Average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Hayward Hills Health Care Center during CMS and state inspections, most recent first.
Oxygen Therapy Not Set to Ordered Flow Rate: A resident with severe cognitive impairment and respiratory diagnoses was observed receiving O2 via NC at 5 LPM, although the physician’s order called for 3 LPM. The LVN acknowledged the ordered rate and stated it was her responsibility to verify the oxygen flow, and the DON stated the flow should have been checked at the start of the shift. The care plan directed staff to administer oxygen as ordered, and the facility policy instructed staff to set the unit to the desired flow rate.
A resident with a history of DVT, PE, and AFib had Eliquis held for bleeding, but staff did not document ordered bleeding checks or follow up to clarify when the anticoagulant should be restarted; the resident later developed extensive bilateral DVT. In a separate event, a resident with chest pain, nausea, vomiting, and pallor refused an MD-ordered ACH transfer, but staff did not document that the risks and benefits of refusal were explained before the resident later worsened and required hospital transfer.
Expired and open drugs, a full unlabeled medication disposal bin, and two full drug buster containers were found in the med storage room, along with an opened bottle of MOM. Enteral feeding supplements and nutritional products were stored in a CSR at 82 F with inadequate airflow, above the facility’s stated limit. Medication cart 4 was left unlocked and unattended on two occasions, and four medication carts contained multiple loose unidentified pills in the drawers.
Incomplete temperature monitoring and improper food storage were identified in the kitchen. One freezer had a posted log with multiple blank AM/PM entries, and no temperature logs were posted on the meat freezer, produce refrigerator, vegetable refrigerator, or one refrigerator. Staff gave conflicting statements about who was responsible for checking and documenting temperatures, and the facility also stored foods from outside sources for three residents in one refrigerator.
Improper Storage of Outside Food: Staff failed to follow the facility’s food storage policy for three residents’ outside food items. One resident’s food was undated, another was labeled only with a room number and kept beyond the allowed time, and a third resident’s food was also stored too long in the resident food refrigerator. CNAs, nurses, and housekeeping staff gave conflicting accounts of who was responsible for labeling, removing, and cleaning the refrigerator, while a posted notice required all food to be dated and labeled.
Failure to maintain infection control was cited when staff did not clean hands during meal service, after handling dirty dishes and resident cups, before medication administration, or between uses of shared equipment such as a BP cuff and pill crusher. The IP also could not provide a daily outbreak line list to public health during an active GI illness outbreak affecting multiple residents and a kitchen staff member.
Incomplete flu and PNA vaccine documentation was found for three residents. An IP reviewed EHRs and stated that one resident refused both vaccines but no declination or risks/benefits documentation was found, another had a progress note noting a refusal without identifying which vaccine and no consent/declination form, and a third had a signed but undated flu declination form that did not verify when the vaccine was offered or declined. Facility policy required refusals to be documented in the medical record.
Incomplete COVID-19 Immunization Documentation: The facility failed to maintain complete and accurate COVID-19 vaccine records for three residents. An IP review found one resident’s refusal note did not identify which vaccine was refused and lacked a consent/declination form, another resident had no consent or declination record in the EHR or paper chart, and a third resident’s undated form did not show when education occurred or when the vaccine was declined. The facility’s policy required documentation when a resident refused the COVID-19 vaccine.
Failure to protect a resident from physical abuse when another resident grabbed the resident’s arm in the hallway, causing a bruise and pain. The affected resident had dementia and severe cognitive impairment, and later stated feeling very scared after the incident. An LVN separated the residents, and the DON stated the other resident was not monitored for high-risk behavior and that the incident could have been prevented with better assessment and supervision.
Failure to assess and address hand contractures was identified for a resident with parkinsonism and dementia. Staff observed contractures in both hands, a CNA reported using hand rolls because the resident could no longer open the hands, and the RNA confirmed PROM was ordered only for the lower extremities, not the hands. PT stated the resident would have benefitted from ROM exercises, splinting, or bracing, while the RD confirmed no contracture assessment had been completed and the facility policy required quarterly contracture screens with ROM measurements.
A resident's medical record lacked required physician documentation, including physician progress notes and an H&P, during the stay. The RDCO reviewed the EHR and stated the H&P had been completed by a covering physician but could not be found in the record, and noted that physician notes/H&P should be readily available. The facility policy stated medical records must be readily accessible for resident care 24 hours per day.
The facility failed to ensure timely submission and action on Medical Regimen Review (MRR) reports, leading to delays in therapeutic recommendations for several residents. Despite the Pharmacy Consultant's claim of submitting reports within 48 hours, the Medical Director and nursing staff reported consistent delays, impacting medication and treatment decisions. Specific instances showed months-long delays in acting on recommendations for monitoring dehydration, electrolytes, and other conditions, contrary to the facility's policy of acting within 30 days.
The facility's dishwasher failed to reach the required temperature of 120°F, as observed on multiple occasions, posing a risk of unsanitized dishes. The Dietary Manager confirmed the issue, and the Maintenance Supervisor admitted the broken booster was not logged. The Administrator was unaware of the problem, highlighting a communication breakdown.
The facility failed to properly store and manage narcotic medications, with some found in an unlocked drawer and discrepancies in medication counts. Two residents had narcotic records that did not match the MAR, indicating missing documentation. Additionally, a resident was undermedicated with diazepam, and another received an incorrect dose of lactulose.
A long-term care facility was found to have a medication error rate of 30% during a survey. Errors included a nurse improperly administering multiple medications via a G-tube by crushing and mixing them together, contrary to policy, and failing to administer prescribed medications. Another nurse failed to give a multivitamin to a resident, despite documenting it as given.
The facility failed to ensure proper storage, labeling, and disposal of medications and vaccines, including unlabeled eye drops, expired inhalers, and improperly monitored refrigerator temperatures. These lapses could affect medication efficacy and safety.
The facility was found to have expired chocolate pudding in the refrigerator and uncovered, freezer-burned soup in the freezer. The Dietary Manager confirmed these issues, acknowledging that expired foods should not be stored or served and that freezer burn could affect food taste.
A resident reported an inappropriate touch by a CNA during pericare, but the facility failed to report the incident to the ombudsman or CDPH as required. The DON only conducted a brief interview with the CNA, who denied the event, and no further investigation was documented. The facility's policy mandates reporting such incidents, which was not followed until later.
A facility failed to complete the required PASARR for a resident with an intellectual disability. The resident was admitted with multiple diagnoses, including a developmental disorder of scholastic skills. Despite the requirement to resubmit a new screening after 30 days, the facility did not complete a PASARR after the resident had been in the facility for more than 31 days. This was confirmed by the DON during an interview.
A resident suffered multiple injuries after a CNA attempted a solo transfer using a Hoyer lift, contrary to the care plan requiring two-person assistance. The resident, who was dependent on assistance for transfers, fell during the process, resulting in rib fractures, a pneumothorax, and a femur fracture. The facility's policy and training emphasized the need for two caregivers during such transfers, which was not adhered to in this incident.
Oxygen Therapy Not Provided at Ordered Flow Rate
Penalty
Summary
The facility failed to meet professional standards of quality when nursing staff did not follow the physician’s order for Resident 7’s oxygen therapy. Resident 7’s record showed severe cognitive impairment with a BIMS score of 2 out of 15, along with diagnoses including anemia and interstitial pulmonary disease. During a concurrent observation and interview, Resident 7 was receiving oxygen via nasal cannula at 5 LPM, while the LVN stated the resident was supposed to receive oxygen at 3 LPM as ordered by the doctor and acknowledged it was her responsibility to check that oxygen was running at the correct ordered rate. The DON stated the LVN should have checked the resident’s oxygen flow at the beginning of the shift to ensure oxygen therapy was provided as ordered. The physician’s order report showed an order for oxygen inhalation via nasal cannula at 3 LPM every shift, and the care plan directed staff to administer oxygen as ordered. The facility policy on oxygen administration stated to turn the unit on to the desired flow rate.
Failure to Follow Medication Hold Orders and Document Refusal of Hospital Transfer
Penalty
Summary
Facility staff failed to provide treatment and care according to physician orders for a resident with a history of DVT, pulmonary embolism, and paroxysmal atrial fibrillation. The resident was admitted with an order for Eliquis to be held until bleeding resolved, and the DON stated the medication was held because of bleeding in the resident’s leg. However, the record showed no documentation that the ordered monitoring for bleeding was placed in the physician order or TAR, and there was no documentation that the resident’s left lower extremity was monitored for bleeding. The DON stated the nurses were expected to follow up with the physician when Eliquis needed to be resumed, but the medication was not given from May through October and there was no evidence of follow-up to clarify restart instructions. The resident later developed extensive bilateral DVT. A Doppler report showed extensive DVT from the posterior tibial veins to the common femoral veins, and the ED note documented bilateral lower extremity swelling and tenderness with extensive DVTs, both occlusive and nonocclusive, through the bilateral common femoral veins through the popliteal veins. The resident stated the doctor had taken her off Eliquis in April and that she went to the hospital in October because of blood clots in her legs. The facility policy for medications on hold included nursing responsibilities to assess for bleeding and clarify the restart date and conditions. Facility staff also failed to document or explain the risks and benefits of refusing transfer to the ACH for a resident who complained of chest pain and other symptoms. The resident, who had a history of chronic pulmonary embolism, atrial fibrillation, and dementia but had a BIMS score of 15 and was documented as having capacity to make healthcare decisions, reported chest pain, left arm pain, feeling hot, nausea, and vomiting, and appeared pale and clammy. The MD ordered transfer to the ACH, but the resident refused. The DON stated there was no documentation that the licensed nurses explained the risks and benefits of refusing the hospital transfer, and the progress notes did not show that the risks of refusal were explained. The resident was then monitored over the following days and later developed worsening symptoms, including midsternal chest pain, nausea and vomiting, fluctuating O2 levels, poor oral intake, pale appearance, and cold extremities, leading to transfer to the hospital for further evaluation.
Medication Storage and Security Failures
Penalty
Summary
Drugs and biologicals were not stored and labeled in accordance with accepted professional principles in the medication storage room. During observation with the DON, expired 0.5 fl oz boxes of Carbamide Peroxide ear drops were present, along with an open box of enema that had dried and crusted white substance on the lid. A medication disposal bin was full and did not have a start date or disposal date, and two full drug buster containers filled with discontinued, outdated, or unused medications had not been removed from the room. An opened bottle of Milk of Magnesia was also observed in the storage area. Enteral feeding supplements and related nutritional products were stored in the central supply room at temperatures above the facility’s stated limit. The wall-mounted thermometer and a second thermometer both read 82 degrees F, and there was no adequate ventilation or airflow in the room. Items stored there included Glucerna tube feeding formula, Jevity tube feeding formula, Nepro, thickened lemon-flavored water, applesauce, and Prostat. The DON stated the required storage temperature should not exceed 77 degrees F, and the RDCO removed the supplements from the room and stated they were stored inappropriately. Medication carts were also left unsecured and contained loose unidentified pills. Medication cart 4 was observed unlocked and unattended on two separate occasions, including once outside a resident room and again in the hallway near resident rooms. RN 2 stated she had left the cart unlocked, and the DON stated the cart was supposed to remain locked when not in use. In addition, four medication carts contained multiple loose unidentified pills scattered in drawers, and staff observed removing and discarding some of the loose pills. Facility policy required medication carts and storage bins to remain locked and medication storage areas to be kept neat, clean, and organized.
Incomplete Temperature Monitoring and Improper Food Storage
Penalty
Summary
The facility failed to maintain safe frozen and refrigerated food storage practices for two of two freezers and three of three refrigerators in the kitchen. During observation, one unlabeled freezer had a posted Freezer Temperature Log for Ice Cream/Supplement dated 6/26 on the refrigerator door, but there were no temperature logs posted on the meat freezer, produce refrigerator, vegetable refrigerator, or one unlabeled refrigerator. The Dietary Manager stated the Dietary Aide wrote the temperatures on the logs and that each freezer and refrigerator should have a log. Dietary Aide 1 stated the cooks were responsible for checking freezer and refrigerator temperatures, while another staff member stated the DAs were responsible for checking the temperatures and that the logs should be posted on each unit. Record review showed the Freezer Temperature Log for Ice Cream/Supplement had blank PM temperatures on 6/1/26, 6/2/26, 6/3/26, and 6/7/26, and two rows after 6/4/26 were blank for both AM and PM temperatures. The refrigerator temperature monitoring documents in the binder were dated June with the year blank and only documented dairy produce and DA milk temperatures. The facility also stored foods from outside sources for three residents in one of four refrigerators. The facility policy stated refrigerator temperatures should be recorded two times each day and freezer temperatures should be recorded two times each day.
Improper Storage of Outside Food
Penalty
Summary
The facility failed to store foods brought in from outside in accordance with its policy for three sampled residents. Resident 22 had food in the resident food refrigerator that was unlabeled with a date stored. Resident 30 had food labeled only with a room number and the food had been stored longer than 72 hours. Resident 53 had food in the resident food refrigerator that had also been stored longer than 72 hours. These findings were identified during observation, interview, and record review. During interview, CNA 6 stated CNAs and nurses were responsible for storing food from outside sources in the refrigerator and for writing the resident's name and date the food was received on the container. A posted notice on the refrigerator stated that all food must be dated and labeled and that food older than 48 hours or unlabeled would be thrown out. CNA 6 observed the undated food for Resident 22, the bag labeled only with a room number and dated 05/31/26, and the bag for Resident 53 dated 4/19/26. DSD 1 later removed the three bags and stated food should not be in the refrigerator for more than 3 days and should be discarded to prevent stomach problems for residents. The facility policy stated staff assisting residents shall ensure food items are labeled immediately upon placement in the refrigerator and that labels include the resident name and date stored.
Failure to Maintain Infection Control During Meals, Shared Equipment Use, and Outbreak Reporting
Penalty
Summary
The facility failed to maintain an effective infection control program during meal service when a CNA did not perform hand hygiene after touching a doorway stop banner and before handling meal trays for multiple residents. During observation, the CNA left one resident’s room, closed the stop sign banner against the door, opened the food cart, removed a meal tray, and served another resident without cleaning hands in between tasks. The CNA later repeated the same pattern when serving a second resident. The CNA stated staff are required to wash or sanitize hands before serving food, especially after touching anything dirty, and the Infection Prevention Nurse stated hand hygiene is required when serving and assisting with meals because contamination may lead to stomach infections such as diarrhea. A restorative nursing assistant also failed to perform hand hygiene while assisting with meals. The assistant put away one resident’s finished plate, then touched another resident’s cup at the top where the mouth touches, moved it closer, and then touched the first resident’s cup without cleaning hands in between. The assistant stated that when passing trays, opening lids, and putting away finished plates, hands need to be washed or sanitized between tasks, and acknowledged that touching a dirty plate and then handling a cup did not follow infection control practices. The DON stated that staff must wash hands or use hand sanitizer for any procedure involving meals and should handle cups by the bottom or handle to prevent cross-contamination. The facility also failed to follow outbreak reporting expectations. The Infection Preventionist stated the facility experienced an outbreak of nausea, vomiting, and diarrhea affecting 18 residents and 1 kitchen staff member, but could not provide a daily line list to the local public health department as recommended. The Acute Communicable Disease RN stated the daily line list was recommended so public health could monitor the outbreak and provide disease-specific recommendations regarding testing, isolation, environmental cleaning, and other precautions, and that the outbreak remained an open case because the requested line list had not been provided. Additional infection control failures were observed with shared equipment and medication preparation. A silent knight pill crusher on top of a medication cart had gray and white powder dried into a hardened crust on its surface and surrounding parts, and RN staff stated it was dirty and posed an infection control issue. A shared blood pressure cuff and device were used on one resident and then on another resident without being sanitized in between, and the nurse stated she was supposed to sanitize the equipment after each resident use. RN staff also administered medications to a resident without performing hand hygiene after preparing the medications and after removing a Velcro stop sign from the resident’s door frame, despite a posted sign directing staff to clean hands before entering and when leaving the room.
Incomplete Flu and Pneumococcal Vaccine Documentation
Penalty
Summary
Facility failed to complete and maintain documentation for influenza and pneumococcal vaccinations for three of five sampled residents, identified as Residents 14, 28, and 46. During record review, Resident 14’s undated face sheet showed admission to the facility on [DATE], Resident 28’s undated face sheet showed admission on [DATE], and Resident 46’s undated face sheet showed admission on [DATE]. During a concurrent interview and record review on 6/9/26 at 1:52 p.m., the Infection Preventionist reviewed the electronic health records for these residents and stated that the facility offered influenza vaccinations to all residents upon admission and annually during flu season, and pneumococcal vaccinations to all residents upon admission and to any resident who had not yet received them. The Infection Preventionist stated Resident 46 refused both the influenza and pneumococcal vaccines, but documentation of the declination and the explanation of risks and benefits could not be found in the record. For Resident 14, a progress note dated 11/19/25 indicated a refusal of vaccination, but it did not identify which vaccine was refused, and no consent/declination or explanation of risks and benefits for influenza or pneumococcal vaccination was found. Resident 28 had a signed but undated influenza declination form, and the Infection Preventionist stated that incomplete documentation did not verify whether or when the vaccine was offered or declined. The facility’s undated policies for influenza and pneumococcal vaccines stated that refusals should be documented in the resident’s medical record.
Incomplete COVID-19 Immunization Documentation
Penalty
Summary
The facility failed to ensure complete and accurate COVID-19 immunization records for three of five sampled residents, identified in the report as Residents 14, 46, and 29. During interview and record review, the Infection Preventionist reviewed the Electronic Health Record for immunization information and paper consent forms. The Infection Preventionist stated that COVID-19 vaccinations were administered by an outside immunization agency, but the facility remained responsible for ensuring the documentation was completed in the residents’ charts. For Resident 14, nursing progress notes dated 11/19/25 indicated a refusal of vaccination, but the note did not specify which vaccination was refused, and there was no consent or declination form in the EHR or paper chart. The Infection Preventionist was unable to find Resident 46’s COVID-19 consent or declination record in either the EHR or paper chart. For Resident 29, the consent/declination form was undated, and the Infection Preventionist could not determine when the resident or responsible party received education on the risks and benefits of COVID-19 immunization or when the vaccine was declined. The facility policy stated that each resident is offered the COVID-19 vaccine unless medically contraindicated or already immunized, and that appropriate documentation is made in the resident’s record if the vaccine is refused.
Failure to Protect a Resident from Physical Abuse
Penalty
Summary
The facility failed to ensure a resident was free from physical abuse when another resident grabbed the resident’s left arm in the hallway. The affected resident had dementia and severe cognitive impairment, with a BIMS score of 7 out of 15. During the incident, the resident stated that the other resident came out of nowhere, grabbed the left arm, caused bruising, and made the resident scream until an LVN separated the two residents. The resident later stated feeling very scared from the incident. Record review showed the resident had a bruise to the left arm measuring 6 cm by 4 cm and complained of pain in the left arm. The other resident involved had diagnoses including major depressive disorder with psychotic symptoms and severe cognitive impairment, with a BIMS score of 2 out of 15. The LVN stated the resident was asking for a snack near the med cart when the other resident grabbed the arm, and the DON stated the other resident was not monitored for high-risk behavior and that the incident could have been prevented if the resident’s needs had been assessed and supervision increased.
Failure to Assess Hand Contractures and Provide ROM Exercises
Penalty
Summary
Failure to provide a contracture assessment and ROM exercises was identified for Resident 26, who was admitted with diagnoses of parkinsonism, dementia, and a personal history of diseases of the musculoskeletal system and connective tissue. The MDS dated 5/1/26 indicated the resident was usually understood when expressing ideas and wants and usually understood verbal content. During a concurrent observation and interview on 6/8/26, Resident 26 was observed with contractures of the left and right hands. During interviews on 6/11/26, CNA 4 stated Resident 26 had tightness of the muscles in the hands and that hand rolls were applied because the resident was no longer able to open the hands. RNA 1 stated Resident 26 had a PROM order only for both lower extremities and did not have an order for PROM to the hands. PT 1 assessed both hands and stated the resident would have benefitted from ROM exercises, a splint, or brace to prevent the hands from completely closing. LVN 4 stated there was no physician order to apply the hand roll and could not find an order for ROM exercises. RD 1 stated no contracture assessment had been completed for Resident 26, and the facility policy indicated contracture screens are to be performed at least quarterly with ROM measurements taken.
Missing Physician Documentation in Resident Record
Penalty
Summary
The facility failed to maintain complete and readily accessible medical records for one of three sampled residents, Resident 81, because the resident's medical record did not contain required physician documentation at the time of review. Resident 81 was admitted to the facility on [DATE] and discharged on 4/18/26, but the record contained no physician progress notes or History and Physical for the resident's stay. During a concurrent interview and record review on 6/11/26 at 3:30 p.m., the Regional Director of Clinical Operations reviewed Resident 81's electronic medical record and stated that the H&P had been completed by a covering physician during the stay, but she was unable to locate it in the Electronic Health Record. She also stated that physician progress notes/H&P should be readily available and that she needed to obtain it from the covering physician. The facility's Medical Record Management policy stated that medical records shall be readily accessible and available for resident care 24 hours per day.
Delayed Action on Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure that 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. This issue persisted for four consecutive months, and the facility did not act on the reports within 30 days for five of the ten sampled residents. The delay in receiving and acting upon the MRR reports had the potential to result in residents not receiving timely therapeutic recommendations on drug therapies. Interviews with the PC, Regional Supervisor, and Medical Director revealed discrepancies in the submission and receipt of the MRR reports. The PC claimed to submit the reports within 48 hours of completion, but the Medical Director noted that the reports were consistently late, impacting the ability of medical and nursing staff to make informed decisions regarding residents' medication and treatment plans. The facility's Director of Nursing (DON) and Nurse Supervisor (NS) confirmed the reports were received late and acknowledged delays in acting upon the recommendations. Record reviews indicated specific instances where recommendations for residents were not acted upon promptly. For example, recommendations for monitoring dehydration, electrolytes, and other conditions for several residents were delayed by months. The facility's policies and procedures required that MRR recommendations be acted upon within 30 days, but this was not adhered to, as evidenced by the delayed actions for residents 56, 26, 2, 66, and 54. These delays in addressing the MRR recommendations highlight a significant deficiency in the facility's medication management process.
Dishwasher Temperature Deficiency
Penalty
Summary
The facility failed to maintain a safe and sanitary method for cleaning dishes due to the dishwasher not reaching the required temperature. Observations on multiple occasions revealed that the dishwasher's highest temperature was consistently 110 degrees Fahrenheit, below the minimum safe temperature of 120 degrees Fahrenheit as specified by both the manufacturer's guidelines and the facility's policy. The Dietary Manager confirmed the inadequate temperature readings and acknowledged the risk of dishes not being properly sanitized, which could compromise resident safety. Further investigation revealed that the dishwasher booster, responsible for heating the water, was broken. The Maintenance Supervisor admitted that this issue was not logged in the maintenance records, contrary to the facility's policy requiring documentation of needed repairs. The facility Administrator was unaware of the malfunctioning dishwasher booster and the temperature issue, indicating a communication breakdown within the facility's maintenance and reporting processes.
Improper Storage and Administration of Medications
Penalty
Summary
The facility failed to provide adequate pharmaceutical services by improperly storing and managing narcotic medications. Narcotic medications were found in an unlocked drawer in the Director of Nursing's (DON) office, with discrepancies in the count of medications for several residents. Specifically, seven narcotic medications were missing, and there was no log maintained for narcotics awaiting destruction. The DON acknowledged that these medications should have been stored securely until they could be destroyed with the Pharmacy Consultant. Additionally, during a random audit, discrepancies were found in the narcotic reconciliation records for two residents. The Medication Administration Record (MAR) did not match the Controlled Drug Record, indicating that narcotics were signed out without proper documentation. This lack of documentation meant that the narcotics were not accounted for, as confirmed by the DON. The facility also failed to administer medications as prescribed by physicians. One resident was undermedicated with diazepam, receiving only half of the prescribed dose on multiple occasions. Another resident received an incorrect dose of lactulose, as the Licensed Vocational Nurse (LVN) administered 10 ml instead of the prescribed 15 ml. These errors in medication administration were confirmed through interviews and record reviews.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a cumulative error rate of 30% during a medication pass observation. This was observed in a sample size of 30 opportunities for error, where nine errors were identified. One significant error involved a registered nurse (RN) who improperly prepared medications for a resident with a gastrostomy tube (G-tube). The RN crushed multiple medications together, mixed them with valproic acid liquid and warm water, and administered the mixture via the G-tube, contrary to the facility's policy which requires each medication to be crushed and administered separately with a flush of water in between. Additionally, the RN failed to administer MiraLAX and lactulose as ordered, with the lactulose being unavailable in the medication cart. Another error was noted when a licensed vocational nurse (LVN) failed to administer a multivitamin to a resident, despite documenting that it had been given. The LVN later admitted to forgetting to administer the multivitamin. The facility's policy on enteral tubes, dated September 2018, clearly states that medications should not be mixed together and should be administered separately to avoid interactions and clumping. These practices were not followed, leading to the identified deficiencies.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure the safe storage, labeling, and disposal of medications and vaccinations, leading to several deficiencies. Over-the-counter eye drops were found in a medication cart without a resident's name, and two inhalers were opened without an open date, with one being expired and still in use. Additionally, a multidose TB vial was opened without a documented open date, and twenty-one vaccine syringes were stored past their expiration date in the medication refrigerator. Further observations revealed that intravenous heparin flushes in the emergency kit were expired, and one emergency kit was unsealed with a documented open date of May 2024. The medication/vaccine refrigerator temperature was not monitored twice daily as required, with gaps in documentation for eight months. These lapses in medication management had the potential to compromise the potency and efficacy of medications and vaccines administered to residents. Interviews with staff, including LVNs, the DON, and the DSD, confirmed the lack of adherence to proper medication labeling and storage protocols. The facility's policies and procedures were not followed, as evidenced by the failure to document open dates on multi-dose vials and the improper monitoring of refrigerator temperatures. The Pharmacy Consultant also noted that monthly oversight was in place, but staff failed to consistently monitor the medication refrigerator temperature every shift.
Food Storage and Preparation Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards of food service safety, as evidenced by two specific observations. During an inspection, expired chocolate pudding was found in the refrigerator, with the Dietary Manager (DM) confirming that it should not be stored or served past its use-by date. Additionally, uncovered frozen soup with white crystals, indicative of freezer burn, was observed in the freezer. The DM acknowledged that the soup was improperly stored and noted that freezer burn could affect the taste of the food when served.
Failure to Report Alleged Abuse to Authorities
Penalty
Summary
The facility failed to report an alleged incident of abuse or mistreatment involving a resident to the appropriate authorities. The incident involved a Certified Nursing Assistant (CNA) who allegedly touched the resident inappropriately during pericare. The resident, who had an intact cognitive status with a Brief Interview for Mental Status score of 15, reported feeling uncomfortable and reported the incident to the facility staff shortly after it occurred. However, the facility did not document any follow-up with the resident after the event. The Director of Nursing (DON) conducted an interview with the CNA, who denied the incident, but no further investigation was documented. The facility did not notify the ombudsman or the California Department of Public Health (CDPH) about the incident, as required by their policy. The CNA later stated that he did not remember being interviewed about the incident. The facility's policy indicated that all alleged violations involving abuse, neglect, exploitation, or mistreatment should be reported to CDPH and the ombudsman, which was not done in this case until much later.
Failure to Complete PASARR for Resident with Intellectual Disability
Penalty
Summary
The facility failed to complete the required Preadmission Screening and Resident Review (PASARR) for a resident with a diagnosis of an intellectual disability. The resident was initially admitted to the facility in January 2024 with multiple diagnoses, including a developmental disorder of scholastic skills and other specified disorders of the brain. According to the PASARR dated December 27, 2023, if the resident remains in the nursing facility longer than 30 days, a new screening should be resubmitted on the 31st day. However, the facility did not complete a PASARR for the resident after they had been at the nursing facility for more than 31 days. This oversight was confirmed during an interview with the Director of Nursing, who acknowledged that a PASARR should have been completed due to the resident's diagnosis of an intellectual disability.
Failure to Follow Transfer Protocols Leads to Resident Injury
Penalty
Summary
The facility failed to implement appropriate safety measures during the transfer of a resident using a Hoyer lift, resulting in a serious accident. The incident involved a long-term resident who was dependent on assistance for transfers due to conditions such as generalized muscle weakness, obesity, and anxiety. The resident's care plan specified the need for a Hoyer lift and assistance from two staff members during transfers. However, a Certified Nursing Assistant (CNA) attempted to transfer the resident alone, leading to the resident falling and sustaining multiple injuries, including rib fractures, a pneumothorax, and a femur fracture. The incident occurred when the CNA, without assistance, used the Hoyer lift to transfer the resident from the bed to a shower chair. The resident expressed fear and discomfort, noting that the sling felt too small, which contributed to the fall. The fall was witnessed by the CNA, and the resident was found on the floor by a Registered Nurse (RN), who called 911 due to the resident's difficulty speaking and complaints of chest pain. The resident was subsequently hospitalized for treatment of the injuries sustained during the fall. Interviews with the facility's Director of Nursing (DON) and the RN confirmed that the facility's policy required a two-person assist for Hoyer lift transfers, as emphasized in staff training. The facility's training materials and policy documents also highlighted the importance of using the correct sling size and following manufacturer's instructions to prevent falls and injuries. Despite these guidelines, the CNA proceeded with the transfer alone, directly leading to the resident's fall and subsequent injuries.
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What surveyors actually found near you
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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.
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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) |
|---|---|---|---|---|
| Sage Post Acute | 0.1 mi | ★★★★★ | 4 | 0 |
| Hayward Gardens Post Acute | 0.1 mi | ★★★★★ | 13 | 0 |
| Canyon Creek Post-acute | 0.4 mi | ★★★★★ | 2 | 0 |
| Baywood Court Health Center | 0.6 mi | ★★★★★ | 0 | 0 |
| Vista Post Acute | 1.1 mi | ★★★★★ | 0 | 0 |
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