Hayward Gardens Post Acute

Inspectors wroteBased on interview and record review, the facility did not ensure that Resident 79's binding arbitration agreement was explained to and signed by Resident 79's designated representative. This deficient practice has the potential to result in residents and/or resident representatives not being aware and/or fully understanding the implications of arbitration agreements.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an effective infection control program when:Certified Nursing Assistant (CNA) 4 handled contaminated linen from Resident 33, who is on contact precautions for MRSA, without wearing the required PPE. The contaminated linen was not bagged prior to being placed in the laundry hamper. CNA 1 handled Resident 29's soiled linens and garbage disposal bag without gloves worn and did not perform hand hygiene. Two lighters were found stored in an opened full box of Tegaderm dressings in the medication storage room (Tegaderm is a thin, see through plastic dressing used to cover wounds, scrapes and surgical incisions. It acts as a protective, germ-proof barrier that keeps dirt out of the skin). License Vocational Nurse (LVN) 1 did not perform hand hygiene before preparing and giving medications to Resident 37. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff protected dignity and maintained personal privacy for one of one resident (Resident 29) during preparation and transport for a scheduled shower. This failure resulted in Resident 29 being exposed and insufficiently covered while being moved through the hallway, creating risk for embarrassment, loss of dignity, and violation of personal privacy.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide respiratory care to one of 20 sampled residents when Resident 38's order for incentive spirometer (a handheld, plastic device used after surgery or illness to help exercise the lungs, encourage deep breathing, and prevent lung complications like pneumonia or lung infection) was not followed. This failure had the potential to result in Resident 38 experiencing respiratory distress and a decline in health status. During a review of Resident 38's admission record indicated the resident was admitted on [DATE] with diagnoses that included bronchiectasis and respiratory failure [bronchiectasis is a long-term lung condition where the airways (the tubes that move air in and out of your lungs) become permanently widened, scarred, and inflamed; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure foley catheter (a thin, flexible, indwelling tube inserted through the urethra into the bladder to drain urine into a collection bag) care, monitoring and assessment were documented within the electronic health record (EHR) for one of seven sampled residents (Resident 72). This failure caused a lack of information to facilitate communication among the interdisciplinary team (IDT-a collaborative group of healthcare professionals from diverse specialties who work together to manage complex resident care) and to provide resident-centered care for Resident 72. During record review of admission record, printed on 5/7/26, Resident 72 was admitted on [DATE]. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a qualified and competent director of nursing had oversight of the facility when Assistant Director of Nursing (ADON), who did not have a Registered Nursing license, assumed the director of nursing duties and during the survey, assigned Registered Nurse Supervisor/Director of Nursing (RNS)/[DON], who was not trained nor competent in the role, as director of nursing. The facility was previously cited for assigning ADON as the director of nursing and did not follow their plan of correction which was submitted to the state agency on 12/12/2024. This failure resulted unqualified nursing leadership for 15 months which resulted in nursing staff failing to follow provide adequate mental health services to Resident 1 after Resident 1's suicide attempt (see F tag 742). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure, for residents 1-11, the scheduled (controlled medication, narcotic) medication record system was complete (all documents available) and accurate (data match). The record system included Shipping Manifests (pharmacy delivery receipt), Controlled Substance Accountability Sheets (CDR, Controlled Drug Record), Medication Administration Records (MAR, record of medication administration), and destruction logs (Narcotic Take Back Log). The facility did not have complete records. The facility did not have accurate records. These failures resulted in the potential for undetected loss and diversion (theft). During an interview, on 8/7/25 at 9:20 a.m., Medical Record Director (MRD) was asked to describe the scheduled medication accountably (records of narcotic use) procedure. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide adequate and timely mental health services for one of four sampled residents (Resident 1) who attempted suicide by strangulation when facility:1. allowed Resident 1 access to the same ligature implement used in their suicide attempt for more than three months and, 2. did not provide Resident 1 with adequate follow up care when the Assistant Director of Nursing, who had been acting as director of nursing, provider and police were not informed of Resident 1's suicide attempt. This failure resulted in Resident 1's continued thoughts of suicide without appropriate care or follow up interventions for more than three months. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) received treatment and care in accordance with professional standards of care when:Facility did not monitor Resident 1's rash on bilateral breast fold for increased spread or signs of infection according to care plan. Facility did not promptly notify Resident 1's representative that Resident 1 had rash in multiple areas, bilateral breast fold. These failures caused Resident 1 to not receive appropriate care and services to meet needs and the potential to prevent Resident 1's emotional distress and Resident 1's representative their right to be informed. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to conduct an accurate assessment of one resident's functional capacity when Resident 42's Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan) was coded incorrectly for dental condition. This failure had the potential to cause health decline, and to inhibit or delay proper care planning and treatment.

Inspectors wroteBased on interview and record review, the facility failed to refer one resident with a serious mental disorder for level II Preadmission Screening and Resident Review (PASARR- a federal requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care. PASARR requires that 1. all applicants to a Medicaid-certified nursing facility be evaluated for a serious mental disorder and/or intellectual disability; 2. be offered the most appropriate setting for their needs [in the community, a nursing facility, or acute care setting]; and 3. receive the services they need in those settings. Regulations governing PASARR are found at 42 CFR §483.100-138) screening when Resident 57's Level 1 PASARR did not accurately show the resident's diagnosed psychiatric condition. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one out of five sampled residents (Resident 38) received the necessary services to maintain good grooming, and personal hygiene when Resident 38's shower schedule was not consistently followed and reason for refusals were not documented and acted upon. This failure resulted in Resident 38 having unmet physical, physiological, and psychological needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the Director of Nursing (DON) was a registered nurse (RN) for seven months. This failure resulted in an unqualified nurse being designated the DON and had the potential for inadequate supervision and management of the facility residents and nursing staff.

Inspectors wroteBased on observation, document review, and interviews, the facility failed to comprehensively assess and implement nutritional interventions for one resident (Resident 59), who lost a total of 39.6 pounds over a period of 28 weeks. The facility failed to follow the weight loss policy and procedure including providing recommended nutritional interventions, having interdisciplinary committee meetings to provide an analysis of identified weight loss, and calculating adequate estimated nutritional needs by the registered dietitian. This failure had the potential to result in unintended weight loss which is strongly correlated with increased morbidity (the condition of suffering from a disease or medical condition) and mortality (death) in the older adult for one resident (Resident 59) out of a facility census of 65.

Inspectors wroteBased on observation, staff interviews, and review of facility documents, the facility failed to comply with Federal regulations related to the oversight of food service operations when the facility did not have a full-time dietitian and the requirements were not met as specified in established standards (California Code, Health and Safety Code - HSC § 1265.4) for food service managers which required, employment of a full-time, qualified dietetic supervisor when the dietitian was not full time. The lack of a qualified, competent, full-time supervisor resulted in staff not having adequate supervision, training, and knowledge to carry out Food and Nutrition Services in a safe and sanitary manner. [...]

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure the competency of staff when: 1. a staff did not know how to read a freezer thermometer correctly; 2. staff did not know how to test the food-contact surface sanitizer correctly; 3. staff did not know how to sanitize juice machine according to posted cleaning instructions; and 4. a staff did not label a chemical containing container. These failures had the potential to result in the kitchen not being maintained in a safe and sanitary manner leading contamination of food and utensils, and/or reduced quality of food for 61 residents who received food from the kitchen.

Inspectors wroteBased on observation, staff interview, and facility document review, the facility failed to ensure the planned menu was followed when: 1. Milk was not provided as shown on the lunch menu for 55; 2. Incorrect servings of food were served to10 residents who received a pureed, minced and moist, or a mechanical soft diet. These failures had the potential to result in not meeting the nutritional needs of the residents and compromising the nutritional status of the residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were served palatable food when food was bland and at a low temperature. This deficient practice placed the residents at risk of decreased nutrient intake leading to weight loss and/or nutritional medical complications for 61 residents who received food from the kitchen.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide: 1. an alternate for gluten (a protein found in wheat, barley, and rye) containing food for one resident (Resident 288) who had a documented gluten allergy and a diagnosis of ulcerative colitis (a condition in which the lining of the large intestine (colon) and rectum become inflamed). 2. an alternate for garlic bread at a lunch meal for 61 residents who received food from the kitchen. This deficient practice had the potential to result in decreased nutrient intake leading to weight loss and/or nutrient related medical complications.

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. Stored equipment in the kitchen was dirty and ready for use; 2. Kitchen storage areas, floors, and vents were dirty; 3. A fan in use in a food storage area was dirty; 4. Floor tiles were in poor condition; 5. Food was stored without identifying use-by-dates; 6. The ice machine was dirty. 7. A food preparation sink drain did not have an airgap (a gap between the sink drain and the drain that leads to sewage drain. This gap prevents a back-up of non potable water and/or bacteria into the sink). These failures had the potential for contamination of food resulting in food borne illness for 61 residents who received food from the kitchen.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to maintain the reach in freezer in safe operating condition. This failure had the potential for food stored in the freezer to remain frozen at all times leading to decreased food quality and food safety for 61 residents who received food from the kitchen.

Inspectors wroteBased on interviews and record review, for ten (Resident 19, 20, 23, 28, 53, 59, 60, 64 and 65) of twelve sampled residents that were reviewed for resident assessments, the facility failed to complete quarterly Minimum Data Set assessments (MDS) in a timely manner. (MDS is a resident assessment tool used to guide care). These failure had the potential to result in the delay of assessment of residents' needs, goals of care and inability to monitor each residents' decline and progress over time.

Inspectors wroteBased on interview and record review, the facility failed to provide resident's monthly Resident Council Meeting (RCM-a scheduled meeting where residents voice concerns and grievances to the facility, to improve residents' quality of life). This failure had the potential for residents to not be able to exercise their rights to have a monthly resident council meeting and for the facility to address the residents' concerns

Inspectors wroteBased on interview and record review the facility failed to develop and implement a baseline and/ or comprehensive care plan for two of two sampled resident (Resident 82, and 81) to include resident-centered plan of care within 48 hours of their admission to the facility. This failure resulted in Resident 82, and 81 to not have a baseline and/or a comprehensive plan of care during her stay at the facility.

Inspectors wroteBased on observation, interviews and record review the facility failed to ensure one (Resident 63) of three sampled resident a non English speaker was provided functional system consistent to meet communication needs when; staff did not consistently used a qualified interpreter or translator to help Resident 63 communicate better. This failure had the potential to cause Resident 63 emotional distress.

Inspectors wroteBased on observation, interviews and record review the facility failed to ensure one of four sampled resident ( Resident 49) received treatment services to address decline in range of motion to lower extremities. This failure had the potential to cause Resident 49 pain, injury, difficulty with transfers, turning and repositioning.

Inspectors wroteBased on observation, interviews and record review the facility failed to ensure one of one sampled resident (Resident 17) received treatment and services when; - Resident 9's Tube Feeding (TF) was not administered as ordered by the physician. - Dietician recommendation to increase Resident 17's tube feeding was not acted upon. - The facility's policy and procedure titled, Food and Nutrition Services, revised October 2017 did not addressed who, when and how should nursing staff follow up with dietician recommendations. These failures had the potential to result in residents decline and weight loss.

Inspectors wroteBased on observation, interviews and record review, for one (Resident 9) of four sampled residents the facility failed to ensure pain assessment was completed before the administration of as needed (PRN) pain medication according to professional standard of practice when; Licensed Nurses did not assess and document Resident 9's pain characteristics that included location, severity, duration and timing of pain before the administration of PRN hydromorphone pain medications. Licensed Nurses did not document the adverse side effects of hydromorphone pain medication administered to Resident 9. According to manufacturer Hydromorphone belongs to a class of drugs called opioids, it has a rapid onset of action. Unless using for severe acute pain, opioids are not considered a drug of choice in older patients. [...]

Inspectors wroteBased on interviews and record review, the facility failed to act upon the Consultant Pharmacist's (CP) Medication Regimen Review (MRR) report for two (Resident 23 and 63) of five sampled residents when; - Resident 23 CP recommendation for the physician to consider initiating ACE inhibitor such as Lisinopril 2.5 mg daily as first-line therapy for individuals with hypertension (high blood pressure) and Diabetes Mellitus (high blood sugar) was not acted upon. - Resident 63's CP recommendation to clarify erythromycin eye ointment (an antibiotic medication) to include a stop date was not acted upon. - The facility policy and procedure titled, Medication Regimen Review, revised May 2019 did not addressed who, when and how to follow up with CP medication regimen reviews and recommendations. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and secure storage and accurate labeling of drugs when multiple loose medication pills was observed inside drawers for one of three medication carts inspected. This failure had the potential for loss or misuse of medications and the potential to jeopardize the residents' health and safety and could cause delay in the delivery of treatment services.

Inspectors wroteBased on interview and record review, the facility failed to ensure appropriate use of antibiotic (medication for infection) for one of two sampled residents (Resident 63) when facility did not monitor and reviewed antibiotic eye ointment for a stop date. This failure had the potential for Resident 63 to take unnecessary antibiotics which could lead to antibiotic resistance.