Health inspection·June 18, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of three sample selected residents (Resident 1) stays free from accidents, when Resident 1 fell from the bed while Certified Nurse Assistance (CNA) 1 provided Activities of Daily Living (ADL, those activities needed for self-care and mobility and include activities such as bathing, dressing, grooming, oral care, ambulation, toileting, eating, transferring, and communicating). This failure in practice resulted in Resident 1 sustaining a skin laceration and transported to the emergency department. Findings: During a review of Resident 1's Face Sheet, undated, the Face Sheet indicated Patient 1 was admitted to the facility in 2019 with multiple diagnoses including stroke (a loss of blood flow to part of the brain, which damages brain tissue) and paralytic syndrome (a medical condition characterized by neuromuscular weakness that can progress to paralysis in severe cases) due to stroke. 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) Section G, dated in 2023, the MDS indicated Resident 1 had total dependence on staff for bed mobility (moving from side to side or changing position in bed) with a two person physical assist. During a review of Interdisciplinary Fall, dated 6/4/24, the document indicated .as per CNA resident was given ADL care at the time and resident slipped next to resident's right side of the head . During a review of Resident 1's Body Check, dated 6/5/24, (after Resident 1 was back from hospital), the Body Check indicated Forehead laceration S/P (Status Post) fall. During an interview on 6/17/24 at 4:30 p.m. with CNA 1, CNA 1 stated she was giving Resident 1 ADL care when Resident 1 fell from the bed. CAN 1 stated she had provided ADLs for Resident 1 for many years and none of the nurses told her that two people were needed for Resident 1's ADL. CNA stated usually nurses inform the CNAs about any residents who needed two CNAs to provide ADL, CNA 1 also stated the last few years she was always giving ADL to Resident 1 by herself and never two CNAs involved in Resident 1's care at the same time. During an interview on 6/18/24 at 1:45 p.m. with the Director of Nursing Assistant ([NAME]), [NAME] stated Resident 1 always had one CNA for providing ADLs because Resident 1 was immobile. (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 06/18/2024 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)