Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Driftwood Healthcare Center - Hayward during CMS and state inspections, most recent first.
Patio Gate Latch Secured With Zip Tie: A patio gate used as an emergency exit and evacuation route was observed with its latch secured by a white zip tie. The MD stated he applied the zip tie to keep unnecessary people out, while also acknowledging the gate was used by paramedics and for resident evacuation during emergencies. The Receptionist and CNA stated the gate served as an emergency door, and the facility's evacuation route and P&P identified the patio exit as part of external evacuation.
The facility failed to protect the confidentiality of two residents’ personal and clinical information when the Social Services Director shared their health details with the Ombudsman without obtaining consent. Both residents were alert and oriented, had multiple medical diagnoses including stroke and MS, and had signed Notices of Privacy Practices that allowed release of health information for treatment purposes only. Despite the Ombudsman’s repeated requests not to receive personal health information without resident consent, the SSD acknowledged continuing to disclose such information, contrary to the facility’s policy on resident dignity and personal privacy.
Two residents with acute and chronic respiratory failure did not receive tracheostomy care according to MD orders and the care plan. For one resident, the RT repeatedly cleaned and reused the trach inner cannula over multiple days instead of changing it daily as ordered, with documentation showing cleaning on several specific days rather than daily replacement. For another resident, observation showed that required emergency trach equipment, including a spare inner cannula, was not kept at the bedside, despite the RT, RN supervisor, DON, and the respiratory care plan all indicating that necessary emergency supplies should be readily available to maintain a clear, open airway.
A resident with a history of stroke, depression, and intact cognition had an active PRN order and care plan for Oxycodone to manage moderate to severe pain, but did not receive the medication when requested because the facility had run out of it. The resident reported waiting over 24 hours for pain relief, feeling upset and frustrated, and not wanting to get out of bed without the pain medication. The CN on duty acknowledged the resident’s pain complaint and request for Oxycodone but did not administer it due to lack of stock, while the RN supervisor confirmed that pain medications should be given as ordered and that the facility’s pain management policy required administering ordered pain medication.
Two residents engaged in a physical altercation on a patio, during which they faced each other in wheelchairs, hit one another, and yelled profanities, resulting in one cognitively intact resident sustaining a cut to the hand and pain in the ear and later reporting fear and feeling unsafe. The other resident involved had severe cognitive impairment and did not recall the event. A third resident reported the incident to nursing staff, and social services notes documented that the injured resident admitted striking the other resident out of frustration. These events occurred despite a facility abuse prevention policy requiring protection of residents from abuse by anyone, including other residents.
Two residents sharing a bathroom became involved in a verbal dispute that escalated into shoving and a physical assault with a cane while a CNA was present. One resident had intact cognition and a documented history of aggressive behavior with care plan interventions that included separating involved parties, while the other had moderate cognitive impairment and late-onset cerebellar ataxia. The CNA, unfamiliar with the residents and working her first shift at the facility, attempted only verbal de-escalation and did not physically separate the residents or call for help until after one resident struck the other. The DON later confirmed that staff, including registry staff, were expected by policy to immediately separate residents during verbal altercations or call for assistance, and written policies required protecting residents from abuse and separating residents involved in altercations.
The facility failed to ensure nursing staff had physician orders, policy, and training for using an enteral tube clog removal tool on two residents. The tool was used without proper authorization or training, potentially risking enteral tube perforation. The DON confirmed no training was provided, and the facility's policy lacked procedures for the tool's use.
The facility failed to properly document and destroy 14 controlled medications found in the DON's cabinet, leading to potential drug diversion. These medications, associated with discharged residents, lacked proper documentation and were not destroyed according to state law and facility policy. The DON admitted to not knowing the procedure for destroying medications without documentation, and the facility's method of using water for destruction was deemed unacceptable.
The facility failed to ensure proper puree preparation for residents on a pureed diet, as observed when a cook added excess cooking water to vegetables, resulting in a diluted and bland puree. Despite previous training, the cook did not follow the recipe or taste the food, leading to a product that lacked flavor and proper consistency, putting residents at risk for decreased nutritional intake.
The facility did not follow prescribed menu portions for residents, serving incorrect amounts of orzo, baked apples, and Boston cream pie. A Dietary Aide served 1/2 cup of orzo instead of the required 1/3 cup for CCHO diet residents, used a #12 scoop for baked apples instead of a #10 scoop, and provided a 1x2 inch square of Boston cream pie instead of the specified 2x3 inch portion.
The facility failed to clean the juice machine according to the manufacturer's instructions, risking foodborne illness for 56 residents. A kitchen aide soaked the juice bar gun in hot water instead of lukewarm water and did not perform the required weekly flushing of hoses and lines. There was no log or cleaning schedule to document these activities.
A long-term care facility failed to follow infection control policies, including using non-sterile gloves for tracheostomy suctioning, neglecting hand hygiene between residents, and lacking necessary equipment for respiratory care. Additionally, open system tube feeding lines were used beyond the recommended time, and a wound was not cleansed as per physician's orders, increasing infection risks.
A resident with quadriplegia and cerebrovascular disease did not receive complete fingernail care, resulting in long, pointed nails on one hand. The resident was dependent on staff for personal hygiene and expressed a preference for evenly clipped nails. Interviews with staff indicated that CNAs were responsible for trimming non-diabetic residents' nails, and the importance of nail care for dignity and infection prevention was emphasized.
A resident experienced a 21.27% weight gain over a year due to the facility's failure to implement dietician recommendations for tube feeding adjustments. Despite the resident's complex medical history and reliance on tube feeds, the facility continued administering Glucerna 1.5 at 70 ml/hour for 24 hours, contrary to the dietician's advice. This oversight led to significant weight gain, highlighting a deficiency in the facility's management of the resident's nutritional needs.
A resident receiving hemodialysis at an LTC facility did not receive proper care due to staff's lack of knowledge about managing arterial-venous fistula complications and failure to administer Renagel as prescribed. The resident missed several doses of the medication during dialysis days, leading to elevated phosphorus levels. The facility's policy on hemodialysis care was not adequately followed, indicating a need for improved staff training and adherence to care protocols.
The facility did not ensure the Kitchen Manager completed the required six hours of inservice training on California dietary service requirements. The KM, although certified as a dietary manager, confirmed the lack of training, and the Registered Dietician had not developed or administered it. This resulted in the KM lacking necessary competencies, potentially risking residents' safety.
A resident admitted for pain management and rehabilitation after a hip fracture developed a stage 2 pressure ulcer that worsened and became infected due to the facility's failure to develop a care plan, monitor the ulcer, provide a pressure-reducing mattress in a timely manner, and reposition the resident consistently.
The facility failed to secure medications for 76 residents when three medication carts were found unlocked and unattended. A nurse confirmed the carts were usually locked to prevent unauthorized access, and the DON stated that nurses are expected to lock the carts for resident safety. The facility's policy requires medication carts to be locked after use.
Patio Gate Latch Secured With Zip Tie
Penalty
Summary
The facility failed to provide a safe environment for 79 out of 79 sampled residents when the patio gate latch was secured with a white zip tie. During a concurrent observation and interview with the Maintenance Director in the patio, a black fence surrounding the patio had a gate latch secured with the zip tie, and the Maintenance Director stated he had applied it. He stated there should be no zip tie and explained that he placed it there to prevent unnecessary people from coming into the facility. The Maintenance Director also stated the patio gate was an access point for paramedics picking up residents in an emergency and later stated it was a route for evacuation during emergencies. The Receptionist stated the patio gate was used as an emergency door in case of a fire. CNA 1 stated the Maintenance Director would sometimes place a padlock on the gate because residents tried to open it, and said it was not necessary to lock the gate because residents cannot go out in case of emergency. Review of the Evacuation Route document showed an exit leading to the patio, and review of the facility's Evacuation Guidelines showed external evacuation required residents to assemble more than 35 feet away from the building. The Maintenance Director stated that 35 feet away from the building was outside the patio fence.
Unauthorized Disclosure of Resident Health Information to Ombudsman
Penalty
Summary
The facility failed to maintain confidentiality of personal and medical information for two residents when the Social Services Director (SSD), a licensed social worker, disclosed their information to the Ombudsman without consent. Resident 1’s face sheet showed admission in February 2025 with multiple diagnoses including cerebral infarction (stroke), and the MDS indicated the resident was alert and oriented. Resident 1 had signed a Notice of Privacy Practices (NPP) on 3/19/2025 acknowledging receipt of the NPP and allowing release of health information for treatment only. Resident 2’s face sheet showed admission in October 2025 with multiple diagnoses including Multiple Sclerosis, and the MDS indicated this resident was also alert and oriented. Resident 2 had signed an NPP on 4/9/2025 with the same limitation that health information could be released for treatment only. During an interview, the Ombudsman reported that she had repeatedly asked the facility’s social worker not to share residents’ personal health information with her unless consent was obtained from the residents, but the social worker continued to share such information despite these requests. In a separate interview, the SSD confirmed that she had shared personal information with the Ombudsman regarding both residents without their consent. Resident 1 was not interviewable when asked if personal information had been shared without consent, and Resident 2 was no longer at the facility. The facility’s undated policy titled “Resident Dignity & Personal Privacy” stated that each resident’s right to personal privacy includes the confidentiality of personal and clinical affairs and that staff interactions should assist residents in maintaining and enhancing self-esteem and self-worth.
Failure to Follow Tracheostomy Orders and Maintain Emergency Airway Equipment
Penalty
Summary
The facility failed to provide tracheostomy care consistent with physician orders and professional standards for two residents with respiratory failure. One resident, admitted with acute respiratory failure and with a physician’s order dated 12/7/23 to have the tracheostomy inner cannula changed daily by respiratory therapy, did not have the inner cannula changed for a total of five days, including three consecutive days. Progress notes from 2/13/26 through 2/22/26 documented that the inner cannula was cleaned, rather than changed, on multiple dates (2/13/26, 2/16/26, 2/20/26, 2/21/26, and 2/22/26). The respiratory therapist reported cleaning and reusing the inner cannula for a couple of weeks because replacement inner cannulas were not available, and acknowledged that the inner cannula should have been changed daily per the physician’s order. The RN supervisor also stated it was important to change the inner cannula daily so it would not be clogged and that reusing it multiple times could have been a risk for infection. A second resident, admitted with chronic respiratory failure and with a tracheostomy order specifying a Shiley Covidien size 4 tube, did not have all necessary emergency tracheostomy equipment at the bedside. During observation and interview with the respiratory therapist, the resident was noted to be without a spare inner cannula readily available at bedside, despite the therapist stating that a spare inner cannula was part of the necessary emergency tracheostomy equipment that should be present. The RN supervisor stated that emergency tracheostomy equipment, including the inner cannula, was important to have at bedside to prevent the tracheostomy hole from closing. The DON also stated that emergency equipment, including inner cannulas, should have been at residents’ bedsides. The resident’s respiratory care plan documented the presence of a tracheostomy with risk for congestion and SOB, with a goal to maintain a clear, open airway and an approach of keeping all necessary emergency supplies readily available at all times, which was not followed.
Failure to Provide Ordered PRN Oxycodone for Pain
Penalty
Summary
The facility failed to provide ordered pain medication to a resident with a physician’s order for Oxycodone 7.5 mg PO every 4 hours PRN for moderate to severe pain. The resident, admitted with diagnoses including cerebral infarction and depression, had a BIMS score of 14, indicating intact cognition, and a care plan problem of altered comfort and daily activity due to pain, with an approach to administer Oxycodone as ordered. On the date in question, the Medication Administration Record showed that the resident did not receive any Oxycodone. The resident reported having to wait over 24 hours for Oxycodone because the facility had run out of the medication, stating they felt upset and frustrated and did not want to get out of bed without their pain medication. The charge nurse assigned to the resident’s unit that day stated the resident complained of moderate generalized body pain and requested Oxycodone, but the nurse did not administer it because the facility had no Oxycodone available. The nurse reported informing the resident that there was no more Oxycodone and that it had been ordered but had not yet arrived, and confirmed it did not arrive during that shift. The registered nurse supervisor stated that when residents complain of pain, pain medications should be given as ordered by the physician and that relieving pain is important because it could increase irritability and vital signs. The facility’s pain management policy required administering pain medication as ordered by the physician, but this was not followed for this resident on the identified date.
Failure to Prevent Resident-on-Resident Physical Abuse
Penalty
Summary
The facility failed to protect two residents from physical abuse when they engaged in a physical altercation with each other. One resident, who was cognitively intact with a BIMS score of 13/15, reported that another resident hit him on the head with a closed fist, causing pain to his right hand and left ear and leaving him feeling fearful and unsafe in the facility. The other resident involved had severe cognitive impairment, with a BIMS score of 4/15, and later stated he had no recollection of the altercation. Progress notes documented that a third resident witnessed the incident and alerted nursing staff that the two residents were facing one another in their wheelchairs on the patio, hitting each other and yelling profanities. Nursing notes indicated that the cognitively intact resident sustained a cut on his right knuckle and complained of pain in his left ear. Social services documentation showed that this resident acknowledged striking the other resident and justified his actions by stating he felt frustrated. These events occurred despite the facility’s Abuse Prevention Program policy, which states that the administrator will protect residents from abuse by anyone, including other residents.
Failure to Timely Intervene in Resident-to-Resident Altercation
Penalty
Summary
The deficiency involves the facility’s failure to ensure immediate interventions during a resident-to-resident altercation, allowing a verbal dispute to escalate into a physical altercation without timely staff separation. Resident 1, admitted in November 2023 with acute respiratory syndrome and an anxiety disorder, had a Brief Interview for Mental Status (BIMS) score of 15 on 9/30/25, indicating intact cognition. Resident 1’s care plan dated 11/12/24 documented a history of aggressive behavior toward other residents, with interventions that included emphasizing the resident’s responsibility for physical aggression, describing possible outcomes to self and others, and neutralizing situations by separating involved parties. Resident 2, admitted in June 2025 with late-onset cerebellar ataxia and a BIMS score of 12 on 9/26/25 indicating moderate cognitive impairment, shared a bathroom with Resident 1’s room. According to Resident 2’s interview, the incident occurred early one morning in November 2025 when Resident 2 used the shared bathroom and heard loud yelling from the adjacent room. Resident 2 entered Resident 1’s room through the shared bathroom and observed a staff member present, then told the staff to address the yelling. Resident 2 reported that Resident 1 began yelling and ordered Resident 2 to leave the room, leading to a verbal argument in which they were “challenging each other.” Resident 2 stated that the argument escalated into a physical altercation when Resident 1 struck Resident 2 on the head with a cane, and that staff did not intervene until after the physical contact occurred, at which point male nursing staff separated them. CNA 1, who was providing care to Resident 1’s roommate at the time, stated it was her first time working at the facility and she did not know Resident 2 was assigned to another room. She reported that Resident 2 entered through the shared bathroom and requested that she make the roommate stop yelling. CNA 1 said Resident 1 became upset, began arguing with Resident 2, and told Resident 2 to get out of the room. CNA 1 stated she also instructed Resident 2 to leave, but both residents continued to yell. She observed Resident 1 get up from the bed and both residents began shoving each other. CNA 1 did not physically intervene because she did not want to get in the middle of them and instead attempted verbal de-escalation while “keeping an eye on them” as they continued to argue. She reported that she saw Resident 1 grab a cane and hit Resident 2 on the head, and only then called for assistance, after which male nursing staff separated the residents. The DON stated staff, including registry staff, were expected to immediately separate residents as soon as a verbal altercation occurs or call for assistance if unable to safely manage the situation. Facility policies on abuse prevention and resident-to-resident altercations required protecting residents from abuse and separating residents involved in altercations and instituting measures to calm the situation.
Improper Use of Enteral Tube Clog Removal Tool
Penalty
Summary
The facility failed to ensure that nursing staff had the necessary physician orders, facility policy, and training to use an enteral tube clog removal tool for two residents receiving medications through an enteral tube. This deficiency was identified during observations and interviews with nursing staff and the Director of Nursing (DON). The nursing staff used a plastic clog removal tool on the enteral tubes of two residents without a physician's order or proper training, which could potentially lead to enteral tube perforation or gastrointestinal damage. Resident 274 was admitted for gastrostomy care, tracheostomy care, muscle wasting and atrophy, and chronic respiratory failure. The resident had a physician's order to use a declogger when indicated, but the nursing staff used the clog removal tool without following the facility's policy or receiving training. Similarly, Resident 45, admitted for gastrostomy care, tracheostomy care, chronic respiratory failure, and dysphagia, did not have a physician's order for the use of a clog removal tool, yet the tool was used by the nursing staff. The Director of Nursing acknowledged that there was no inservice or training provided on the use of the clog removal tool and that the facility's policy did not include procedures for its use. The Director of Staff Development confirmed that the orientation record for the involved nurse did not include training on the clog removal tool. The nursing staff was expected to unclog enteral tubes by massaging the tube or using warm water or an enzymatic solution, and to contact the provider for tube replacement if necessary.
Improper Documentation and Destruction of Controlled Medications
Penalty
Summary
The facility failed to ensure the proper documentation and destruction of 14 controlled medications, which were found in the Director of Nursing's (DON) controlled medications cabinet. These medications, which included Norco, Hydromorphone, Lorazepam, Morphine, and Alprazolam, were not destroyed according to state law and facility policy, leading to a potential risk for drug diversion. The medications were associated with discharged residents, and many lacked proper documentation, such as receipt dates, discontinuation dates, and count sheets. During an interview, the DON stated that the primary pharmacist, Pharmacist Consultant 1 (PC 1), was responsible for the monthly destruction of controlled medications alongside the DON. However, the DON admitted to not knowing the procedure for destroying medications without proper documentation. The facility's method of using water to dissolve medications was also found to be unacceptable by Pharmacist Consultant 2 (PC 2), who was completing documentation for the destruction of the medications. The facility's policies on medication destruction and disposal were reviewed, revealing that the facility was expected to destroy controlled medications within 90 days of receipt and to use substances like coffee grounds or kitty litter for destruction, not water. The policies also required documentation of the destruction process in a drug destruction log book, as per state and federal law. The failure to adhere to these policies resulted in the controlled medications not being destroyed in a timely and compliant manner.
Improper Puree Preparation in Dietary Services
Penalty
Summary
The facility failed to ensure that cooks had the necessary education and skills to properly puree food for residents on a pureed diet. This deficiency was observed during multiple instances where a cook, identified as C-1, improperly processed vegetables by adding excess cooking water to the blender, resulting in a diluted and watery puree. The cook did not taste the pureed vegetables upon completion, which is a required step according to the facility's procedure. This improper preparation led to pureed food that was bland, lacked flavor, and did not meet the expected texture and consistency. During a review of the facility's recipe for pureed carrots, it was noted that water was not listed as an ingredient, yet it was inadvertently added during preparation. Additionally, the facility's training records indicated that dietary staff had previously received education on how to puree food and adhere to recipes. However, the observed practices did not align with the training provided, as the cook failed to follow the recipe and did not perform a taste test to ensure the food's palatability. This failure put residents at risk for decreased satiety and nutritional intake, which could potentially lead to weight loss.
Non-compliance with Prescribed Menu Portions
Penalty
Summary
The facility failed to adhere to the prescribed menu portions for residents on a Controlled Carbohydrate (CCHO) diet, as well as for those on regular diets. During an observation and record review, it was noted that a Dietary Aide served 1/2 cup of orzo to residents on a CCHO diet, whereas the Spring/Summer 2024 Diet Spreadsheet specified a portion of 1/3 cup. Additionally, the Dietary Aide used a #12 scoop to serve baked apples, while the spreadsheet required a #10 scoop for both regular and CCHO diets. Furthermore, residents were served a 1x2 inch square of Boston cream pie, contrary to the specified 2x3 inch portion. These discrepancies in portion sizes could potentially affect the residents' ability to maintain normal body weight and receive appropriate nutritional values.
Improper Cleaning of Juice Machine
Penalty
Summary
The facility failed to ensure proper cleaning of the juice machine according to the manufacturer's instructions, which posed a risk of foodborne illness to 56 residents receiving juice. During an observation and interview, a kitchen aide was seen soaking the juice bar gun in hot water, contrary to the manufacturer's procedure that required soaking in lukewarm water. Additionally, the facility did not perform the required weekly flushing of all hoses, pumps, and bar gun lines. The kitchen aide also mentioned that there was no log or cleaning schedule to document these cleaning activities.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to infection control policies and procedures, resulting in multiple deficiencies. Staff did not use sterile gloves when performing tracheostomy suctioning on a resident, despite the expectation to maintain sterility to prevent respiratory infections. The registered nurse supervisor used non-sterile gloves during the procedure, and the sterile gloves provided in the suction catheter package were not utilized. This oversight was observed by a respiratory therapist and acknowledged by the infection preventionist and the director of nursing, who confirmed the requirement for sterile technique. Additionally, staff failed to perform proper hand hygiene when switching between residents requiring tracheostomy care. A respiratory therapist was observed moving between residents without washing hands or changing gloves, which is against the facility's hand hygiene policy. This lapse in protocol was noted by the infection preventionist and the director of nursing, who emphasized the importance of hand hygiene in preventing infections, especially in residents with tracheostomies. The facility also lacked necessary equipment to change suction canisters and ventilator circuits, as required by their policy. Observations revealed that suction canisters were not dated or changed regularly, and a resident's ventilator circuit was soiled and overdue for replacement. The respiratory therapist confirmed the shortage of supplies, and the director of nursing acknowledged past issues with equipment ordering. Furthermore, open system tube feeding lines were used beyond the recommended 24-hour period, increasing the risk of bacterial growth and gastrointestinal infections. Lastly, a licensed nurse did not cleanse a resident's wound with normal saline before applying treatment, contrary to the physician's order, which could lead to infection.
Failure to Provide Complete Fingernail Care for a Resident
Penalty
Summary
The facility failed to provide complete fingernail care for one of the residents, identified as Resident 25, who was dependent on staff for personal hygiene and grooming due to quadriplegia and cerebrovascular disease. The resident's Minimum Data Set (MDS) indicated moderately impaired cognition and a need for assistance with activities of daily living (ADL). During an observation, it was noted that the resident's left-hand fingernails were long and pointed, while the right-hand fingernails were clipped. The resident expressed a preference for having all fingernails clipped evenly. Interviews with staff, including a Certified Nursing Assistant (CNA) and the Director of Staff Development (DSD), revealed that CNAs were responsible for trimming the fingernails of non-diabetic residents. The DSD emphasized the importance of nail care for maintaining resident dignity and preventing skin injuries and infections. The facility's lesson plan on nail care highlighted the need for daily cleaning and regular trimming to prevent infections and skin problems. The failure to provide complete fingernail care left Resident 25 feeling helpless and at risk for potential infections and self-injury.
Failure to Implement Dietician Recommendations for Tube Feeding
Penalty
Summary
The facility failed to ensure consistent intervention and recommendations were carried out for a resident who relied solely on tube feeds for nutrition. This oversight resulted in an unintended and unplanned weight gain of 21.27% over the course of a year. The resident, who had a complex medical history including chronic respiratory failure with ventilator dependency, hypertension, hyperlipidemia, diabetes, and difficulty swallowing, experienced significant weight changes that were not adequately addressed by the facility. The resident's weight was monitored monthly, and despite recommendations from the registered dietician to adjust the tube feeding rate, the facility continued to administer Glucerna 1.5 at 70 ml/hour for 24 hours. The dietician had recommended a reduction in the feeding rate to 70 ml/hour for 22 hours and later suggested switching to Glucerna 1.2 due to notable weight gain related to edema. However, these recommendations were not consistently implemented, leading to continued weight gain. The facility's policy on weight measurements required that progressive weight changes be reported to the attending physician and documented in the medical record. Despite this policy, the resident's significant weight gain was not effectively managed, as evidenced by the continued administration of the same feeding regimen despite dietician recommendations and the facility's awareness of the weight gain. This lack of action contributed to the deficiency identified in the report.
Deficiencies in Dialysis Care and Medication Administration
Penalty
Summary
The facility failed to provide adequate care and services for a resident receiving hemodialysis, leading to two main deficiencies. Firstly, a Licensed Nurse (LN) was not fully knowledgeable about managing complications at the resident's arterial-venous fistula site post-dialysis. This lack of knowledge could result in improper intervention and delayed physician notification in case of a dysfunctional access site condition. The Registered Nurse Supervisor admitted uncertainty about the correct interventions for major bleeding at the fistula site, indicating a need for further training on dialysis care. Secondly, the facility did not ensure the resident received Renagel, a phosphate binder, as prescribed three times daily with meals. The medication was not administered during the 12 p.m. dose on dialysis days, as the resident was unavailable due to being at the dialysis center. This oversight was not communicated to the physician, leading to elevated phosphorus levels in the resident, which could potentially harm the resident's heart. The Licensed Vocational Nurse confirmed the missed doses and acknowledged the lack of documentation informing the physician or dialysis center about these omissions. The resident, who has a history of diabetes mellitus and end-stage renal disease, was dependent on renal dialysis. The facility's policy on hemodialysis care was not adequately followed, as evidenced by the lack of proper medication administration and insufficient staff training on managing dialysis-related complications. These deficiencies highlight the need for improved staff education and adherence to care protocols to ensure the resident's well-being.
Failure to Provide Required Dietary Training
Penalty
Summary
The facility failed to ensure that the Kitchen Manager (KM) completed the required six hours of inservice training on the specific California dietary service requirements as mandated by the California Code of Regulations (CCR) Title 22. This deficiency was identified during an interview with the KM, who confirmed that she worked full time and was certified as a dietary manager but had not received the necessary training. Additionally, the Registered Dietician (RD) acknowledged that she had not administered or developed the required training for the KM. This oversight resulted in the KM lacking the competencies and skills needed to carry out food and nutrition functions, potentially putting residents at risk for foodborne illness.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide adequate pressure ulcer prevention and treatment for a resident who was admitted for pain management and rehabilitation after a left hip fracture. Upon admission, the resident was assessed to be at high risk for developing pressure ulcers, with a Braden score of 12, indicating very limited mobility and confinement to bed. Despite this high risk, the facility did not develop a care plan for the resident's pressure ulcer upon its discovery, nor did they monitor the ulcer effectively. The resident developed a 1 cm x 1 cm stage 2 pressure ulcer on the right buttock, which grew to 7 cm x 7 cm and became abscessed over 25 days due to lack of proper care and monitoring. The facility also failed to provide a pressure-reducing mattress in a timely manner. Although a physician's order for a low air loss (LAL) mattress was placed on 4/3/23, the resident was not documented to be on the mattress until 4/27/23. This delay in providing the necessary equipment contributed to the worsening of the pressure ulcer. Additionally, the facility did not consistently reposition the resident to alleviate pressure on the affected area. Progress notes from 4/4/23 to 4/26/23 did not indicate that the resident was repositioned, and there was no documentation of the resident refusing repositioning or wound care. Interviews with staff revealed that certified nursing assistants (CNAs) were instructed to reposition residents but did not document the times or positions of turning and positioning. Licensed nurses were responsible for this documentation but failed to do so. The facility's policy and procedure for pressure ulcer and skin care management required the development of a care plan and consistent interventions by all staff, which were not followed in this case. As a result, the resident's pressure ulcer worsened and became infected, necessitating a course of antibiotics and further medical intervention.
Failure to Secure Medication Carts
Penalty
Summary
The facility failed to ensure medications were secure for a census of 76 residents when three medication carts were found unlocked and unattended. During an observation, three medication carts in the sub-acute hall were seen up against the wall, side by side, and left unattended and unlocked. A Licensed Nurse confirmed that the carts with prescription medications were unlocked and stated that they usually lock the carts before leaving them to prevent unauthorized access. The Director of Nursing also confirmed that the expectation is for nurses to lock the carts before leaving them to ensure the safety of residents. The facility's policy and procedure on the use of medication carts indicated that the nursing staff should lock the medication cart with the key or locking bar after use.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near Hayward
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| St Francis Healthcare Center | 0.1 mi | ★★★★★ | 27 | 0 |
| Golden Harbor Healthcare Center | 1.2 mi | ★★★★★ | 60 | 0 |
| Morton Bakar Center | 1.3 mi | ★★★★★ | 0 | 0 |
| Hayward Healthcare & Wellness Center | 1.6 mi | ★★★★★ | 1 | 0 |
| Serenethos Care Center, Llc | 1.7 mi | ★★★★★ | 0 | 0 |
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