Driftwood Healthcare Center - Hayward

Inspectors wroteBased on observation, interview, and record review, for nine of 22 residents (Resident 2, 3, 4, 5, 6, 7, 8, 9 and 10) who had tracheostomy (a surgically created opening [stoma] in the front of the neck and directly into the windpipe [trachea]), the facility failed to ensure that sufficient tracheostomy inner cannula (easily removable tube inside the tracheostomy's outer tube, which catches mucus, can be cleaned or disposed of without removing the entire tracheostomy tube. This prevents airway blockages) supplies were available and immediately accessible as required for safe and effective respiratory care. This failure had the potential to place the residents at risk for infection, airway obstruction and inadequate ventilation, and delayed emergency response. During a review of facility's undated record titled Resident Face Sheet (RFS), the RFS indicated the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff adherence to its infection control policies and Centers for Disease Control and Prevention recommended (CDC, lead federal agency responsible for protecting public health and safety) transmission based precautions when a Certified Nursing Assistant (CNA) 1 entered Residents 13, 14, 15, 16, 9, 8, 7, and 17's room requiring contact precautions without donning the required personal protective equipment (PPE, is equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses). This failure exposed residents and staff to potential cross contamination and increased the risk of transmission of infectious organisms.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a safe environment for 79 out of 79 sampled residents when the patio gate latch was zip tied. This failure had the potential to result in delay in resident's evacuation in an event of emergency.

Inspectors wroteased on interview and record review, the skilled nursing facility failed to maintain resident confidentiality for two of the three sampled residents (Residents 1 and 2) when the licensed social worker disclosed personal information without obtaining consent from Residents 1 and 2. This resulted in a violation of resident confidentiality. During a record review of Resident 1's clinical document Resident Face Sheet (RFS), the RFS indicated the facility admitted Resident 1 in February of 2025 with multiple medical diagnosis including cerebral infarction (stroke). During a review of Resident 1's clinical document MDS 3.0 Nursing Home Comprehensive (NC) Version 1.20.1 (MDS) dated [DATE], the MDS indicated Resident 1 was alert and oriented. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of three sampled residents (Resident 1 and 3), received tracheostomy care consistent with professional standards of practice, their physician's orders and their care plan when: 1. Resident 1's tracheostomy (a surgical procedure that creates an opening in the neck to create an artificial airway) inner cannula (a removable, lockable tube inserted into the outer tube to maintain an open airway and manage secretions) was not changed for a total of five days, including three consecutive days. 2. Resident 2 did not have the necessary emergency tracheostomy equipment at bedside. This failure had the potential to cause Residents 1 and 2 increased risk for infection and respiratory distress. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) received Oxycodone (a medication used to treat moderate to severe pain) as ordered by their physician. This failure had the potential to cause Resident 1 unnecessary frustration and pain. During a review of Resident 1's admission Record, printed 2/5/26, the record indicated Resident 1 was admitted to the facility in 2025 with a diagnosis of cerebral infarction (A stroke that occurs when the blood supply to part of the brain is blocked or reduced), and depression. During a review of Resident 1'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. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of six residents (Resident 1 and Resident 2) were free from physical abuse when both struck each other during a physical altercation. This resulted in Resident 1's right hand and left ear getting hurt and making him feel fearful within the facility. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure immediate interventions during a resident-to-resident altercation for two sampled residents (Resident 1 and Resident 2) when a verbal altercation between Resident 1 and Resident 2 escalated into a physical altercation without timely staff separation. This failure placed Resident 1 and Resident 2 at risk for escalation of aggressive behaviors, physical injury, and emotional distress. During a review Resident 1's Face Sheet, printed on 1/22/26, the Face Sheet indicated Resident 1 was admitted to the facility in November 2023 with diagnoses of acute respiratory syndrome (life-threatening lung injury that allows fluid to leak into the lungs) and anxiety disorder (a mental health condition causing excessive and persistent fear or worry). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure nursing staff had physician order, facility policy and training to use enteral tube (tube placed into a surgically create hole leading into the gastrointestinal tract) clog removal tool and followed facility expectations when performing enteral tube clog removal care for two of 16 sampled residents (Resident 274 and 45) who were receiving medications through an enteral tube. This failure had the potential for enteral tube perforation or gastrointestinal damage when nursing staff inserted plastic clog removal tool into Resident 274 and 45's enteral tube without physician order, facility policy or training on use of the clog removal tool.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 14 controlled medications (substances that have an accepted medical use, medications which fall under US Drug Enforcement Agency (DEA) Schedules II-V, and have a potential for abuse, ranging from low to high, and may also lead to physical or psychological dependence) from the Director of Nursing (DON) controlled medications cabinet were documented and destroyed according to state law and facility policy. This failure had resulted in 14 controlled medications not being destroyed and had the potential for drug diversion.

Inspectors wroteBased on observation, interview, and record review. the facility failed to ensure cooks had education and skill to puree food properly for 11 of 11 residents receiving a pureed diet when they over processed and over mechanicalized food, which was watery, bland and without flavor. This failure resulted in residents being at risk for decreased satiety and nutrition intake which could result in weight loss.

Inspectors wroteBased on observation and record review, the facility failed to follow menu portions when serving orzo, baked apples and Boston cream pie. This failure resulted in residents receiving portion sizes in excess or below their required needs per physician order or dietician recommendation, potentially putting residents at risk for inability to maintain normal body weight and receiving acceptable nutritional values.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the juice machine was cleaned according to manufacturer's instructions when the machine was not flushed weekly and the bar gun was soaked in hot water. This failure resulted in improper sanitation and the risk for transmission of foodborne illness to 56 residents receiving juice.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure infection control policy and procedure was followed for 10 of 23 sampled (Residents 21, 16, 32, 60, 3, 27, 51, 273, 272 and 59) residents when: 1. staff did not use sterile gloves when performing sterile tracheostomy (artificial airway at the throat which is kept open with a tube inserted into the opening) suctioning (procedure to remove secretions from the respiratory tract by vacuum) on Resident 21, 2. staff did not perform hand hygiene when switching between three residents (Resident 16, 32, and 60) who needed tracheostomy care, 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 17 sampled residents (Resident 25) received good grooming and personal hygiene care when resident did not receive complete fingernail care. This failure resulted in Resident 25 to feel helpless and placed him at risk for developing infections and hurting himself with long, pointed fingernails.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure consistent intervention and recommendation was carried out for tube feeds according to patient needs for (Resident 44) while tube feeds was the sole source of nutrition. This failure resulted in an unintended, unplanned weight gain of 21.27% in one year creating potential risks including: 1. Increased Risk of Cardiovascular Disease: Excess weight can lead to increased strain on the heart, potentially causing or worsening conditions such as hypertension, heart disease, and stroke. 2. Development or Worsening of Diabetes: Weight gain, particularly in the abdominal area, can lead to insulin resistance and increase the risk of developing type 2 diabetes or exacerbate existing diabetes. 3. Worsening of Respiratory Issues: [...]

Inspectors wroteBased on interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical well-being for one of 17 sampled residents (Resident 43, receiving hemodialysis [a process of filtering the blood of a person whose kidneys are not working normally] treatment) when: 1. Licensed Nurse (LN) was not fully knowledgeable about the management of care in the event of Resident 43's arterial-venous fistula (a direct connection between the artery and a vein for dialysis access) site complications, post dialysis treatment. This failure resulted in the potential that staff may not correctly perform the proper intervention and prompt physician notification for a resident's dysfunctional access site condition after return from dialysis treatment. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Kitchen Manager (KM) had completed the required six hours of inservice training on the specific California dietary service requirements contained in California Code of Regulations (CCR) Title 22 prior to assuming full time duties as a dietetic services supervisor at the health facility, This failure resulted in the KM not possessing competencies and skills for California to carry out food and nutrition functions, potentially putting residents at risk for foodborne illness.

Inspectors wroteBased on interview and record review, the facility failed to provide pressure ulcer (a tissue injury resulting from unrelieved pressure over an area of the body) prevention and treatment for one of two sampled residents (Resident 1) when the facility failed to: · develop a care plan for Resident 1 ' s pressure ulcer upon discovery, · monitor Resident 1 ' s pressure ulcer, · provide a pressure reducing mattress, · and reposition Resident 1 off the pressure ulcer. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper handling and delivery of respiratory care consistent with the facility's policy and procedures (P&P) and the professional standards of practice for three out of eight sampled residents (Resident 3, Resident 5, and Resident 7) when: 1. Resident 3's nasal cannula (a medical device with two prongs that is connected to an oxygen source used to deliver supplemental oxygen directly into the nostrils) was not labeled with the date it was first used; 2. Resident 5's nasal cannula and nebulizer (machine that turns liquid medicine into a mist that can be easily inhaled) simple facemask and tubing was not labeled with the date it was initially used and Resident 5's physician's orders for oxygen therapy were not followed; and, 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow and maintain an effective infection prevention and control program for a census of 78 residents when: 1. Three facility staff entered a contact isolation precaution room (an isolation precaution implemented when a patient infected with a bacteria, virus, or other microorganism which is transmittable through direct or indirect contact with the patient or the patient ' s environment) without using all the required personal protective equipment (PPE); and, 2. Resident 3 and Resident 7's nasal cannula, and Resident 5's respiratory care tubing were not labeled with the date it was initially used. [...]

Inspectors wroteBased on interview, and record review, the facility failed to provide preventive care for pressure injury/ulcer (PI/PU, injury to skin and underlying tissue resulting from prolonged pressure) consistent with professional standards of practice for one of eight sampled residents (Resident 8) when Resident 8's physician's order of turning and repositioning every two hours was not consistently implemented. This failure resulted in Resident 8's sacral (lower back near the crease of the buttocks) wound to get worse and had the potential for Resident 8's skin condition to get worse, develop complications, and/or possible development of other pressure related injuries.

Inspectors wroteBased on observation and interview, the facility failed to ensure medications were secure for a census of 76, when 3 medication carts were found unlocked and unattended. This failure had the potential to expose residents, staff, and visitors to unauthorized access to medications, resulting in possible injury or drug diversion.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to store, prepare, and distribute food in a safe and sanitary manner when: 1. Expired food items were found in the dry storage rack in kitchen; 2. Freezer 1 temperature was not reaching Zero (0) degree Fahrenheit and lower; 3. There was no air gap (a gap of air between the floor and a drainpipe to prevent backflow of sewage into the equipment) for food preparation sink; 4. There was no proper air gap in the ice machine; 5. Microwave was not cleaned and had food residue on the top inside surface; and 6. Kitchen counter under the steamer was sticky and dusty. These failures had the potential to cause food borne illnesses for 59 residents who received food from the kitchen for a facility census of 75.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff followed proper standard and transmission-based precautions to prevent the spread of infection when: 1. Laundry Staff (LS 1) stored personal items in the clean linen/laundry area; 2. Oxygen (O2) tubing was not labeled and dated for Residents 34, 39, and 57; 3. Licensed Vocation Nurse (LVN) 2 did not perform hand hygiene during medication administration; and 4. LVN 2 did not clean/disinfect the shared blood pressure (BP) machine and medication tray in between residents; and These failures had the potential to result in cross contamination and spread of infections for Residents 34, 39, 57 and other residents in the facility.

Inspectors wroteBased on interviews and record reviews, the facility failed to complete 17 of 18 sampled residents' (Residents 6, 9, 32, 33, 11, 27, 16, 3, 5, 2, 10, 29, 4, 21, 37, 12 and 19) Minimum Data Set (MDS - an assessment tool to guide resident care) assessments within 92 calendar days. This failure resulted in Residents 6, 9, 32, 33, 11, 27, 16, 3, 5, 2, 10, 29, 4, 21, 37, 12 and 19 to not receive a timely assessment and had the potential to delay resident's care based on their individual physical and psychosocial needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three of five sampled residents (Resident 51, 43 and 75) received grooming and personal hygiene care when: 1. Resident 51 and 43 had long, sharp fingernails with black matter underneath on both hands; and 2. Resident 75 did not receive toenail care. These failures resulted in Residents 51, 43 and 75 to feel helpless and placed them at risk for developing infections and hurting themselves with long nails.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three of seven sampled residents (Resident 15, 27 and 484) received medications without an error. The facility's medication pass observation during the survey resulted in seven errors out of 25 opportunities and indicated a medication error rate of 28 percent (%). This failure placed Residents 15, 27 and 484 at risk for not getting the full therapeutic effect of their prescribed medications and had the potential to result in undesired health care outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe medication and biological storage when: 1. Seven expired hypodermic needles (needle used to inject a substance), one expired COVID-19 (a respiratory virus) antigen test kit were stored in the medication storage room; 2. One expired intravenous (IV) connector and Maxitrol (medication to treat swelling of the eye) eye ointment for a resident no longer in the facility (Resident 485) was found in the subacute Medication Cart 2; and 3. 10 loose pills and Resident 72's Humalog (blood sugar medication) was opened for more than 28 days were stored in the Medication Cart 2. These failures had the potential of exposing residents to drugs and biologicals with questionable potency and efficacy.

Inspectors wroteBased on interview and record review, the facility failed to follow its pneumonia vaccination policy and procedure for three of five sampled residents (Residents 5, 6, and 70) when the pneumococcal vaccine was not provided to Residents 5, 6, and 70. This failure had the potential for Resident 5, 6 and 70 to contract and develop a pneumococcal infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately code rehabilitative services and functional status for one of 18 sampled residents (Resident 5) Minimum Data Set (MDS - an assessment tool to guide resident care) assessment. This failure resulted in an inaccurate reflection of Restorative Nursing Aide (RNA) interventions and functional status for Resident 5 and had the potential for Resident 5 to not receive care to meet their needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow the fall prevention care plan for one of one sampled resident (Resident 40) when Resident 40 did not receive frequent monitoring every 15 minutes after experiencing three falls within a one month period. This failure resulted in Resident 5 experiencing three falls, not receiving individualized care and placing Resident 5 at risk of further falls and avoidable injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the physician's order for one of three sampled residents (Resident 26) with a risk of developing pressure sores when the physician's order to apply heel protectors for Resident 26 was not followed. This failure put Resident 26 at risk for developing pressure ulcers or injury to both heels.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure appropriate indwelling catheter (a tube inserted into the urinary bladder which drains urine into a drainage bag outside the body) care for one of eight sampled residents (Resident 179) when Resident 179's. This deficient practice had the potential for Resident 179 to develop an infection or a urinary tract infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the tracheostomy care policy and procedure and provide one of 23 residents (Resident 35) tracheostomy (a surgical opening on the neck for placing a breathing tube) care consistent with professional standards of practice when Resident 35's tracheostomy had thick greenish matter around the tracheostomy opening and soiled dressing around the stoma site (the opening in the neck where the tracheostomy tube is placed). This deficient practice placed Resident 35 at risk for airway obstruction, skin irritation, and infection.

Inspectors wroteBased on interview and record review, the facility failed to develop, implement and maintain an ongoing effective Quality Assurance and Performance Improvement (QAPI) plan for infection prevention and control which was identified as a facility-wide problem at the facility. (Cross Reference F880) This failure had the potential to place all 75 residents residing at the facility at a higher risk of morbidity and mortality due to spread of infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an environment that promoted dignity while dining for one of 22 (Resident 9) sampled residents when Certified Nursing Assistant (CNA) 1 remained standing while assisting Resident 9 with his meal. For Resident 9, this deficient practice had the potential to result in Resident 9 receiving an undignified dining assistance.

Inspectors wroteBased on interview and record review, for one (Resident 1) of 22 sampled residents, the facility failed to transmit Resident 1's admission and quarterly Minimum Data Sets (MDS - an assessment tool used to direct care) within the allowable timeframes after completing Resident 1's admission and quarterly MDS assessments. This deficient practice resulted in the delay of resident-specific information to reflect Resident 1's overall status, necessary for the provision of care.

Inspectors wroteBased on observation, interview, and record review, for one of 22 sampled residents (Resident 79) the facility failed to provide the necessary care to maintain personal hygiene when Resident 79 did not receive assistance with shaving for a week. This failure resulted in Resident 79 having long facial and neck hair growth.

Inspectors wroteBased on observation, interview and record review, for one of 22 sampled residents (Resident 17), the facility failed to ensure that drugs were stored in accordance with the manufacturer's instructions for use when Resident 17's Lantus insulin (injectable medication that treats diabetes) vial was stored in the medication cart beyond use by date. This failure had the potential to result in diminished efficacy of these medications.

Inspectors wroteBased on interview and record review, the facility failed to maintain accurate medical records on one ( Resident 133) of 22 sampled residents when Resident 133 did not have an entry tracking record completed upon returning to the facility. This deficient practice resulted in Resident 133 not being listed on the Center for Medicare and Medicaid Services (CMS) facility census and had the potential for Resident 133 to not receive care and services that were needed.