Health inspection·March 27, 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. Based on interview and record review, for one of four sampled residents (Resident 1), the facility failed to ensure accurate procedure for administering medications to meet the needs of each resident when non-crushable medications were crushed and administered without consultation with the prescribing physician. This failure had the potential to result in rendering the medications ineffective while increasing their side effects. Findings: During a review of Resident 1's admission Record, printed 3/27/24, the admission Record indicated Resident 1 was admitted to the facility in March 2024 with essential hypertension (high blood pressure), cerebrovascular disease (a group of conditions that affect blood flow and the blood vessels in the brain), dysphagia (difficulty swallowing), and sepsis with pneumonia (life-threatening complication of an infection, pneumonia, an infection in the lung). During a review of Resident 1's Skilled Nursing Facility Orders, printed 3/1/24, the Skilled Nursing Facility Orders indicated for Resident 1 to receive pureed diet and for Pneumonia Prevention, staff should contact pharmacy to determine which medications can be crushed or for alternative and contact the physician to verify the medications. During a review of Resident 1's Medication Review Report, dated 3/27/24, the Medication Review Report indicated the following physician's orders: 1. May crush crushable medications. 2. Ferrous sulfate (iron supplement that treats anemia) 325 (65 Fe) milligram (mg) one tablet by mouth daily every Monday, Wednesday, and Friday. 3. Metoprolol succinate (lowers blood pressure) ER (Extended Release) 24 Hour 100 mg one tablet by mouth twice daily. 4. Pantoprazole sodium (reduces the amount of acid your stomach makes) 40 mg Delayed Release oral tablet, one tablet by mouth twice daily. During a review of the Drug Label Information, the Drug Label Information indicated the following: (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: 555398 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 555398 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hayward Post Acute 25919 Gading Road 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)