a concurrent interview and record review on 1/17/24 at 10:35 a.m. with CNA, facility ' s form titled Shower Day Skin Inspection filed in a purple binder at the nursing station was reviewed. The form had a section that includes Resident name, Room number and a skin assessment. Additionally, there were checklists provided to document shower if rendered or if refused. CNA stated residents shower schedule could be found on the first page of the binder. CNA showed the shower schedule and stated, Resident 1 ' s shower schedule were Mondays and Fridays, morning, and evening respectively. CNA also stated, she would use the form to document completion of shower or refusal. (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 2 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 02/05/2024 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)