Health inspection·December 11, 2025

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. Based on observation, interview, and record review, the facility failed to allow one out of 22 Residents (Resident 11) to exercise their right to self-determination when they were not provided nutrition in accordance with their preferences. This failure had the potential to result in Resident 11 feeling upset and disrespected. During a review of Resident 11's admission Record, printed 12/9/25, the record indicated Resident 11 was admitted to the facility in January 2025 with a diagnosis of moderate protein-calorie malnutrition. During a review of Resident 11's Brief Interview for Mental Status (BIMS, is a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.), dated 2/3/25, the record indicated Resident 11's BIMS score was 14. During a concurrent observation and interview on 12/8/25, at 12:43 p.m., with Resident 11, Resident 11's lunch tray was observed with mixed vegetables that included cauliflower. Resident 11 stated it made them upset, and they would not eat it. During a review of Resident 11's Lunch Meal Ticket, dated 12/8/25, the Meal Ticket indicated, Resident 11's Dislikes: . Cauliflower. During an interview on 12/8/25, at 12:54 p.m., with [NAME] (CK) 1, CK 1 stated Resident 11 should not have received mixed vegetables that had cauliflower, and it was a mistake. During an interview on 12/11/25, at 2:49 p.m., with Director of Nursing (DON), DON stated it was important to honor resident food choices so they could have eaten more, prevent weight loss and for resident happiness. During a review of Resident 11's Care Plan, Resident is at nutritional risk., printed 12/11/25, the Care Plan indicated, Honor food preferences within meal plan. 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 12/11/2025 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)