Health inspection·September 30, 2024

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to have the ordered medication Levetiracetam or Keppra (used to prevent and control seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness]) for one resident (Resident 1). This failure of Resident 1 not receiving Keppra on 8/14/24 resulted in Resident 1 ' s delayed treatment which had the potential to result in seizure episodes. Resident 1 subsequently had two seizure episodes in the morning of 8/15/24. Findings: During a review of Resident 1 ' s face sheet, undated, the face sheet indicated Resident 1 was admitted to the facility on [DATE] at 2:55 p.m., with a diagnosis of seizures. During a review of Resident 1 ' s Order Details, the Order Details indicated a physician order on 8/14/24 at 1531 (3:31 p.m.) for Levetiracetam Oral Tablet 500 mg, give 1 tablet by mouth two times a day for seizure precautions. During a review of Resident 1 ' s Medication Administration Record (MAR) for August 2024, the MAR indicated Resident 1 did not receive Levetiracetam Oral Tablet 500 mg scheduled for 8/14/24 at 1700 (5:00 p.m.). During a review of the pharmacy ' s Consolidated Delivery Sheets, the Consolidated Delivery Sheets indicated Levetiracetam 500 mg tablet for Resident 1 was delivered to the facility on 8/15/24 at 1200 a.m. (midnight). During an interview on 9/11/24, at 10:50 a.m., with Registered Nurse (RN) 1, RN 1 stated when Keppra was not available for the 1700 medication pass, the situation should have been elevated to the Administrator especially since Resident 1 had a significant history of seizures. The medication could have been ordered for delivery ASAP (as soon as possible). During an interview on 9/30/24, at 11:55 a.m., with Registered Nurse (RN) 2, RN 2 stated Keppra was a seizure medication. RN 2 stated when a dose is missed, patient could have a seizure. RN 2 also stated when Keppra was not available for the evening dose, the Director of Nursing (DON) should have been involved. During an interview on 9/30/24, at 1:00 p.m., with the DON, the DON stated Keppra needed to be (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: 056463 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 056463 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/30/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Emmanuel Post Acute Care - Hayward 26660 Patrick Avenue Hayward, CA 94544 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)