Hayward Hills Health Care Center

Inspectors wroteBased on observation, interview and record review, the facility failed to meet professional standards of quality for one of two sampled Residents (Resident 7) when nursing staff did not follow the physician's order for Resident 7's oxygen therapy. This failure had the potential to cause health complications to Resident 7.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of two sampled residents (Resident 27 and 80) received treatment and care in accordance with professional standards of practice when:1. Direct Care Staff did not follow physician's orders to assess Resident 27 for bleeding and did not follow up with Resident 27's physician regarding her orders to hold or to restart Eliquis (an anticoagulant medication used to prevent and treat blood clots, and lower stroke risk in patients with atrial fibrillation, an irregular and often very rapid heart rhythm) for a period of over six months. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to store and label medications and enteral feeding supplements for nutrition in accordance with professional standards when:1a. Expired, discontinued, and compromised drugs and biologicals in medication storage room were not disposed.1b. Pharmaceutical waste container filled with unused drugs was not labeled with date of first use and dispose of by.1c. Two full drug buster (medication disposal system) containers were not discarded.2. Enteral feeding supplements, nutritional shake and meal replacement products were not stored within the required storage room temperature range of 59 F to 77 F (Fahrenheit - temperature scale)3. Medication cart 4 was left unlocked and unattended on two separate occasions.4. Four of five medication carts observed had multiple loose unidentified pills scattered inside the drawers.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain safe frozen and refrigerated food storage practices for two out of two freezers and three out of three refrigerators in the kitchen. Facility did not store foods in accordance with professional standards for food service safety for three of three residents (Resident 22, 30 and 53) when foods from outside sources was stored in one of four facility refrigerators. Freezer 1 had no documented temperature for two mornings (AM) and six evenings (PM) and meat freezer, produce refrigerator, vegetable refrigerator and refrigerator 1 did not have a documented temperature. These failures had the potential to result in foodborne illnessFindings:During a concurrent observation and interview on 6/8/26 at 9:33 a.m. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to store foods in accordance with its policy on food brought in from outside for three of three sampled residents (Resident 22, 30 and 53). Resident 22's food was unlabeled with date stored, Resident 30's food was labeled only with room number and was stored longer than 72 hours and Resident 53's food was stored longer than 72 hours in resident food refrigerator. These failures placed Resident 30, 53 and 22 at risk for food borne illnesses. During an interview on 6/9/26 at 3:20 p.m. with Certified Nursing Assistant (CNA) 6, CNA 6 stated CNAs and nurses were responsible for storing food from outside sources in the refrigerator. CNA 6 stated CNAs and nurses were also responsible for writing the resident's name and date the food was received on the container. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an effective infection control program when:1. Certified Nursing Assistant (CNA 5) did not perform hand hygiene when serving meals to two of five sampled residents (Resident 47 and 60) after touching the doorway stop banner (a bright yellow, high visibility banner with a red STOP message that mounts across doorways or halls using quick release straps or Velcro to visually deter wandering while staying collapsible for safety).2. Restorative Nursing Assistant (RNA 2) did not perform hand hygiene after touching Resident 47's finished plate then touching Resident 60's top part of her cup. 3. [...]

Inspectors wroteBased on interview and record review, facility failed to complete and maintain documentation for three of five sampled residents (Residents 14, 28 and 46) for Influenza (commonly known as Flu, a highly contagious viral infection that attacks your nose, throat, and lungs) and Pneumonia (PNA, an infection in one or both lungs that causes the tiny air sacs to become swollen and filled with fluid) vaccination (getting a shot to help the body safely build a defense against a specific harmful disease) This failure of having incomplete documentation had a potential of missed or delayed vaccinations to Residents 14, 28 and 46.

Inspectors wroteBased on interview and record review, the facility failed to ensure three of five sampled residents (Residents 14, 46, 29) had complete and accurate records for COVID- 19 (highly contagious illness of the lungs caused by virus) immunization (getting a shot to help the body safely build a defense against a specific, harmful disease). This failure resulted in incomplete immunization records for Resident 14, 46 and 29; and placed them at risk for not having been immunized for COVID-19.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of two sampled residents (Resident 28) was free from physical abuse when Resident 59 grabbed Resident 28's left arm in the facility hallway. This failure resulted in Resident 28 having a bruise (when blood pools under your skin after an injury, causes discoloration) and pain on the left arm. During a record review of Resident 28's admission record, the record indicated Resident 28 was admitted to the facility on [DATE]. The record indicated Resident 28 has diagnoses of dementia (a loss of brain function affecting memory, thinking, language, judgment, or behavior). [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide a contracture (permanent tightening and shortening of muscles, tendons, ligaments, or skin) assessment and range of motion (ROM, full movement potential of a joint) exercises for one of five sampled residents (Resident 26) when Resident 26 was not screened for left and right hands contractures on an ongoing basis. This failure placed Resident 26 at risk for further decline in range of motion of left and right hands.

Inspectors wroteBased on interviews and record reviews, the facility failed to maintain complete and readily accessible medical records for one of three sampled residents (Resident 81), when Resident 81's medical record lacked required physician documentation at the time of review. This failure had the potential to result in staff not having essential information needed to understand Resident 81's overall care needs, which could delay or compromise safe and effective care. During a record review of Resident 81's Face Sheet, the Face Sheet indicated Resident 81 was admitted to the facility on [DATE] and discharged on 4/18/26. During a record review of Resident 81's medical record, Resident 81's medical record contained no physician progress notes or a History and Physical (a doctor's complete health report or assessment of the patient) for Resident 81's stay at the facility. [...]

Inspectors wroteBased on interviews and record reviews the facility failed to ensure the Pharmacy Consultant (PC) provided the Medical Regimen Review (MRR) recommendations and Executive Summary to the facility within the timeframes established in the facility's policies and procedures for four out of four months and the facility did not act on the reports within 30 days for five of 10 sampled residents (Residents 56, 26, 2, 66, and 54). This failure had the potential to result in Residents not receiving therapeutic recommendation on drug therapies.

Inspectors wroteBased on observation, interview, and record review, the facility failed to clean dishes in a safe and sanitary method when the dishwasher did not reach the required temperature. This failure had the potential to result in 65 residents being served food on dishes that were not sanitized, which could lead to the spread of disease.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide pharmaceutical services to meet the needs of residents by failing to ensure the proper storage and destruction of narcotic (a drug that relieves pain and induces drowsiness) medication and the delivery of the correct dose of medication as ordered by the physician when: 1. Narcotic medication was stored in an unlocked drawer in Director of Nursing (DON) office, with 7 missing narcotic medications. 2. Narcotic medication was missing during a random narcotic audit for two of three sampled residents (Residents 24 and 64). 3. Resident 24 was undermedicated with diazepam (medication used to treat anxiety, muscle spasms, seizures, and alcohol withdrawal). 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure it was free from medication error rate of 5% or greater during the medication pass observation. The facility had a cumulative medication error rate of 30% consisting of nine errors where medications were not administered in accordance with physician's orders, in a sample size of 30 opportunities for error. These deficient practices had the potential to result in adverse consequences. Findings During an observation on 8/12/24 at 4:18 p.m. with Registered Nurse (RN) 1, RN 1 prepared medication for Resident 29 to be delivered via gastrostomy tube (G-tube, a tube inserted through a surgically created hole through the abdomen to deliver food/medications/fluids directly into the stomach) during evening medication schedule. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the safe storage, labeling, open date, expiration date, and disposal of medications and vaccinations. Medications and vaccines were not stored and maintained within standards for safety when: 1. Over the counter eye drops were not labeled with resident's name. 2. Two open inhalers did not have opened dates and one open inhaler was expired and still being used. 3. One aplisol multidose TB vial opened without a documented open date with instructions to discard product after 30 days of being opened. 4. Twenty-one vaccine syringes, stored in medication refrigerator, expired 6/30/2024. 5. Intravenous (IV) heparin flushes were expired 7/20/24 in the emergency kit (E-kit is a limited supply of medication and intravenous supplies for urgent use in a sealed box.) 6. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store and prepare food in accordance with professional standards of food service safety when: 1. Expired chocolate pudding was observed in the refrigerator. 2. Uncovered frozen soup with white crystals on top was observed in the freezer. These failures had the potential to result in food-borne illnesses or unpalatable food.

Inspectors wroteBased on interview and record review, the facility failed to report alleged abuse or mistreatment for Resident 32 to the appropriate authorities. This failure had the potential to result in the event not being investigated completely, which could lead to further events of abuse or mistreatment.

Inspectors wroteBased on interview and record review, the facility failed to complete the required 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) for one of three sampled residents (Resident 63). 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.) This failure had the potential to result in residents not receiving appropriate care for their mental disorders or intellectual disabilities. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement measures to safely transfer one of two sampled residents (Resident 1) when a staff transferred Resident 1 from bed to a shower chair using a Hoyer lift (mechanical device that lifts a resident for transfer, the resident will be suspended in the air in a sling while being move from a bed to a chair) without assistance from another staff member. This failure resulted in Resident 1 falling and sustaining multiple injuries: Multiple rib fractures (broken ribs), Trace Right-Sided Pneumothorax (presence of air in the space between the lung and chest wall leading to breathing difficulty and chest pain), Left Femur Peri-Prosthetic Fracture (broken bone around the artificial joint of the left thigh); and caused Resident 1's pain, emotional trauma, and an increased fear in Hoyer lift transfers.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 2) was free from abuse when: There was no care planning intervention developed, implemented, and monitored for effectiveness after the first incident of physical abuse to Resident 2 by Resident 1. This failure resulted in further physical abuse to Resident 2, 21 days after the initial abuse by Resident 1. This failure also had the potential to expose other residents to an environment lacking protection and safety from abuse that may result in injuries and psychosocial distress, compromising their health and safety. During a review of face sheet for Resident 1, the face sheet indicated, Resident 1 was originally admitted [DATE], re-admitted on [DATE], with diagnoses that included stroke with R sided weakness, hypertension, and depression. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop an individualized comprehensive care plan with measured objectives and specific interventions for one of two sampled residents (Resident 2) when there was no care plan to address the physical, mental, and psychosocial wellbeing of Resident 2 after two cases of abuse. This deficient practice had the potential for Resident 2 ' s needs not to be identified and negatively impact his physical, mental, and psychosocial functioning.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide activities of daily living (ADLS,Activities of daily living are those needed for self-care and mobility and include activities such as bathing, dressing, grooming, oral care, ambulation, toileting, eating, transferring, and communicating.) to one of three sampled residents (Resident 1), when Resident 1 did not receive schedules showers for nine weeks and fingernails were long with brown matter underneath the nail. This failure placed Resident 1 feeling not cared for and neglected.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure residents had a safe and comfortable environment when; 1. Resident rooms [ROOM NUMBERS]'s room temperature was above 81 degrees Fahrenheit (F). 2. Resident 59's bed was broken. 3. Closet doors for 12 of 70 residents (Residents 56, 36, 60, 41, 64, 13, 118, 119, 40, 62, 48, 10) did not close. 4. Built in dresser drawers for 12 of 70 residents (Residents 53, 36, 60, 41, 12, 18, 118, 119, 40, 62, 48, 10) were covered in thick, textured paint making them difficult to open and close and were dirty inside. 5. The automatic patio door in lobby was non-operational. These deficient practices did not ensure a homelike environment and had the potential to cause discomfort from high environmental temperatures inside the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide four (Residents 2, 23, 26 and 29 ) sampled residents restorative nursing care (RNA). No RNA services were provided for Resident 2's lower extremities and contractures (hardening or shortening of a muscle) and no splint was applied for Resident 23's left hand. For Resident 26, no ambulation was provided or Resident 29's range of motion (ROM) to the upper extremities, all of which were ordered by the physician and according to the residents' plan of care. These deficient practices had the potential to cause a decrease in Residents 2, 23, 23, and 29 ROM.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store and prepare food in accordance with professional standards of food service safety when: 1. Dietary Aide (DA) 1 did not wear a hair net while inside the kitchen. 2. An opened container of syrup was stored inside the refrigerator beyond its use-by date. 3. Storage bins for rice, lentils and food thickener had dusty covers. 4. Soft and sprouted potatoes were stored. 5. A dented seven-pound can of chocolate pudding was stored together with non-dented canned food items in the dry storage area. These failures had the potential to result in food-borne illnesses.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure the Air-conditioning (AC) system on A side was cooling when residents' rooms [ROOM NUMBERS] air temperature was 83 degrees. {Acceptable air temperature ranges between 71 degrees to 81 degrees Fahrenheit(F)} This deficient practice had the potential to cause residents discomfort and susceptible to heat exhaustion.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement or develop the Comprehensive Plan of Care policy and procedure for the following three (Resident 37, 56 and 57) of 22 sampled residents when; -Resident 56's care plan was not developed to ensure safe smoking interventions were implemented. For example, an apron to protect clothing and self against burns. -Resident 57 did not have a care plan to address an impairment of the lower extremities. - Resident 37 had no care plan developed for range of motion. These deficient practices had the potential for residents to not receive care and treatment services based on care assessment needs.

Inspectors wroteBased on interview and record review, the licensed nursing staff routinely administered pain medication in the absence of pain for one of 22 sampled residents (Resident 7). Resident 7 was ordered Morphine (an opioid/narcotic), twice a day for moderate pain. Staff routinely administered the narcotic when the resident denied having pain. Staff also continued to administer the medication when Resident 7 had become lethargic. This failure resulted in respiratory depression, and unnecessary admission to the hospital.

Inspectors wroteBased on observation, interview, and record review, for one of one sampled resident (Resident 29) reviewed for dialysis (process when a machine filters the blood of wastes when the kidneys are not healthy enough to do it), the facility failed to ensure that a phosphate binder (binds/attaches to some of the phosphate in food reducing one's blood phosphorus levels) was administered as ordered by the physician. This failure had the potential to result in increased blood phosphorus (mineral) levels.

Inspectors wroteBased on interviews and record review, the facility failed to ensure two sampled residents (Resident 2 and 29) were free from unnecessary drugs when; -Resident 2 was administered Clonazepam (Klonopin- antianxiety) without adequate monitoring of behavior manifestations and medication side effects. -Resident 29 was administered Remeron (antidepressant) medication without appropriate indication and gradual dose reduction. These failures had the potential for residents to receive unnecessary medications and adverse medication side effects.

Inspectors wroteBased on observation, interview, and record review, for one of three sampled residents (Resident 29) reviewed for food concerns, the facility failed to provide food at a safe and appetizing temperature when Resident 29 was served a lunch tray that had been sitting at the bedside for two hours or more. This failure had the potential to result in food borne illness and resulted in Resident 29 being served cold food.

Inspectors wroteBased on observation, interview, and record review, the licensed staff did not provide the necessary rehabilitative services for one of 22 sampled residents. (Resident 25). Resident 25 had bilateral foot drop (inability to lift the front part of the foot causing the toes to drag on the ground which may be due to muscular problems or other underlying issues). Staff had not supported Resident 25's feet with a splint and there were no RNA (Restorative Nursing Assistant) visits documented in the clinical record. This failure resulted in the potential decrease in muscle strength in her feet and general range of motion.

Inspectors wroteBased on interview and record review, for one of four (Resident 49) sampled residents reviewed for advanced directives, the facility failed to ensure medical records were complete and accurate when Resident 49's Physician Order for Life -Sustaining Treatment (POLST, a form that gives seriously-ill patients control over end-of-life care decisions including medical care, prevents unwanted treatments and ensure patient's wishes are honored) was incomplete and not signed by Resident 49 or the Resident Representative. This failure had the potential to result in unwanted treatment and medical interventions and not honoring Resident 49's wishes for end-of-life care.