Hayward Post Acute

Inspectors wroteBased on interview and record review, the facility failed to develop and revise a comprehensive person-centered care plan for Resident 1 when their nasogastric tube (NGT is a soft tube inserted through the nose, throat and into the stomach to provide nutrition, hydration, and medications when a person can't eat by mouth ) dislodged three times within a 17-day period. This failure placed Resident 1 at risk for aspiration, interruption of nutrition and hydration, missing medication doses, and repeated exposures to X-rays. During a record review of Resident 1's admission Record (AR) printed on 5/13/26, the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including stroke (brain suddenly stops getting enough blood) and dysphagia (have trouble swallowing). [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure that one of seven sampled residents (Resident 2) received the necessary care and services according to their clinical needs related to diabetes (a chronic disease in which the body has elevated blood sugar, also call blood glucose) monitoring, ileostomy (surgical procedure that creates an opening in the abdominal wall, bring the end of the small intestines to the surface to allow waste to exit the body directly into external pouch call ileostomy bag, bypassing the colon and rectum.) care, medication management, and indwelling urinary catheter (also called Foley catheter, a thin, flexible tube inserted into the bladder and left in place to continuously drain urine) care when1. Resident 2 was receiving insulin (a medication that lowers blood glucose), yet the facility did not document their blood glucose levels.2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure adequate monitoring and implement appropriate interventions for Resident 1 when Resident 1's nasogastric tube (NGT is a soft tube inserted through the nose, throat and into the stomach to provide nutrition, hydration, and medications when a person can't eat by mouth) dislodged three times within a 17-day period. This failure placed Resident 1 at risk for aspiration, interruption of nutrition and hydration, missing medication doses, and repeated exposures to X-rays. During a record review of Resident 1's admission Record (AR) printed on 5/13/26, the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including stroke (brain suddenly stops getting enough blood) and dysphagia (difficulty swallowing). [...]

Inspectors wroteBased on interview and record review, the facility failed to follow up on Resident 1's grievance. This failure led to Resident 1 feeling angry and sad.

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. The kitchen refrigerator had packages of uncooked meat stored directly above fruit.2. Diet Aide (DA) 1 had uncovered facial hair while they prepared resident food. These failures had the potential for contamination of food resulting in food borne illness for the 88 residents who lived at the facility. During an observation on 12/8/25 at 9:30 a.m., in the kitchen, the refrigerator had uncooked turkey and beef stored directly over cantaloupes. During an observation on 12/8/25 at 12:53 p.m., in the kitchen, DA 1 had uncovered facial hair while DA 1 prepared resident sandwiches. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to allow one out of 22 Residents (Resident 11) to exercise their right to self-determination when they were not provided nutrition in accordance with their preferences. This failure had the potential to result in Resident 11 feeling upset and disrespected. During a review of Resident 11's admission Record, printed 12/9/25, the record indicated Resident 11 was admitted to the facility in January 2025 with a diagnosis of moderate protein-calorie malnutrition. During a review of Resident 11's Brief Interview for Mental Status (BIMS, is a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. [...]

Inspectors wroteBased on interview, and record review, the facility failed to develop new interventions to address the prevention of displacement and clogging of one of one sampled resident's (Resident 1) nasogastric tube (NGT, a tube that is inserted through the nose going down into the stomach) when Resident 1's NGT was displaced or clogged five times between January to July 2024. This deficient practice resulted in five transfers to the acute care hospital emergency department for NGT reinsertion for Resident 1. This also had the potential of making Resident 1 feel discomfort and develop infections.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to store, prepare, and distribute food in a safe and sanitary manner when: 1. Corn was rinsed in the handwashing sink, during food preparation, 2. Meat was thawed in still water, 3. There was no air gap (a gap of air between the floor and a drainpipe to prevent backflow of sewage into the equipment) for the 3-part compartment sink, 4. Hand Hygiene protocol was not followed during food preparation, and 5. Hand Hygiene protocol was not followed during tray line. These failures had the potential to cause food borne illnesses for 81 residents who received food from the kitchen for a facility census of 88.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two of four sample selected residents (Resident 193 and Resident 43) received the necessary services to maintain good grooming, and personal hygiene, when Resident 193 and 43's shower schedules were not followed as scheduled. This deficient practice resulted in Resident 193 and 43 not receiving showers and were unhappy about their hygiene.

Inspectors wroteBased on interview and record review, for one of one sampled resident (Resident 70) investigated for resident assessment, the facility failed to electronically transmit Minimum Data Set (MDS, an assessment tool used to direct resident care) Discharge assessment within the required 14 days. This failure had the potential to result in the lack of specific information for quality measure purposes.

Inspectors wroteBased on interview and record review, the facility failed to accurately complete the Preadmission Screening and Resident Review (PASRR) assessment for one (1) of two (2) sampled residents (Resident 35) when Resident 35's PASRR assessment did not indicate diagnoses of Schizophrenia (A mental disorder characterized by delusions, hallucinations, disorganized thoughts, speech, and behavior), and Depression (mental condition where the affected feels negative emotions more strongly than ever). This failure placed Resident 35 at risk to not receive care and services appropriate to his needs.

Inspectors wroteBased on observation, interview and record review, for one of three (Resident 33) sampled residents investigated for limited range of motion (the extent or limit to which a part of the body can be moved around a joint or a fixed point), the facility failed to ensure the comprehensive care plan that addressed Resident 33's limited range of motion was revised. This failure had the potential to result in the lack of coordination of care for Resident 33.

Inspectors wroteBased on observation, interview and record review, for one of four (Resident 33) sampled residents reviewed for activities of daily living care (ADL care), the facility failed to ensure Resident 33 received proper treatment and care to maintain good foot health when podiatry (branch of medicine devoted to the study, diagnosis, and treatment of disorders of the foot, ankle and lower limb) services were not provided. This failure had the potential to result in foot pain and loss of toenails for Resident 33.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure effective storage of non-controlled medications when medications for disposal were not securely stored and rendered irretrievable. This failure had the potential for misuse of the medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sample selected residents (Resident 1) stays free from accidents, when Resident 1 fell from the bed while Certified Nurse Assistance (CNA) 1 provided Activities of Daily Living (ADL, those activities needed for self-care and mobility and include activities such as bathing, dressing, grooming, oral care, ambulation, toileting, eating, transferring, and communicating). This failure in practice resulted in Resident 1 sustaining a skin laceration and transported to the emergency department.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain resident's privacy for one of three residents (Resident 1) when the privacy curtain was not fully drawn, exposing resident's body, brief (diaper), and legs during provision of care for activities of daily living (ADLs, are those needed for self-care and mobility and include activities such as bathing, dressing, grooming, oral care, ambulation, toileting, eating, transferring, and communicating). This deficient practice had the potential to result in public exposure of Resident 1's body during provision of care and cause emotional distress.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary services to maintain bathing, personal hygiene, turning & repositioning for one of three resident samples (Resident 1), when one staff instead of two staff provided care for activities of daily living (ADLs, are those needed for self-care and mobility and include activities such as bathing, dressing, grooming, oral care, ambulation, toileting, eating, transferring, and communicating) for Resident 1. This failure caused undue pain and distress for Resident 1.

Inspectors wroteBased on interviews and record review, the facility failed to ensure the Resident Representative (RR) was notified of changes in condition and treatment of one (Resident 1) of three sampled residents, when: 1. Resident 1 developed an unstageable pressure injury and the wound progressed to a Stage 4 pressure injury and received wound debridement (process of removal of dead (necrotic) or infected skin tissue to help a wound heal) multiple times as part of the treatment plan. 2. Resident 1 ' s Physician was not notified and updated on the progress of wound from skin shear to Stage IV pressure injury (a pressure injury develops when one or more layers of skin and tissue are damaged from continuous pressure to the area. [...]

Inspectors wroteBased on interviews and record review, the facility failed to provide treatment consistent with professional standards to promote healing of a pressure ulcer for one (Resident 1) of three sampled residents when: 1. Resident 1 did not have a physician ' s order for wound treatment and no wound treatments were documented on treatment administration record from 1/25/24 to 2/22/24. 2. Resident 1 ' s weekly skin assessment was not completed and accurately documented for multiple months. This deficient practice placed Resident 1 at risk for worsening existing pressure ulcer and slow healing of a stage IV pressure injury (a localized damage to the skin and/ or underlying soft tissue, usually over a bony area, or related to a medical or other device).

Inspectors wroteBased on interview and record review, for one of four sampled residents (Resident 1), the facility failed to ensure accurate procedure for administering medications to meet the needs of each resident when non-crushable medications were crushed and administered without consultation with the prescribing physician. This failure had the potential to result in rendering the medications ineffective while increasing their side effects.

Inspectors wroteBased on interview and record review, the facility failed to ensure the comprehensive plan of care for oral care was developed for one of three sampled residents (Resident 1) in accordance with Resident 1 ' s current assessed needs. This deficient practice had the potential for the facility not to meet Resident ' s current physical needs.

Inspectors wroteBased on observation, interview, and record review, for one of three sampled residents (Resident 1), who required assistance from staff for grooming and personal hygiene, the facility failed to provide assistance with urinary and bowel incontinence to ensure good personal hygiene. This failure resulted in Resident 1's poor personal hygiene and grooming. Resident 1's bedside and bed linens reeked of strong urine-like smell.

Inspectors wroteBased on interview and record review, the facility failed to ensure one (Resident 1) of three sampled residents received a copy of requested medical records in a timely manner. This failure resulted in a delay of 29 days before release of copies of Resident 1's requested medical records.

Inspectors wroteBased on interview and record review, for eight of 13 residents (Resident 3, 5, 6, 11, 12, 13, 14, and 24) reviewed for resident assessments, the facility failed to assess residents using the quarterly review instrument as required. This failure had the potential to result in the delay of assessment of the residents' needs and goals of care and inability to monitor each residents' decline and progress over time.

Inspectors wroteBased on observation and interview, the facility failed to store food in sanitary conditions when several food items in the kitchen refrigerator were either unlabeled or stored beyond their use-by dates. This failure had the potential to result in foodborne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement their infection prevention and control program policies and procedures (P&P) designed to provide a safe and sanitary environment to prevent the spread of disease and infections when: 1. Improper signage on two of two resident room doors (Residents 79 and 85) with confirmed COVID-19 (a mild to severe lung illness). 2. Disposal of used isolation gown outside of resident room (Resident 85) with known COVID-19. 3. No surveillance vital signs (temperature, pulse, respiratory rate and blood pressure) for multiple days for five of five sampled residents. 4. Eye drop vials used for a resident, fell on the floor and was returned in the medication cart without being disinfected. 5. Nurse had long acrylic nails. [...]

Inspectors wroteBased on interview and record review, the facility failed to immediately notify one (Resident 235) sampled residents' physician and representative or family member of a significant weight loss of 20 pounds in a month. This deficient practice had the potential to deny Resident 235's necessary treatment options and his representative the right to be informed.

Inspectors wroteBased on interview and record review, for two of 13 residents (Resident 2 and 10), the facility failed to conduct an annual/comprehensive Minimum Data Set (MDS, an assessment tool used to direct resident care) assessment in a timely manner. This failure had the potential to result in the lack of assessment of residents' needs, strengths, and goals of care.

Inspectors wroteBased on interviews and record review the facility failed to initiate a person centered care plan and or evaluate care for three sampled residents (Residents 29, 73, 86) when, 1. The facility did not initiate a care plan when Resident 29 had repeated episodes of vaginal bleeding. 2. Resident 86 was not evaluated for pain relief after the administration of narcotic pain medication. 3. Resident 73 had a wound on the right great toe and did not identify a developing wound of the right second toe. These deficient practices resulted in the decline in physical condition and delayed treatment. Resident 86 had the inability to perform daily tasks and tolerate treatment. For Resident 73, no treatment was provided for wounds on the right toes.

Inspectors wroteBased on interviews and record review, the facility failed to ensure one sampled resident (Resident 77) was free from unnecessary drugs. Resident 77 was administered Depakote (a mood stabilizer) medication without monitoring the target behavior and adverse medication side effects. This deficient practice had the potential for Resident 77 to receive unnecessary drugs and possible adverse side effects.

Inspectors wroteBased on interview and record review, the facility failed to implement the policy regarding food brought to residents by family and provide a safe handling and sanitary storage, including refrigeration. This failure had the potential to result in foodborne illness.

Inspectors wroteBased on observation and interview, the facility failed to ensure proper garbage and refuse disposal when garbage was stored in bins without lids outside the kitchen. This failure had the potential to result in an unsanitary environment and the potential to attract pests.