Health inspection·July 18, 2024

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few Note: The nursing home is disputing this citation. Based on observation, interview, and record review, the facility failed to implement measures to safely transfer one of two sampled residents (Resident 1) when a staff transferred Resident 1 from bed to a shower chair using a Hoyer lift (mechanical device that lifts a resident for transfer, the resident will be suspended in the air in a sling while being move from a bed to a chair) without assistance from another staff member. This failure resulted in Resident 1 falling and sustaining multiple injuries: Multiple rib fractures (broken ribs), Trace Right-Sided Pneumothorax (presence of air in the space between the lung and chest wall leading to breathing difficulty and chest pain), Left Femur Peri-Prosthetic Fracture (broken bone around the artificial joint of the left thigh); and caused Resident 1's pain, emotional trauma, and an increased fear in Hoyer lift transfers. Findings: During a review of Resident 1's Face Sheet, printed July 2024, the Face Sheet indicated Resident 1 was a long-term resident since September 2014 and was readmitted to the facility in October 2023 with diagnoses that includes contact with lifting devices, generalized muscle weakness, bed confinement status, obesity, and anxiety (mental disorder characterized by excessive worry or fear). 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 October 2023, the MDS indicated Resident 1's Brief Interview for Mental Status (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) was 14 out of 15, indicating cognitively intact mental status. The MDS also indicated resident was dependent on transfer to and from a bed to a chair. During a review of Resident 1's Fall Care Plan, problem start dated 4/16/16, the Fall Care Plan indicated Resident 1 was at risk for fall and injury due to history of falls and balance problem .Resident's risk of fall and injury will be minimize .Keep environment free of hazards .identify type of assistance resident needs .provide assistance as identified in transfer. During a review of Resident 1's Care Plan Essentials (pertinent information on resident's care used by nursing staffs), dated May 2023, the document indicated Resident 1 was a high risk for falls, required a Hoyer lift for transfers, and an assist of two people required. During a review of Resident 1's Observation Detail List Report, dated 10/14/23 and completed by Registered Nurse (RN), the report indicated at 8:15 a.m., Resident 1 fell from a Hoyer lift during a (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 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 07/18/2024 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)