Health inspection·April 22, 2022

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to meet the needs for two (Resident 8 and Resident 10) of 16 sampled residents when the facility did not develop and implement a care plan for Resident 8's dialysis (treatment of kidney failure that rids your blood of unwanted toxins, waste products and excess fluids by filtering your blood) care and for Resident 10's hospice care. This deficient practice may result in Resident 8 and Resident 10's physical, psychosocial and functional needs to go unmet. Findings: 1. A review of Resident 8's Facesheet, dated 4/20/22, the face sheet indicated Resident 8 was admitted on [DATE] with a diagnosis of an infected dialysis catheter (tube inserted into the vein). A review of Resident 8's Minimum Data Set (MDS- an assessment tool) dated 2/10/22, the MDS indicated Resident 8 is on dialysis treatment. During an interview on 4/20/22 at 9:53 a.m. with Dialysis Nurse, Dialysis Nurse stated, Resident 8 had been receiving dialysis at Dialysis Nurse's clinic since February 2022. Dialysis Nurse stated, the dialysis access site for Resident 8 had been her left upper chest catheter. Dialysis Nurse further stated, Resident 8's left upper arm graft had not been used since admission in February 2022. During a concurrent record review of Resident 8's care plan on 4/21/22 at 11:16 a.m. with Director of Nursing (DON), DON stated, the care plan for Resident 8 was not updated with the use of a dialysis catheter. She further stated, it is important to update the care plan because the care for a dialysis catheter is different from the care for a dialysis graft. 2. A review of Resident 10's Facesheet, dated 4/21/22, Facesheet indicated, Resident 10 was admitted on [DATE], under palliative care (specialized care that focuses on providing patients relief from pain and other symptoms of a serious illness, no matter the diagnosis or stage of disease). A review of Resident 10's MDS dated [DATE], MDS indicated, Resident 8 is on hospice (end of life care). During a concurrent record review of Resident 10's care plan on 4/21/22 at 11:27 a.m. with DON, there was no care plan for hospice care. DON stated, the hospice team does the care plan and any documents that are needed, the facility staff will ask from the hospice team. DON further stated, it is (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 8 Event ID: 555914 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 555914 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE We Care Skilled Nursing Facility 21863 Vallejo Street 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)