Hayward Health Services

Inspectors wroteBased on interview and record review, the facility did not ensure resident (R) was cared for in a manner to enhance their quality of life (R1). Facility staff administered diuresis medication of Furosemide 80 mg (milligrams) at 8:48 AM and Furosemide 80 mg at 10:10 AM. before R1 was going to an appointment outside the facility premises where R1 could not properly be toileted when needed. R1 suffered 3 incontinent episodes and became emotionally upset and affected by the incontinence episodes.

Inspectors wroteBased on observations, interviews and record reviews, the facility did not provide care and treatment by professional standards of practice to maintain a resident's highest practicable level of physical well-being for 1 of 3 residents (R) reviewed (R1). Staff did not follow physician orders to manage R1's Congestive Heart Failure (CHF) diagnosis in managing fluid overload. Staff did not notify provider of R1's weight fluctuations as ordered.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure pharmaceutical services (including procedures that ensure the accurate administering of all drugs and biologicals) to meet the needs of each resident, for 1 of 1 resident (R) observed receiving the diuretic medication Furosemide (R1).-R1 was given both AM and 12:00 PM dose of Furosemide equaled to 160 mg on 01/12/26 at 1:31 PM.-R1 was given Furosemide 80 mg on 03/05/26 at 9:25 AM and then second dose at 12:10 PM.-R1 was given Furosemide 80 mg on 07/13/26 at 8:48 AM and then second dose at 10:10 AM.

Inspectors wroteBased on observation, record review and interview, the facility did not have a system in place to ensure snack/nourishment refrigerators on the unit are maintained to prevent the potential for foodborne illness. The facility practices had the potential to affect all 33 residents. Per facility guidelines attached to resident refrigerator titled Attention all residents and family members, We are happy to provide a refrigerator to our resident's food that you provide for them outside of the facility. However, there are new specific guidelines that we need to enforce for the protection of all of our residents. It stated in part, Any food placed in the resident refrigerator must be clearly marked with the resident name and dated with a new USED BY DATE. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable disease and infections. This had the potential to affect all 33 residents in the facility. COVID positive resident (R) did not have a sign outside R door indicating Transmission Based Precautions (TBP) were in place. Facility staff did not don and doff Personal Protective Equipment (PPE) appropriately. Staff did not sanitize hands or place a barrier while providing nebulizer care. Clean linens were not covered for two of carts in the facility's laundry room and personnel had open beverage in work area touching clean gown used to handle clean linen.

Inspectors wroteBased on interview and record review, the facility did not ensure that every resident was treated with dignity and respect when providing activities of daily living (ADL) for 2 of 12 residents (R7 and R29) reviewed. During one observation of a nebulizer treatment provided to R7, the nurse providing cares did not speak to R7 or explain what procedure they were going to provide. During one observation of insulin administration provided to R29, the nurse providing the administration did not speak or explain what procedure nurse was going to provide to R29 and did not remove R29 from the dining prior to administering insulin. This is evidenced by:Facility policy titled, Residents Rights, dated reviewed on July 2022 states in part: [...]

Inspectors wroteBased on record review and staff interview, the facility did not ensure 1 resident (R7) of sampled 12 residents has the right to retain personal possessions, including furnishings, as space permits, unless to do so would infringe upon the rights or health and safety of other residents. Facility did not allow R7 to have personal refrigerator in R7's room.

Inspectors wroteBased on interview and record review, the facility did not ensure that every resident has the right to make choices about aspects of their life in the facility that are significant to them for 1 of 12 residents (R7) residents reviewed for choices. R7 requests to staff that R7 wants to smoke outside, and facility has refused to take R7 out due to staffing issues or too busy.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure that a resident (R) received treatment and care to address the resident's mobility needs in accordance with professional standards of practice for 1 out of 4 residents reviewed for mobility, range of motion, and/or positioning (R2). The facility did not provide services to increase and/or prevent further decrease in mobility for R2, who required assistance with ambulation.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure a resident with a pressure injury received care necessary treatment and services, consistent with professional standards of practice, to promote healing for 1 of 3 residents (R) reviewed for pressure injuries (23). R23's care plan interventions of repositioning to heal and prevent worsening of a pressure injury were not implemented. R23's physician orders to treat a pressure injury were not implemented. The facility policy titled, Turning and Repositioning, dated 12/06/22 states: It is our policy to implement turning and repositioning as part of our systematic approach to pressure injury prevention and management. This policy establishes responsibilities and protocols for turning and repositioning. The policy further identifies Explanation and Compliance Guidelines in part .:1. [...]

Inspectors wroteBased on observations, record review and staff interviews, the facility did not ensure 1 of 1 resident (R) reviewed who required oxygen and respiratory care was provided such services consistent with professional standards of practice, the resident's comprehensive person-centered care plan, and physician orders (R7).

Inspectors wroteBased on interview and record review, the facility did not ensure each resident's drug regimen was free from unnecessary drugs for 1 of 5 residents (R29) reviewed. Facility failed to discontinue Trazadone for R29 after pharmacy recommended R29 to discontinue if no sleep concerns.

Inspectors wroteBased on observation, record review and interview, the facility did not ensure a medication error rate of 5% or less for 2 of 6 residents (R), R25 and R15, observed for medication pass. The facility had 31 opportunities and 3 medication errors resulting in an 9.68% error rate. Registered Nurse (RN) L administered Atropine drops sublingual to R25 with unknown open date. RN E administered insulin pen without checking the expiration date and the correct physician order for R15. This is evidenced by:According to the Food and Drug Administration (FDA), insulin pens should be discarded 28 days after opening the pen to ensure effectiveness of the medication. Example 1On 12/16/2025 at 8:33 AM, Surveyor observed RN L administer medications to R25. RN L administered Atropine drops sublingual. [...]

Inspectors wroteBased on observation, record review and interview, the facility did not ensure that residents are free of significant medication errors for 1 of 6 residents (R), R15, observed for medication admonistration. Registered Nurse (RN) E administered 16 units of insulin glargine 100 UNT/ML Pen Injector [Lantus] insulin to R15 with no physician order for Lantus. This is evidenced by:According to the Food and Drug Administration (FDA), insulin pens should be discarded 28 days after opening the pen to ensure effectiveness of the medication. On 12/16/25 at 8:19 AM, Surveyor observed RN E administer 16 units of insulin glargine 100 UNT/ML Pen Injector [Lantus] insulin to R15 without checking physician order and open date of insulin pen, so expiration was unknown resulting in a medication error. [...]

Inspectors wroteBased on observation and interview, the facility did not ensure drugs and biologicals were labeled in accordance with currently accepted professional principles and did not ensure expired medications were removed from residents' (R) medication supply. (R15 and R25) One insulin Lantus pen was not labeled with an open date or expiration of medication for R15 in 1 of 2 residents observed who received insulin. Atropine drops were not labeled with an open date or expiration of medication for R25 in 1 of 1 resident observed who received Atropine.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure standards of practice were followed for verification of gastrostomy placement before medication administration. The facility also failed to provide proper infection control measures by performing hand hygiene during medication administration and ensuring the enteral formula used to provide nutrition was changed every 24 hours for 1 of 1 resident (R) reviewed for tube feeding. (R34) This is evidenced by: Facility policy titled, Medication Administration 7.10 Enteral Tubes dated 05/23, states in part, - .8. Verify tube placement per facility protocol. -9. Check gastric content for residual feeding. Return residual volumes to the stomach. Report any residual above 100mL . [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure a medication error rate of 5% or less. During the medication administration task, Surveyor observed 2 errors out of 35 medication opportunities, resulting in an error rate of 5.71%. This affected 2 out of 6 residents (R) (R34 and R240) observed for medication administration. Licensed Practical Nurse (LPN) D did not follow physician orders for R34's heparin injection and administered heparin via incorrect route. R34 did not receive 2 units of insulin per sliding scale per physicians' orders.

Inspectors wroteBased on observation, interview and record review, the facility did not maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases and infections. Staff did not perform hand hygiene when changing gloves during resident cares and procedures for 3 of 4 resident (R) care observations (R29, R240, and R34). Staff did not wear proper personal protective equipment (PPE) when caring for a resident on Enhanced Barrier Precautions. (R34)

Inspectors wroteBased on record review and interviews, the facility did not ensure a resident's (R) advanced directives for code status were implemented according to resident wishes for 1 of 14 residents (R) 35 reviewed for advanced directives. R35 had a Do Not Resuscitate (DNR) order signed by R35 on [DATE] and signed by the physician on [DATE]. On [DATE], R35 became unresponsive requiring the invoking of R35's code status. Staff was unable to find the advanced directives and code status for R35 and performed cardiopulmonary resuscitation (CPR). Despite R35 indicating the intent to not receive CPR, R35 was provided CPR on [DATE]. R35 did not survive the code status and was pronounced deceased following the event. The facility's failure to follow a resident's advanced directive created a finding of immediate jeopardy that began on [DATE] at 6:30 p.m. [...]

Inspectors wroteBased on observation and interview, the facility did not establish and implement an ongoing infection prevention and control program to prevent and control the onset and spread of infection. This occurred for observation of cares for 1 of 2 residents (R) R4. Staff did not perform proper hand hygiene during observation of cares for R4. This is evidenced by: Surveyor reviewed the facility policy entitled Hand Hygiene, dated 11/02/22, which states either soap and water or alcohol-based hand rub will used when hands are visibly dirty, before and after handling clean or soiled dressings, linens, etc., after handling items potentially contaminated with blood, body fluids, secretions, or excretions. On 09/13/23 at 10:37 AM, Surveyor observed Certified Nursing Assistant (CNA) C conducted the following during cares on R4 that included incontinence care: [...]