Health inspection·June 6, 2024

F 0550 privacy . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555398 If continuation sheet Page 2 of 4 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 06/06/2024 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)

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 necessary services to maintain bathing, personal hygiene, turning & repositioning for one of three resident samples (Resident 1), when one staff instead of two staff provided care for activities of daily living (ADLs, are those needed for self-care and mobility and include activities such as bathing, dressing, grooming, oral care, ambulation, toileting, eating, transferring, and communicating) for Resident 1. Residents Affected - Few This failure caused undue pain and distress for Resident 1. Findings: A review of Resident1's admission record indicated Resident 1 was admitted with diagnoses that included diabetes, generalized muscle weakness, lack of coordination, hypertensin, and depression. 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 3/21/24, the MDS indicated Resident 1 was totally dependent on the assistance of two staff for ADLs, Helper does ALL the effort. Resident does none of the effort to complete the activities. Or the assistance of 2 or more helpers is required for the resident to complete the activity for performances such as toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, ., personal hygiene; roll left and right, . During an interview on 6/6/24 at 10:45 am with Resident 1, Resident 1 stated he was blind and only able to see slightly with the right eye. Resident 1 stated he could not move and can only move his legs a little. Resident stated it was always uncomfortable and painful when staff move and turn him in bed. Resident 1 stated it has always been one staff assisting him with turning. During an observation on 6/6/24 at 11:30 am in Resident 1's room, Certified Nursing Assistant (CNA) 1 assisted Resident 1 with a bed bath and incontinent care. CNA 1 urged Resident 1 to help with turning during the ADL care. Resident 1 informed CNA1 that he was unable to and never did help turn. CNA 1 attempted to place her hands on Resident 1 ' s left arm and shoulder to turn him, Resident 1 cried out in pain and asked CNA 1 to use the drawsheet under him instead. Then CNA 1 turned Resident 1 with the drawsheet, but Resident 1 still cried out in pain. The skin on Resident 1's buttocks area was red and had abrasions (scrapes). Resident 1 had wounds on his right leg and left foot, with dressings on them. Resident 1 was moved and turned by CNA 1 three times during the ADL care for Resident 1. After changing the bed sheet, placing a clean brief, and putting on a clean gown for Resident 1, CNA 1 then moved Resident 1 up in the bed with the draw sheet which was also uncomfortable and painful for Resident 1. During an interview on 6/6/24 at 12:15 pm with CNA 1, CNA 1 acknowledged Resident 1 is dependent and needed two people to change and turn him to ensure resident was comfortable and for safety. During a concurrent interview and record review on 6/6/24 at 12:40 pm with Licensed Vocation Nurse (LVN) 1, Resident1's MDS, dated 3/21/24, was reviewed. LVN 1 stated two people were needed to change Resident and it was indicated in the MDS that Resident 1 is dependent and requires two or more helpers to complete the activity for turning/repositioning. During a concurrent interview and record review on 6/6/24 at 12:58 pm with LVN 1, Resident 1's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555398 If continuation sheet Page 3 of 4 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 06/06/2024 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)

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Physician Orders, dated June 2024, were reviewed. The Physician Orders indicated Gabapentin (medication to treat nerve pain) for Resident 1. LVN 1 stated Resident 1 did not have PRN (as needed) pain medication ordered. During an interview on 6/6/24 at 3:30 pm with Director of Nursing (DON) and assistant DON (ADON), DON stated that they are supposed to have two staff to change and reposition dependent residents such as Resident 1. DON and ADON stated they gave all staff in-service yesterday. During a review of the weekly summaries dated 5/12, 5/19, 5/26, and 6/5/24, the weekly summaries indicated one person performed ADLs for Resident 1. During a review of the facility's policy and procedure (P&P) titled, SNFCLINIC Activities of Daily Living (ADLs) Supporting Personal Care, revised March 2018, indicated, .Appropriate care and services will be provided for residents who are unable to carry out ADLs independently .including appropriate support and assistance with: Hygiene (bathing, dressing .). A resident's ability to perform ADLs will be measured using clinical tools, including the MDS . During a review of the P&P titled, SNFCLINIC Repositioning, Positioning and Moving, revised May 2013, the P&P indicated, Check the care plan, assignment sheet or the communication system to determine resident's specific positioning needs .resident level of participation and the number of staff required to complete the procedure .Use two people and a draw sheet to avoid shearing while turning or moving the resident up in bed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555398 If continuation sheet Page 4 of 4