Hayward Healthcare & Wellness Center

Inspectors wroteBased on interview and record review the facility failed to provide adequate supervision and interventions to prevent elopement (leaving a facility or safe area unnoticed often due to confusion), for one of three sampled residents (Resident 1), with cognitive impairment (difficulties in one or more mental abilities such as memory, learning, language, attention, problem-solving, or decision-making that are more pronounced than expected for a person's age or education level) when Resident 1 was sent to a doctor's appointment without an escort despite needing an escort. This failure resulted in Resident 1 wandering off to the streets alone in cold and rainy weather for approximately three hours. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure medication was given according to the physician's order for three of three sampled residents (Resident 1, 2, 3) when: 1. Resident 1 did not receive the medication Gabapentin (used for nerve pain, which can be caused by different conditions, including diabetes.) 2. Resident 2 did not receive the medication Humalog insulin (helps control blood sugar levels after meals.) 3. Resident 3 did not receive the medication Hydralazine (used to treat high blood pressure.) This deficient practice had the potential for worsening of Resident 1, 2 and 3's clinical condition.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff were competent in appropriately testing and recording the surface sanitizer. This failure put 95 residents who received food from the kitchen at risk for illness from potentially ineffective sanitizing solution not being identified.

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 resident food refrigerator was dirty, food was not labeled and dated, and the refrigerator temperatures were not monitored appropriately to keep food safe. 2. Staff did not follow appropriate hand hygiene procedures. 3. Stored equipment and utensils were dirty and ready for use. 4. The inside surface of the ice machine bin door was dirty. 5. Dry food storage bins were dirty and cracked. 6. Food storage areas were dirty. 7. Eggs and chicken were not stored appropriately. 8. A reach-in freezer door was in poor condition. 9. Plastic bags used to store food were not durable to protect food from contamination and adulteration (the action of making food poorer quality or unsafe by the addition of another substance). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff followed the facility policy for food brought into the facility for residents by family and/or visitors and stored for residents up to 48 hours. This failure had the potential for a decreased consumption of food, as well as create an environment that was not home-like for 95 residents out of a facility census of 95.

Inspectors wroteBased on interview and record review the facility failed to a water management program to help reduce the risk for legionella and prevent spread of water borne pathogen growth. This failure had the potential to cause spread of water borne pathogen growth in the facility.

Inspectors wroteBased on observation, interview, and document review, the facility failed to provide palatable pureed bread for 11 residents on a pureed textured diet and palatable bread rolls for at least 10 residents on a regular textured diet. Serving food that was not palatable had the potential for 21 of 95 residents to consume a decreased amount of nutrients leading to weight loss and/or nutrient related medical complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Freezer #3 was maintained in good repair when the rubber gasket (a rubber piece that surrounds the inside perimeter of the freezer door to help keep the cold air in) around the interior perimeter of the door was torn and peeled away from the door. This failure had the potential for the freezer to not maintain appropriate temperatures that put the facility at risk for decreasing the quality of food stored in the freezer and/or affecting the safe storage of food leading to food borne illness for 95 residents who received food from the kitchen.

Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate allegation of abuse for one of two sampled residents ((Resident 75). Resident 75 alleged that a dark young male staff came to his room, knocked him on his head when he inquired about him coming to his room. The Administrator (Admin)/ designated representative did not interview Certified Nursing Assistant (CNA3) a male staff member that was assigned to provide care for Resident 75. This failure had the potential to place Resident 75 at risk for emotional distress, mistreatment or abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and maintain a care plan that was comprehensive and person-centered to meet the resident needs, for one resident (Resident 60) out of 26 sampled residents. This failure had the potential for one resident to not attain or maintain her highest practicable quality of life and/or receive quality care and services.

Inspectors wroteBased on interview and record review, the facility failed to ensure the comprehensive plan of care for one resident (Resident 60) out of 26 sampled residents, was written by a qualified staff. This failure placed one resident at risk for not attaining or maintaining her highest practicable quality of life and/or receive quality care and services.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide assistance needed for toenail care as ordered by the physician for one (Resident 54) of two sampled residents when Resident 54 had crooked ingrown toenails (a condition in which the corner or side of a toenail grows into the flesh). This failure had the potential for residents prone to injury and infection

Inspectors wroteBased on interview and record review the facility failed to ensure one (Resident 41) of six sampled resident received treatment services to address functional limitation in range of motion when; the Rehabilitation Department did not provide Resident 41 Physical and Occupational therapy {PT/OT} as ordered by the physician. {Physical Therapy- the treatment of disease, injury, or deformity by physical methods such as massages, heat treatment, and exercise rather than by drugs or surgery}. {Occupational Therapy- a form of therapy for those recuperating from physical or mental illness that encourages rehabilitation through the performance of activities required in daily life}. This failure had the potential to cause Resident 41 decline in mobility, range of motion, difficulty with transfers, turning and repositioning.

Inspectors wroteBased on observation, interview and record review, the facility failed to assess and evaluate one (Resident 54) of three sampled residents for an appropriate size wheelchair when; Director of Rehabilitation (DOR1) provided Resident 54 a wheel chair that was small and tight. Resident 54 sustained a bruise (an injury appearing as an area of discolored skin on the body caused by a blow or impact rupturing underlying blood vessels) to right lateral thigh. This failure caused Resident 54 bruise to her right lateral thigh and potential to cause wheelchair bound residents injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide dental services to meet resident's needs for one of 22 sampled residents (Resident 57) when referral to outside dentist was not acted upon. This failure had the potential to result in Resident 57 to have tooth infection, difficulty eating and weight loss.

Inspectors wroteThe facility failed to provide food preferences for one resident (Resident 60). This failure had the potential to result decreased nutrient intake leading to unplanned weight loss and nutritional related medical complications for one resident out of 26 sampled residents.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to provide physician ordered snacks for one resident (Resident 60). This failure had the potential to result in increased weight loss and nutritional related medical complications for 1 resident out of 26 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the outside garbage storage area was maintained in a sanitary condition when refuse, bones, and dark liquid waste was found on the ground surrounding the garbage receptacles. This failure put the facility at increased risk for attracting pests and potentially causing pest related disease in 95 of 95 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow proper sanitation and food handling practices when there were multiple plastic wares stored wet inside the kitchen cupboard. These deficient practices had the potential to result in foodborne illnesses.

Inspectors wroteBased on interview and record review, for one of 25 (Resident 5) sampled residents, the facility failed to inform and provide information to the residents and/or the resident representatives, the option to formulate an advance directive (a legal document in which a person specifies what actions should be taken for their health if they are no longer able to make a decision for themselves because of illness or incapacity). This failure had the potential to result in delay of the treatment directions to healthcare providers regarding Resident 5's medical care.

Inspectors wroteBased on observation, interview, and record review, for one of 25 sampled residents (Resident 73), the facility failed to provide care and services for feeding tubes. Certified Nursing Assistant (CNA) 2 lowered Resident 73's head of the bed to the flat position to provide personal hygiene care while Resident 73's enteral feeding (nutrition taken through the mouth or through a tube that goes directly to the stomach or small intestine) was being administered through the G-Tube (Gastrostomy Tube - a tube inserted through the belly that brings nutrition directly to the stomach) via a pump. For Resident 73, this failure had the potential to result in aspiration (inhalation) of the feeding formula and lead to aspiration pneumonia (a lung infection that develops after aspirating food, liquid, or vomit into the lungs).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure on (Resident 4) of 21 sampled residents received assistance with activities of daily living (ADL - e.g. personal hygiene) when Resident 4 (a female) did not receive assistance personal grooming and had a full beard. This failure resulted in Resident 4 feeling bad about herself.

Inspectors wroteBased on observation, interview and record review, for two of 21 sampled residents, the facility failed to implement their Pain Management policy and procedure when Residents 6 and 243 experienced pain and Licensed Vocational Nurse (LVN) 1 did not assess the Residents for pain using the zero to 10 pain scale (zero being no pain and 10 being the worst pain). This failure had the potential to result in Resident 6 and Resident 243's pain to be incompletely relieved or managed.

Inspectors wroteBased on observation, interview and record review, for one of 21 sampled residents (Resident 69), the facility failed to implement their Dressings - Application to ensure cleanliness policy and procedure when Licensed Vocational Nurse (LVN) 2 did not re-clean Resident 69's sacral (lower back) pressure injury (localized damage to the skin and/or underlying soft tissue usually over a bony prominence) after Resident 69 rolled onto the open wound during a dressing change. This failure had the potential to result in infection.