Health inspection·May 22, 2019

F 0677 wanted her facial hair shaved. Level of Harm - Minimal harm or potential for actual harm During a separate observation and concurrent interview on 5/20/19 at 11:44 a.m., Resident 80 remained with unshaven facial hair. Mental Health Worker (MHW 1) stated, I will shave her today. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555611 If continuation sheet Page 2 of 6 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 555611 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Morton Bakar Center 494 Blossom Way Hayward, CA 94541 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Record review on 5/21/19 of the document titled, admission Record, showed the facility admitted Resident 16 on 1/26/17 with diagnoses which included kidney disease. Review of the document titled, MDS 3.0 Nursing Home Comprehensive Version, (Minimum Data Set - An assessment used to direct health care needs) dated for 2/4/19, showed Resident 16 was on an anticoagulant (blood thinner) medication. Review of Resident 16's Medication Administration Record dated for 1/1/9 through 2/28/19, showed no reference of an anticoagulant medication. In an interview on 5/21/19 at 8:30 a.m., the facility's Director of Nursing (DON) confirmed Resident 16 had not been receiving an anticoagulant medication and the MDS documentation that indicated he was, was a mistake. In an interview on 5/21/19 at 9:15 a.m., the facility's Minimum Data Set Coordinator (MDSC) confirmed the indication of Resident 16 being on an anticoagulant medication on Resident 16's MDS form, was an error. 2. During a review of the clinical record 5/19/19 at 6 p.m., the admission record (face sheet), indicated that Resident 193 was admitted to the facility on [DATE] from a Regional Medical Center/Psychiatric Hospital with diagnoses which included Schizophrenia (a mental illness hallmarked by delusions and/or hallucinations). Review of discharge records from the transferring facility for Resident 193 dated on 4/29/19 showed that the coordination of transfer from the community hospital that Resident 193 came from was not indicated on the admission record. Review of the facility's social services progress notes dated on 4/30/19 at 4:41 p.m., showed that the admission history and physical for Resident 193 dated for 5/3/19 indicated Resident 193 was admitted from a hospital and location different than was indicated on the admission record. During an interview on 5/21/19 at 10:30 a.m., the Medical Records Director (MRD), stated the nurses enter information into the electronic admission record upon a resident's arrival to the facility. The MRD stated that documents received from a discharge location are used in order to audit the medical/clinical record within 72 hours of admission to the facility. The MRD confirmed the admitted from and admission location information on the admission record was incorrect for Resident 193. In an interview on 5/22/19 at 10 a.m., the Director of Nursing (DON) stated that the incorrect information in Resident 193's admission record, would make it difficult to contact the previous care team for information or coordination of care for Resident 193. Review of a document on 5/21/19 titled, PROTOCOL on the electronic health record system showed that the Licensed Nurse will activate the resident's record and enter all other information such as completion of face sheet based on information gathered from discharging facility and that Medical Records will audit accuracy of information within 72 hours after admission. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555611 If continuation sheet Page 3 of 6 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 555611 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Morton Bakar Center 494 Blossom Way Hayward, CA 94541 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 0842 Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to maintain medical records that were accurate for three (Residents 25, 193 and 16) of three sampled residents when: 1. For Resident 25 the social services form titled, Danger to Self, Danger to Others Risk Assessment was incorrectly dated and Resident 25 was identified by a different name. Residents Affected - Some 2. For Resident 193, the admission Record did not reflect the correct location of the facility Resident 193 was admitted from. 3. For Resident 16, the Minimum Data Set (MDS- an assessment tool used to direct health care needs) was coded inaccurately. These failures resulted in inaccurate information being shared and had the potential for Residents 25, 193 and 16 to receive uncoordinated care. Findings: 1. Review of Resident 25's admission Record on 5/19/19 indicated Resident 25 was admitted to the facility on [DATE] with multiple diagnoses which included Schizoaffective Disorder (a mental disorder in which a person experiences a combination of hallucinations or delusions and is also hallmarked by a mood disorder such as depression or mania). Continued review of Resident 25's Initial Minimum Data Set (MDS - an assessment tool used to direct health care needs) dated 2/14/19 indicated that Resident 25 was cognitively intact meaning that she had the ability to understand and be understood by others. Further review of a document titled, Social Services-Danger to Self/Others Risk Assessment, dated on 2/7/18 showed that Resident 25 was identified by another name. During an interview on 5/20/19 at 10:00 a.m., the Social Worker (SW 2) confirmed the date and name on the risk assessment were incorrect and that the assessment was done on 2/7/19. SW 2 stated however that she was describing Resident 25 and that the written notes on the assessment were accurate. SW 2 further stated she understood the importance of accuracy of medical records. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555611 If continuation sheet Page 4 of 6 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 555611 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Morton Bakar Center 494 Blossom Way Hayward, CA 94541 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 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the skilled nursing facility did not coordinate hospice care for two of two sampled residents (Residents 24 and 31). Facility staff did not have a schedule for hospice nursing visits, maintain complete copies of the hospice nursing visit notes in the clinical record, or document communication/coordination with hospice services during their visits. These failures resulted in the potential for lack of continuity of care for Residents 24 and 31 who were receiving hospice services at the facility. Findings: 1. Review of the clinical record on 5/19/19 of the document titled admission Record showed the facility admitted Resident 24 on 2/4/19 with diagnoses which included malnutrition. In an interview on 5/20/19 at 2:20 p.m., the facility's Director of Nursing (DON) stated that licensed staff coordinated care with the hospice by checking to see if there were any new documented orders. The hospice nurse asks facility staff if they have any concerns. The DON stated however that this information should be documented in the clinical record. In an interview on 5/21/19 at 9:25 a.m., Licensed Vocational Nurse (LVN 3) stated there was no documented hospice nurse visit schedule at the facility. LVN 3 stated the hospice nurses, Just come, and they do not routinely leave a copy of their visit notes in the clinical record. LVN 3 then stated it would be better if they left copies so facility staff could ensure they were, On the same page, and that provision of coordinated and consistent care occurred. LVN 3 stated without a visit schedule or notes, the facility staff do not know when hospice visited or what type of care was provided. In an interview at on 5/21/19 at 10:12 a.m., the Social Worker (SW 1) stated the hospice agency re-evaluates Resident 24's hospice status at each visit. SW 1 stated hospice Manages the case, and she did not know when the hospice nurses made their visits to see Resident 24. In an interview at on 5/21/19 at 11:36 a.m., the facility's Associate Director of Nursing (ADON) stated once the hospice agreement and admission forms are signed, staff communicate with the hospice staff over the phone, and that this communication is not documented in the clinical record. In an interview at on 5/21/19 at 1:05 p.m., the hospice agency nurse (HPCC) stated hospice nursing staff do not send a schedule for visits to the facility and do not consistently leave copies of their visit notes. The HPCC stated the hospice agency focuses on the physical care of the resident while the facility focuses on the psychological care. In an interview on 5/22/19 at 11:16 a.m., the DON confirmed there was no documentation which showed staff communicated with the hospice agency. The DON stated, even if there wasn't a change in condition or new orders, the facility staff should document in their daily notes that hospice had made a visit on a particular day and staff discussed with them the continued effectiveness or ineffectiveness of the current plan of care. Record review on 5/24/19 of the documents titled HSPC Routine Visit, (hospice nursing visit notes) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555611 If continuation sheet Page 5 of 6 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 555611 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Morton Bakar Center 494 Blossom Way Hayward, CA 94541 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 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some showed Resident 24 had been seen by hospice on 3/27/19, 3/29/19 and 4/2/19. There was no documentation in the clinical record which showed that the facility staff communicated or coordinated with the hospice nurse. Review of the document titled, Letter of Agreement for Routine and/or General Inpatient Levels of Care of a Hospice Patient in a Skilled Nursing Facility,(an agreement signed between the hospice and the facility) showed, The Medicare Conditions of Participation require that Hospice collaborate with Facility to develop a coordinated Plan of Care and that All services provided in accordance with this agreement must be documented. 2. Review of Resident 31's admission Record on 5/19/19 indicated Resident 31 was admitted to the facility on [DATE] with multiple diagnoses which included protein-calorie malnutrition (a form of malnutrition that is defined as a range of pathological conditions arising from lack of dietary protein and/or energy (calories) in varying proportions). Continued review of the clinical record showed that Resident 31 was admitted to the hospice care program (care designed to give supportive care to people in the final phase of a terminal illness and focus on comfort and quality of life, rather than a cure) with the terminal diagnosis of cardiomyopathy (refers to a disease of the heart muscle which causes the heart muscle to become enlarged, thick or rigid) on 8/15/18. Further review of Resident 31's medical record showed hospice nurse staff visits on 4/2/19, 5/9/19, 5/14/19, and 5/20/19. There was no documentation of hospice visits in Resident 31's medical record. During an interview on 5/21/19 at 10:10 a.m., Licensed Vocational Nurse (LVN 1) stated they have a hospice nurse visit schedule and it is usually hanging in the facility's chart room. LVN 1 was unable to show the hospice visit schedule and further stated that the licensed staff communicates with hospice service via phone. LVN 1 continued by stating she has called the hospice nurse due to Resident 31 running out of medication, but she did not document the conversation in Resident 31's medical record. LVN 1 stated that she, just wrote it on the 24-hour (nursing) report. During an interview on 5/21/19 at 10:35 a.m., Licensed Vocational Nurse (LVN 2) stated there is no schedule for hospice nurse visits, but that hospice services calls the facility on the day they visit Resident 31. LVN 2 admitted the hospice nurse did not call yesterday, but she knew hospice services was at the facility because LVN 2 saw the guy. LVN 2 also stated she did not document a discussion she had with the hospice Nurse Practitioner (NP) concerning another resident on hospice which was a very important concern but she did not document it, and that she should have charted it because it was important. In an interview with the Hospice Patient Care Coordinator (HPCC) on 5/21/19 at 1:00 p.m., HPCC stated there were no calendars for nurses' visits. HPCC further stated copies of visit notes are sometimes left in the chart, sometimes not. The HPCC also stated hospice deals with the physical/medical side of the resident and the facility deals with their mental side. Review of the facility policy and procedure titled, Hospice Care, dated 4/1/13 indicated, The hospice and the facility communicate, establish, and agree upon a coordinated plan of care which reflects the hospice philosophy . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555611 If continuation sheet Page 6 of 6