Emmanuel Post Acute Care - Hayward

Inspectors wroteBased on observation, interview, and record review, the facility had a 17.39 % error rate when four medication errors out of 23 opportunities were observed during a medication pass for one of nine residents (Resident 2). These failures resulted in medications not given in accordance with the Physician's Orders and may affect Resident 2's health conditions. During a medication pass observation on 3/6/26 at 9:50 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 was observed to give Resident 2 six medications, including 1. Docusate Sodium 250 milligrams (mg. a form of measurement) capsule, 2. Hydrochlorothiazide 12.5 mg tablet, 3. Metoprolol Tartrate 25 mg tablet, 4. Multiple Vitamins tablet, 5. Senna 8.6 mg tablet and 6. Vitamin B12, 2000 micrograms (mcg. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement Resident 3's oncology referral ordered by the General Acute Care Hospital (GACH) upon the resident's discharge to the facility (oncology is a specialized branch of medicine dedicated to the diagnosis, treatment, and prevention of cancer). This failure resulted in Resident 3 having a delay in the referral for her cancer treatment. During a phone interview on 3/5/26, at 9:37 a.m., with Resident 3's Family Member (FM) 1, FM 1 stated, the facility failed to timely refer the resident to an oncologist. FM 1 stated that this caused a referral delay until she intervened on 1/14/26. FM 1 also stated that the facility referral to oncologist was only made due to FM 1's follow-up (an oncologist is a doctor who diagnoses and treats cancer). [...]

Inspectors wroteBased on interviews, and record review, the facility failed to protect Resident 1 from hitting his right foot and toes during care on two separate occasionsThis resulted in Resident 1 sustaining right foot and toes pain and swelling. During a review of Resident 1's Facesheet ( information containing contact details, brief medical history at-a-glance) dated 3/5/26 indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis caused by stroke ( hemiplegia is a form of paralysis that affects one side of the body, usually due to a brain injury and hemiparesis is weakness on one side of the body). During an interview on 3/5/26 at 10:21 a.m., Resident 1 stated that the staff repeatedly accidentally hit his right foot and toes in the door and bathroom wall while being transported in the shower chair and commode. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure 3 out of 5 sampled residents (Residents 8, 9, and 51) were free from unnecessary psychotropic medications (drugs that affects brain activities associated with mental processes and behavior) when all three residents received psychotropic medications without documented evidence of behavioral (or non-pharmacological) interventions attempted. The employment of non-pharmacological/non-drug interventions allows the facility to minimize the need for psychotropic medications, use the lowest possible dose, or discontinue the medications. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the nursing practices that met professional standards for 3 out of 31 sampled residents (Resident 49, 57, and 74) when:1. There was no blood pressure (BP) assessment prior to Lasix (a medication to treat high BP and other conditions) administration for Resident 49.2. Pain medication orders were not followed as prescribed for Residents 57 and 74.3. Elevated ammonia level (toxic waste product produced by the body's metabolism of protein) was not communicated with the physician for Resident 57. The failures resulted in medications not being given as ordered, and inadequately monitored or untreated medical conditions for the residents.1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary one to one (1:1; one staff to one resident) feeding assistance to seven out of 42 sampled residents (Residents 19,66, 67, 85, 62, 29 and 58). This failure resulted in Resident 19, 66, 67, 85, 62, 29 and 58 to be fed more than 15 minutes after meal trays were delivered to bed side. During record review of Resident 19's MDS, dated [DATE], section 'GG-Functional Abilities' indicated, Impairment on one side to upper extremity, and Dependent (Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity.) regarding eating. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the provision of pharmaceutical services that included availability of medications, accurate administration of medications, safe medication storage, and accurate accountability of controlled substances (that can be easily abused and are under strict government control) when:1. Lovenox (an anticoagulant to treat blood clots) was not available for administration for Resident 34 on 6 occasions since May 2025. This had the potential for the resident to develop blood clots.2. Glipizide (a medication for diabetes) as not accurately administered as per manufacturer's specifications for 2 residents (Residents 9 and 51). This resulted in the residents not receiving the optimized therapeutic effect of the medication.3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility had a medication error rate of 15.15% when five medication errors occurred out of 33 opportunities during the medication administration for three out of eight residents (Residents 62, 70 and 1). Resident 62 received an insulin (medication to lower blood sugar) dose via insulin pen without the pen being primed prior to administration. Resident 70 did not receive two medications as scheduled; and Resident 1 did not receive two medications as prescribed. The failures resulted in the residents not receiving medications as prescribed and had the potential for complications of their medical conditions (such as high/low blood sugar, breathing problems or blood clots). 1. During a medication observation on 8/25/25 at 4:38 p.m. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure proper labeling and storage of medications according to the facility policy and procedures (P&P) and/or manufacturer specifications in two of two medication carts and two of two medication rooms when:Three unopen bottles of latanoprost (a medication for glaucoma) eye drops and an unopened insulin lispro (a pre-filled insulin pen containing a short-acting insulin called insulin lispro, used to treat high blood sugar) pen were found stored at room temperature. Two opened containers of glucose test strips and an opened vial of tuberculin purified protein derivative (PPD, protein substance used to diagnosis tuberculosis (TB), an infection in the lungs) were not dated with an open date. [...]

Inspectors wroteBased on observation, interview, record review, the facility failed to maintain walk in freezer temperature below zero degrees Fahrenheit. This failure had the potential to spread foodborne illnesses to all residents. During an interview and observation on 08/26/2025 at 10:04 AM the walk-in freezer in kitchen thermometer read 10 F. Dietary Manager (DM) placed a new thermometer. DM stated staff use the largest thermometer to document onto temperature log. Largest thermometer read 10 F. Touch tested ice cream, broccoli, donuts, chicken, fries, diced carrots, meat patties, all items frozen hard/solid. During an observation on 08/26/2025 at 10:10 AM walk-in freezer thermometer read 8 F on two separate thermometers. During an observation on 08/26/2025 at 11:34 AM the walk-in freezer temperature read 8 F on two separate thermometers. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of eight sampled Resident's (Resident 21) Responsible Party (RP; the party responsible for making health care decisions when the principal party is unable to make said health care decisions for him or herself) choice in Resident's hair cut was considered. This failure resulted in Resident 21 receiving an unwanted haircut and feeling terrible. During record review of admission record, printed on 8/28/25, Resident 21 was admitted on [DATE]. During record review of Resident 21's Minimum Data Set (MDS, an assessment used to guide care) dated 5/25/25, indicated Resident 21's Brief Interview for Mental Status (BIMS, an assessment used to assess mental status) score was 12 out of 15, indicated Resident was mildly impaired. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of eight sampled Resident's (Resident 21) Responsible Party (the party responsible for making health care decisions when the principal party is unable to make said health care decisions for him or herself) choice in Resident's hair cut was considered. This failure resulted in Resident 21 receiving an unwanted haircut and feeling terrible. During record review of admission record, printed on 8/28/25, Resident 21 was admitted on [DATE]. During record review of Resident 21's Minimum Data Set (MDS, an assessment used to guide care) dated 5/25/25, indicated Resident 21's Brief Interview for Mental Status (BIMS, an assessment used to assess mental status) score was 12 out of 15, indicated Resident was mildly impaired. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary treatment and services to one of eight Residents (Resident 21) to increase and/or prevent a further decrease in range of motion (ROM; the full movement potential of a joint.). This failure resulted in Resident 21 not receiving physician ordered passive range of motion (PROM; the movement of a joint through the range of motion with no effort from the patient) exercises for two months and feeling weak. During record review of admission record, printed on 8/28/25, Resident 21 was admitted on [DATE]. During record review of Resident 21's Minimum Data Set (MDS, an assessment used to guide care) dated 5/25/25, indicated Resident 21's Brief Interview for Mental Status (BIMS, an assessment used to assess mental status) score was 12 out of 15, indicated Resident was mildly impaired. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care according to the facility's policy and procedures (P&P) for one of one resident (Resident 1) receiving medications via the gastrostomy tube (aka G-tube, a tube inserted through the abdomen that delivers nutrition and medications directly to the stomach). The nursing staff did not verify tube placement and check residual volume (the amount of fluid contents remaining in the stomach) prior to administering medications. In addition, the nursing staff administered the medications by pushing through the tube instead of allowing them to go down by gravity. [...]

Inspectors wroteBased on interview and record review, the facility's consultant pharmacist (CP) failed to identify and report irregularities during the monthly drug regimen review (MRR) for 3 out of 31 sampled residents (Residents 9, 51, and 57) when Resident 57 received lactulose (medication to treat constipation and liver disease) for a wrong indication; and Residents 9 and 51 did not receive glipizide (medication for diabetes) as per manufacturer's specifications. The failure resulted in inadequate monitoring for effectiveness and adverse effects for Resident 57's lactulose; and Residents 9 and 51 not receiving the optimized therapeutic effect of glipizide.1. A review of Resident 57's medical record indicated Resident 57 was admitted to the facility with diagnoses that include: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of 31 sampled residents (Resident 57) was free from unnecessary medications. Resident 57 received lactulose (a medication commonly used for liver disease) for a wrong indication for use. This failure resulted in an inadequate treatment plan and insufficient monitoring for medication effectiveness and adverse outcomes related to liver disease. A review of Resident 57's medical record indicated Resident 57 was admitted to the facility with diagnoses that include: alcoholic liver disease (a condition of liver damage) and portal hypertension (elevated pressure in the portal vein, commonly caused by liver disease). Resident 57's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 5/29/25, indicated Resident 57 has no cognitive impairment. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to prepare one out of 42 (Resident 60) Resident meal tray according to resident preferences. This failure resulted in Resident 60 receiving lunch tray without double portion of protein, per Resident preferences. During record review of Resident 60's Minimum Data Set (MDS, an assessment used to guide care) dated 05/17/25, indicated Resident 60's Brief Interview for Mental Status (BIMS, an assessment used to assess mental status) score was 00 out of 15, indicated Resident 60 had severe cognitive impairment. During an observation on 08/26/2025 at 12:32 PM Resident 60 tray was prepared and placed on meal tray cart for delivery but was not given extra protein as listed on meal tray card. [...]

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to employ appropriate infection control practices during the medication administration for 1 out of 8 residents (Resident 1) when:1. Registered Nurse (RN) 1 did not wear a protective gown while administering medications via the resident's gastrostomy tube (aka G-tube, a tube inserted through the abdomen that delivers nutrition and medications directly to the stomach), a practice inconsistent with the facility's enhanced barrier precautions (EBP) policy.2. RN 1 did not change gloves and perform hand hygiene between care and after touching surfaces and going in and out of Resident 1's room. The failures had the potential to increase the risk of cross-contamination and infections, compromising patient safety.1. During medication pass observation on 8/26/25 at 9:20 a.m. [...]

Inspectors wroteBased on observation and interview the facility failed to store all drugs and biologicals in locked compartments when one medication cart and one treatment cart located in hallways were not locked. This finding had the potential for errors , missing medication and create an unsafe environment for residents.

Inspectors wroteBased on interview and record review, the facility failed to provide pressure ulcer (localized damage to the skin and/or underlying soft tissue usually over a bony prominence) care for one of three sampled residents (Resident 1), when staff: 1. did not notify the provider to obtain wound treatments for nine days, 2. did not provide Resident 1 with a low air loss mattress (LAL mattress, pressure relieving device to prevent skin and tissue breakdown) for four days and, 3. did not complete a care plan for Resident 1 ' s sacral pressure ulcer. This failure resulted in Resident 1 ' s sacral pressure ulcer growing from one by 1.5 centimeters (cm, a unit of measurement) to seven by six cm over nine days.

Inspectors wroteBased on interview and record review, the facility failed to have the ordered medication Levetiracetam or Keppra (used to prevent and control seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness]) for one resident (Resident 1). This failure of Resident 1 not receiving Keppra on 8/14/24 resulted in Resident 1 ' s delayed treatment which had the potential to result in seizure episodes. Resident 1 subsequently had two seizure episodes in the morning of 8/15/24.

Inspectors wroteBased on interview and record review the facility failed to schedule a registered nurse (RN) for 8 hours a day, 7 days a week. This failure had the potential to place residents at risk to receive inaccurate assessments and incorrect care.

Inspectors wroteBased on observation, staff interview, and record review, the facility failed to store and prepare food in accordance with professional standards for safety when: 1. A dry food bin lid was unclean; 2. A frozen food bag was open to air; 3. A can with a large dent was available for use These failures had the potential for contamination of food resulting in food-borne illness for 88 residents who received food from the kitchen. 1. During an initial walkthrough observation of the kitchen on 2/26/24, at 10:00 a.m., there were bins stored on shelves in the dry food storage area. A bin containing flour had a fine dusting of white powder all over the top of the lid. During an interview on 2/28/24, at 12:29 p.m., with the Dietary Manager (DM), the DM stated bin lids covered with food debris can attract pests, and bin lids should always be kept clean. [...]

Inspectors wroteBased on Interview and record review the facility failed to electronically submit complete and accurate direct care staffing information based on payroll data to Centers for Medicare and Medicaid (CMS). This failure had the potential to result in the facility's staffing to be unavailable for audit by CMS.

Inspectors wroteBased on interview and record review, the facility failed to ensure the quarterly Minimum Data Sets (MDS, an assessment tool used to guide resident care) were completed within 14 days of the Assessment Reference Date (ARD, a date set to establish a uniform look-back period for all the responses to MDS coding items) for two of 4 sampled residents (Resident 61 and Resident 143). This deficient practice had the potential to result in Residents 61 and 143 not receiving the appropriate care and services needed based on their current health status.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Sets (MDS, an assessment tool used to guide resident care) were completed and submitted to the Centers for Medicare and Medicaid Services (CMS) within the required time frames determined by the Assessment Reference Date (ARD, a date set to establish a uniform look-back period for all the responses to MDS coding items) when two out of 4 Resident's (Resident 31 and 83) Discharge MDS' were not completed and transmitted within 14 days of the ARD. This deficient practice had the potential to result in Residents 31 and 83, not receiving the appropriate care and services needed based on their current health status and to be billed incorrectly.

Inspectors wroteBased on observation, interview and record review, the facility had a 5.71% error rate when two medication errors out of 35 opportunities were observed during the medication pass for two of 10 sampled residents (Resident 143 and Resident 144). Resident 143 did not receive Cosopt (eye drop medication used to treat Glaucoma (an eye condition that causes blindness) as ordered and Resident 144 was not given instructions to rinse mouth after administered a Wixela (Fluticasone/Salmeterol) Inhub Inhalation (medication used to treat asthma [a condition in which airways narrow and swell] and chronic obstructive pulmonary disease COPD, a lung disease that block airflow and make it difficult to breathe]). These failures resulted in medication not given in accordance with the prescriber's orders, which may negatively affect Resident 143 and Resident 144's health conditions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection prevention and control practices when: 1. For one of 38 sampled residents (Resident 85), Licensed Vocational Nurse 1 (LVN 1) did not wear gloves prior to nasogastric tube (NGT, a tube inserted through the nose, down the throat and esophagus, and into the stomach used to administer nutrition or medication to patients who are unable to tolerate oral intake) feeding administration. 2. LVN 1 did not perform hand washing or hand hygiene after removing gloves from sanitizing used blood glucose machine. 3. One pill cutter (a medical device with stainless steel blade used to cut pills and tablets) at Nurses Station 2A medication cart and three pill cutters at Nurses Station 2B medication carts were stored unclean after use. 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Minimum Data Set (MDS-an assessment and care screening tool used to guide care), was accurate for one of one sampled resident (Resident 9) when Resident 9's annual MDS was not coded accurately to reflect a functional impairment of the left hand. This failure resulted in the potential for Resident 9 to not receive appropriate care and treatment for identified conditions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 38 sampled residents (Resident 25) received fingernail trimming as needed. This failure had the potential to result in skin scratches, wounds, and infections from the long fingernails.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure range of motion (ROM) exercises were provided for one of two sampled residents (Resident 34) reviewed for limited ROM. This failure had the potential to result in decline in the Resident 34's ROM.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide pharmaceutical services for two of 10 sampled residents (Resident 143 and Resident 144) when: 1. For Resident 143, eye medication was unavailable for administration three consecutive times. 2. Resident 144 was not given instructions to rinse mouth after administered a powdered inhaler. These failures resulted in medication not given in accordance with the prescriber's orders, which may negatively affect Resident 143 and Resident 144's health conditions.

Inspectors wroteBased on interview and record review, the facility failed to ensure skin integrity nursing assessment was done weekly for one of three residents (Resident 1). This failure resulted in the potential delay in prevention and treatment of a Stage 2 (shallow open sore) pressure ulcer.

Inspectors wroteBased on interview and record review, the facility failed to ensure a pharmacist completed a monthly Medication Regimen Review (MRR, a review of all ordered medications for administration safety and medication compatibility) for 10 of 10 sampled residents (Resident 1, 2, 3, 6, 10, 11, 16, 19, 20 and 24) during the months of December 2021 and January 2022. This failure had the potential to result in the administration of unnecessary or incompatible medications for the ten residents during December 2021 and January 2022.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set (MDS, an assessment tool used to guide care) was completed within 14 calendar days for three of three sampled residents (Residents 1, 2 and 3). This failure resulted in delayed completion and submission of Residents 1, 2, and 3's MDS assessments and had the potential to result in delayed care plan development and implementation for Residents 1, 2, and 3.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure: 1. Expired drugs were removed from the medication cart for two of ten sampled residents (Resident 10 and Resident 5). 2. Expired antimicrobial (Silvadene gel) and antiseptic (Betadine) solutions were not accessible for stock use. 3. Pill cutters were cleaned after use. For Resident 10, Veltassa Oral Suspension (a medication used to treat increased potassium level in the blood) was one month past the expiration date. This had the potential to result in Resident 10 having increased blood potassium levels due to administration of expired and less effective medication. For Resident 5, Clearlax Oral Powder (medication used to treat occasional constipation) was one month past the expiration date. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 15 sampled residents (Resident 178) had implementation of national standards designed to prevent and control the spread of the contagious infection of Clostridia difficile. (C. diff, a bacterial infection which causes severe diarrhea and can lead to serious health problems. C. diff bacteria shed spores, a single cell organism capable of growing into the bacteria C. diff, in the feces of infected individuals. The spores can be transferred to the environment or the hands of healthcare personnel who have touched a contaminated surface or item.) The failure of Registered Nurse Consultant (RNC) to wear a gown and gloves during direct contact with Resident 178, a resident diagnosed with a C. [...]

Inspectors wroteBased on interview and record review, the facility failed to document: 1. The vaccination status of one (Resident 176) of five sampled residents at the time of admission for pneumococcal pneumonia (PNA, a respiratory infection causing difficulty breathing) and influenza (the flu, a contagious respiratory illness caused by influenza viruses). 2. The refusal of one (Resident 177) of five sampled residents to be vaccinated for PNA and the flu. The failure to verify and document the vaccination status of Resident 176 had the potential to result in unnecessary repeated vaccination or no offer of vaccination and subsequent infection. The failure to document the vaccine education and vaccine refusal of Resident 177 had the potential to result an increased risk of infection due to an uninformed choice from inadequate education.

Inspectors wroteBased on interview and record review, the facility failed to document one (Resident 177) of five residents received education about Covid-19 vaccination (COVID-19, a respiratory infection which can result in breathing difficulty and other complications, including death.) and refused vaccination. This failure had the potential to result in Resident 177 not receiving adequate education to make an informed choice about Covid-19 vaccination, and increased risk of Covid-19 infection.