Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
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 Hayward Post Acute during CMS and state inspections, most recent first.
Failure to Develop and Revise NGT Care Plan: A resident with stroke and dysphagia had an NGT dislodged three times over a short period, but the care plan did not include measurable, person-centered interventions to prevent repeat dislodgement. After the first event, the plan only added shift monitoring and securing of the tube, with no documented assessment of contributing factors or monitoring parameters, and later events still did not prompt reassessment of behavior or causes.
A resident with type 2 DM, insulin use, an ileostomy, and a Foley catheter had insulin given without documented BG results, while also receiving MiraLax despite loose, watery stools and Loperamide for diarrhea. The record showed large watery stools, a later change in condition with hypotension and altered mental status, and no evidence of Foley catheter care or monitoring, with no care plan in place for the Foley or ileostomy.
Inadequate Monitoring of Dislodged NGT: A resident with stroke and dysphagia had an NGT in place, but the tube was pulled out three times over a short period. The care plan did not identify interventions to prevent dislodgement or address the repeated events, and there was no evidence of increased supervision or assessment of contributing factors. The DON stated the resident was being checked hourly, but documentation was not available, and the facility policy did not include guidance on NGT monitoring.
A resident with anxiety disorder and intact cognition repeatedly reported distress caused by another resident's disruptive behavior, including yelling and banging, to staff. Despite multiple complaints, no action was taken, and management was not informed, resulting in the resident feeling angry and sad. Staff interviews confirmed awareness of the complaints, but the DON and ADON were unaware, indicating a breakdown in the grievance process.
Improper food storage and food prep practices were observed when uncooked turkey and beef were stored directly above cantaloupes in the kitchen refrigerator, and a DA prepared resident sandwiches with uncovered facial hair. The RD stated raw meat should not be stored over fruit due to cross contamination concerns, and the facility policy required hair and facial hair to be properly restrained.
A resident with moderate protein-calorie malnutrition and intact cognition was served mixed vegetables containing cauliflower despite cauliflower being listed as a dislike on the meal ticket. The resident said the food upset them and they would not eat it. A CK said it was a mistake, and the DON stated honoring food choices was important for intake, weight, and resident happiness.
A resident with a nasogastric tube (NGT) experienced repeated dislodgement and clogging, leading to multiple hospital transfers for reinsertion. Despite the resident's medical history and impaired decision-making capacity, the facility did not update the care plan with new interventions to prevent these issues. Interviews with staff revealed that the care plan was not revised, contrary to facility policy, contributing to the repeated hospitalizations.
The facility failed to maintain safe food storage, preparation, and distribution practices, risking foodborne illnesses for 81 residents. Corn was rinsed in a handwashing sink, meat was thawed improperly, and the 3-part sink lacked an air gap. Hand hygiene protocols were not followed, with an employee using the same gloves for multiple tasks, leading to potential cross-contamination. The facility's food preparation policies were not adhered to.
Two residents did not receive scheduled showers, impacting their personal hygiene and satisfaction. One resident, with C-Diff and Osteomyelitis, had not been showered since admission, while another, with Hemiplegia, missed a scheduled shower. Staff interviews revealed documentation errors and lack of adherence to hygiene schedules, with no records explaining missed showers.
A facility failed to transmit a resident's MDS Discharge assessment within the required timeframe. The assessment, completed for a resident with idiopathic aseptic necrosis of the right femur, was delayed due to a computer system error, resulting in a transmission well beyond the 14-day requirement.
A resident with documented diagnoses of Schizophrenia and Depression had an inaccurately completed PASRR Level I assessment, which failed to indicate these serious mental disorders. This error was confirmed during a review of the resident's records and an interview with an LVN, who acknowledged the incorrect coding and its importance for determining the need for a Level II evaluation.
A resident with limited range of motion due to hemiplegia and hemiparesis was not using prescribed aids like a splint or rolled hand towel, as observed during multiple instances. Despite a physician's order, the facility failed to revise the resident's care plan in a timely manner, and staff were unaware of the resident's refusals to use these aids. The care plan was not updated until several months later, contrary to the facility's policy of quarterly reviews.
A resident with diabetes and cognitive communication deficit did not receive necessary podiatry services as ordered, resulting in thickened, discolored toenails and dry, scaly skin on the feet. Facility staff confirmed the need for podiatry services, but the Social Services Director noted a lack of podiatrist availability since October 2023.
A facility failed to properly dispose of non-controlled medications, as observed when an LVN discarded medications in a trash bin instead of following protocol. The DON confirmed the error, noting that medications should be disposed of in a collection receptacle to prevent misuse.
A resident with a history of stroke and paralytic syndrome, requiring total dependence on staff for bed mobility, fell from the bed while a CNA provided ADL care alone, resulting in a forehead laceration. The CNA was unaware of the need for a two-person assist, and the facility lacked a policy for accident prevention.
A resident's privacy was compromised during ADL care when a CNA did not fully draw the privacy curtain, exposing the resident's body. The resident, dependent on staff for ADLs, was in a two-bed room near a window, and staff were observed passing by, potentially exposing the resident to public view. Interviews confirmed the privacy breach, which violated the facility's policy on maintaining resident dignity and privacy.
A resident, dependent on two staff for ADLs due to conditions like blindness and muscle weakness, was assisted by only one CNA, causing pain and distress. Observations showed the resident's skin was red with abrasions, and interviews confirmed the need for two staff as per the MDS and facility policy.
A resident developed a Stage IV pressure injury, and the facility failed to notify the Resident Representative (RR) and the physician about the change in condition and treatment. Despite the resident's severe cognitive impairment and multiple wound debridements, the RR and physician were not informed, preventing timely medical interventions and participation in the care plan.
The facility failed to provide proper pressure ulcer care and documentation for a resident, including the absence of physician's orders for wound treatment and missing weekly skin assessments for multiple months. This placed the resident at risk for worsening pressure ulcers and slow healing.
Failure to Develop and Revise NGT Care Plan
Penalty
Summary
The facility failed to develop and revise a comprehensive person-centered care plan for a resident with a nasogastric tube in place for nutrition, hydration, and medications after the tube became dislodged three times within a 17-day period. The resident was admitted with diagnoses including stroke and dysphagia, and the MDS dated 12/30/25 showed a BIMS score of 15 out of 15, indicating the resident was cognitively intact. The care plan initiated on 12/27/25 identified that the resident had an NGT in place to meet nutritional needs, but it did not identify interventions to prevent dislodgement. After the first dislodgement on 12/28/25, the care plan was updated to closely monitor and secure the NGT every shift, but there was no evidence of monitoring parameters or assessment of factors contributing to the dislodgement. After the second dislodgement on 12/30/25, the care plan was not revised to identify the cause of the repeated dislodgements or to implement person-centered interventions. After the third dislodgement on 1/11/26, the resident was confused at the time of the event, and the care plan still did not show reassessment of behavior, evaluation of the cause of repeated dislodgements, or implementation of person-centered interventions to prevent further episodes.
Failure to Document BG, Manage Bowel Medications, and Provide Foley Catheter Care
Penalty
Summary
Resident 2 was admitted with diagnoses including type 2 diabetes, long-term insulin use, urine retention, and ileostomy status. The MDS dated 1/26/26 indicated the resident had an indwelling catheter, an ileostomy, and was receiving insulin injections as well as oral medication to decrease blood glucose levels. The facility’s January 2026 MAR showed insulin was administered twice daily on 1/23, 1/24, and 1/25, and once on 1/26, with blood glucose monitoring ordered before meals and at bedtime; however, the blood glucose results were not documented for review, except for one documented blood glucose entry on 1/25/25 at 5:55 a.m. The January 2026 MAR also showed the resident received MiraLax 17 grams by mouth daily on 1/23, 1/24, 1/25, and 1/26, with instructions to hold for loose stool, and Loperamide 2 mg by mouth on 1/22 through 1/26 for diarrhea. The Documentation Survey Report showed large, watery stools on 1/23 at 5:33 a.m., 2:59 p.m., and 8:43 p.m., and again on 1/25 at 6:59 a.m. A Change in Condition Evaluation dated 1/26/26 at 8:52 p.m. documented a change in mental status, a blood pressure drop to 60/45, and transfer to the emergency room for evaluation. During record review and interview, there was no evidence that Foley catheter care or monitoring had been provided, and no care plan was in place for the Foley catheter or ileostomy. The DON stated these were basic nursing measures that should be implemented and care-planned upon admission. The DON and LVN also stated nursing staff should monitor and document blood glucose levels, bowel movements for residents with ileostomy, and urine output and characteristics for residents with a Foley catheter, and that the physician should be contacted to clarify whether the resident should receive medication for both diarrhea and constipation at the same time.
Inadequate Monitoring of Dislodged NGT
Penalty
Summary
The facility failed to ensure adequate monitoring and appropriate interventions for a resident with an NGT after the tube became dislodged three times over a 17-day period. The resident was admitted with diagnoses including stroke and dysphagia, and the MDS documented a BIMS score of 15, indicating the resident was cognitively intact. The care plan initiated on 12/27/25 identified that the resident had an NGT in place to meet nutritional needs, but it did not identify interventions to prevent the tube from becoming dislodged. On 12/28/25, the resident's NGT was found pulled out, and the CICE documented that the physician ordered reinsertion and an X-ray to confirm placement. A care plan entry on 12/28/26 included close monitoring and securing of the NGT every shift, but there was no evidence of monitoring parameters or assessment of factors contributing to the dislodgement. On 12/30/25, the resident pulled out the NGT again, and the care plan was not revised to identify the cause of the repeated dislodgements or to show increased supervision or other IDT interventions. On 1/11/26, the NGT was pulled out for a third time, and the resident was confused at that time. Later, on 1/28/26, the resident developed a productive cough and O2 saturation decreased to 89 percent, resulting in transfer to the hospital. During interview, the DON stated residents with NGTs are at high risk for dislodging and aspiration and should be monitored closely, but could not provide documentation supporting hourly monitoring. The facility policy on NG tube/tube feeding/reinsertion did not include guidance on monitoring the NGT.
Failure to Address Resident Grievance Regarding Disruptive Behavior
Penalty
Summary
The facility failed to follow up on a resident's grievance regarding disruptive behavior from another resident. The affected resident, who was cognitively intact and had a diagnosis of anxiety disorder, reported feeling angry and sad due to the ongoing yelling, screaming, and banging from a neighboring resident. Despite bringing these concerns to staff on multiple occasions, no action was taken to address the issue. Interviews with staff, including a CNA, LVN, and RN, confirmed that the resident had repeatedly complained about the disruptive behavior, and that management was aware of the complaints. However, both the Assistant Director of Nursing and the Director of Nursing stated they were not aware of the grievance and emphasized that nursing staff should inform management of such concerns. A review of the facility's grievance policy indicated that any resident or their representative may file a grievance regarding care or the behavior of other residents or staff. The lack of follow-up on the resident's grievance resulted in the resident experiencing ongoing distress without resolution.
Improper Food Storage and Uncovered Facial Hair During Food Preparation
Penalty
Summary
Food was not stored and prepared in accordance with professional standards for safety. During observation in the kitchen, uncooked turkey and beef were stored directly above cantaloupes in the refrigerator, creating a condition where raw animal foods were placed over fruit. During a later observation, a Diet Aide prepared resident sandwiches while having uncovered facial hair. In interview, the Registered Dietician stated uncooked meat should not have been stored over fruit because of cross contamination concerns and stated the Diet Aide should have covered facial hair while preparing resident food. The facility policy titled Staff Attire, revised January 2025, stated staff hair must be confined in a hair net or cap and facial hair properly restrained.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to allow one resident to exercise the right to self-determination when nutrition was not provided in accordance with the resident’s preferences. Resident 11 was admitted in January 2025 with a diagnosis of moderate protein-calorie malnutrition and had a BIMS score of 14, indicating intact cognitive status. During a concurrent observation and interview, the resident’s lunch tray contained mixed vegetables with cauliflower, and the resident stated it made them upset and that they would not eat it. The resident’s lunch meal ticket listed cauliflower as a dislike. A CK stated the resident should not have received mixed vegetables with cauliflower and that it was a mistake. The DON stated it was important to honor resident food choices so they could eat more, prevent weight loss, and support resident happiness. The resident’s care plan identified the resident as at nutritional risk and directed staff to honor food preferences within the meal plan.
Failure to Update Care Plan for NGT Management
Penalty
Summary
The facility failed to develop new interventions to prevent the displacement and clogging of a resident's nasogastric tube (NGT), which was dislodged or clogged five times over a period of several months. This resulted in the resident being transferred to the hospital emergency department for NGT reinsertion on multiple occasions. The resident, who had a history of cerebrovascular disease, dysphagia, and hemiplegia, was admitted with an NPO diet order and required Glucerna through the NGT. Despite the resident's impaired memory and decision-making capacity, the facility did not update the care plan with new interventions after the initial incidents of NGT dislodgement and clogging. Interviews with facility staff, including a Licensed Vocational Nurse (LVN) and the Director of Nursing (DON), revealed that the care plan was not revised to address the recurring issues with the NGT. The LVN acknowledged that updating the care plan could have prevented some of the hospital transfers. The facility's policy required care plan updates when there was a significant change in the resident's condition or after a hospital readmission, but no such updates were made. The lack of documentation and care plan revision contributed to the repeated hospital transfers for NGT reinsertion.
Food Safety and Hygiene Deficiencies
Penalty
Summary
The facility failed to maintain safe and sanitary food storage, preparation, and distribution practices, which could potentially lead to foodborne illnesses for 81 residents. Observations revealed that corn was rinsed in a handwashing sink, which is not intended for food preparation, leading to potential bacterial or chemical cross-contamination. Additionally, meat was improperly thawed in still water instead of under cold running water, which is necessary to flush away loose particles and prevent contamination. Furthermore, the facility's 3-part compartment sink lacked an air gap, which is essential to prevent backflow of sewage into the equipment, as confirmed by the Maintenance Director. Hand hygiene protocols were also not followed during food preparation and tray line service. An employee was observed using the same gloves for multiple tasks without changing them, leading to potential cross-contamination. This included handling meat, touching various kitchen surfaces, and serving food without changing gloves or performing hand hygiene. The Registered Dietician confirmed that these practices were unacceptable and posed a risk of cross-contamination. The facility's policy and procedure on food preparation and service were not adhered to, as evidenced by the improper thawing of frozen food and handling of ready-to-eat food without suitable utensils.
Failure to Provide Scheduled Showers to Residents
Penalty
Summary
The facility failed to ensure that two residents, identified as Resident 193 and Resident 43, received the necessary services to maintain good grooming and personal hygiene. Resident 193, who was admitted with diagnoses including C-Diff and Osteomyelitis, did not receive any showers since admission, only having one sponge bath, which left him unhappy. Resident 43, admitted with Hemiplegia, missed a scheduled shower and expressed dissatisfaction with the frequency of showers provided. The facility's records indicated that Resident 193 was supposed to have showers twice a week, while Resident 43 was scheduled for showers on specific days, but these schedules were not adhered to. Interviews with the residents and staff revealed that Resident 193 was not given a shower due to being on isolation and contact precaution, and a CNA admitted to mistakenly documenting a sponge bath that was not given. The Director of Nursing was unable to provide documentation explaining why Resident 43 missed a shower, and there was no record of shower refusals. The facility's policies emphasized the importance of maintaining cleanliness and observing residents' skin conditions, but these were not followed, leading to the deficiency.
Delayed Transmission of MDS Discharge Assessment
Penalty
Summary
The facility failed to electronically transmit the Minimum Data Set (MDS) Discharge assessment for a resident within the required 14 days. The resident, who was admitted for idiopathic aseptic necrosis of the right femur, had their discharge assessment completed on February 16, 2024, but it was not transmitted until June 24, 2024. This delay was identified during a joint interview and record review with the MDS Coordinator and a Licensed Vocational Nurse, where it was revealed that an error in the computer system led to some MDS assessments being missed.
Inaccurate PASRR Assessment for Resident with Mental Disorders
Penalty
Summary
The facility failed to accurately complete the Preadmission Screening and Resident Review (PASRR) assessment for a resident, identified as Resident 35, who had documented medical diagnoses of Schizophrenia and Depression. The PASRR Level I Screening, submitted earlier in the year, incorrectly indicated that the resident did not have a serious diagnosed mental disorder. This discrepancy was confirmed during a review of the resident's admission record and Minimum Data Set (MDS), which both listed Schizophrenia and Depression as diagnoses. During an interview and record review, a Licensed Vocational Nurse (LVN) acknowledged that the PASRR Level I assessment was incorrectly coded, which should have been marked 'Yes' to indicate the presence of a serious mental disorder. The LVN explained that accurate completion of the PASRR Level I assessment is crucial to determine if a Level II evaluation is necessary. Such an evaluation would help in identifying any special accommodations or recommended services needed for the resident's care and well-being.
Failure to Revise Care Plan for Resident with Limited Range of Motion
Penalty
Summary
The facility failed to revise the comprehensive care plan for a resident with limited range of motion, specifically affecting the right side of the body due to conditions such as hemiplegia and hemiparesis. Observations revealed that the resident was not using a splint or rolled hand towel as prescribed, despite a physician's order for their use in case of splint refusals. The resident was observed on multiple occasions without these aids, and staff interviews indicated a lack of awareness and documentation regarding the resident's refusal to use the hand splint or rolled towel. The resident's care plan, initially created in September 2023, was not revised until June 2024, despite the resident's ongoing refusal to use the prescribed aids. The Assistant Director of Nursing was unaware of the resident's refusals until the day of the interview, indicating a lack of communication and documentation within the facility. The facility's policy requires care plan goals and objectives to be reviewed and revised at least quarterly, which was not adhered to in this case.
Failure to Provide Podiatry Services
Penalty
Summary
The facility failed to provide proper foot care for Resident 33, who was diagnosed with type 2 diabetes mellitus and a cognitive communication deficit. The resident's admission record indicated a physician's order for podiatry services every 61 days to address hypertrophic toenails and other foot problems. However, during an observation, it was noted that Resident 33 had thickened, curly, and yellowish-gray toenails, with the left pinky toenail absent and the right pinky toenail covering only one-fourth of the nail bed. The resident's skin on both feet was also very dry and scaly. Interviews with facility staff, including an LVN, RN, and the Assistant DON, confirmed that Resident 33's toenails were too thick for staff to clip and required podiatry services. The Social Services Director revealed that residents had not received podiatry services since October 2023 due to the podiatrist rescheduling visits and reducing hours. The facility's policy on foot care indicated that residents should be assisted in making appointments with specialists as needed, but this was not adhered to, resulting in the deficiency.
Improper Disposal of Medications
Penalty
Summary
The facility failed to ensure the effective storage and disposal of non-controlled medications, which had the potential for misuse. During an observation, a Licensed Vocational Nurse (LVN) prepared medications for a resident but was unable to administer them. Instead of following proper disposal procedures, the LVN discarded the medications in a trash bin attached to the medication cart, leaving the bin open. This action was observed and confirmed during an interview with the LVN, who incorrectly stated that non-controlled medications could be discarded in a regular trash bin or flushed in the toilet. The Director of Nursing (DON) later retrieved the discarded medications from the trash bin and confirmed that they should not have been disposed of in that manner. The facility's policy, dated November 2022, requires that medications not returned to the pharmacy be disposed of in accordance with regulations, using a collection receptacle. The DON stated that when medications cannot be administered, they should be covered, labeled, and given to the DON or Assistant Director of Nursing (ADON) for proper disposal. The improper disposal of medications could lead to accidental ingestion, as noted by the DON.
Resident Falls Due to Inadequate Supervision During ADL Care
Penalty
Summary
The facility failed to ensure that a resident remained free from accidents, resulting in the resident falling from the bed while a CNA was providing Activities of Daily Living (ADL) care. The resident, who had a history of stroke and paralytic syndrome, was totally dependent on staff for bed mobility and required a two-person physical assist. However, the CNA providing care was not informed of this requirement and had been providing ADL care alone for several years. This oversight led to the resident falling and sustaining a forehead laceration, necessitating transport to the emergency department. Interviews with the CNA and the Director of Nursing Assistant revealed a lack of communication regarding the resident's care needs. The CNA stated that she was not informed that two CNAs were needed for the resident's ADL care, and the Director of Nursing Assistant confirmed that the facility did not have a policy and procedure for accidents. The facility's policy on Resident Rights emphasized the resident's right to be free from abuse and neglect, but there was no specific guidance on preventing accidents.
Failure to Maintain Resident Privacy During ADL Care
Penalty
Summary
The facility failed to maintain the privacy of a resident during the provision of activities of daily living (ADL) care. The incident involved a resident who was totally dependent on the assistance of two staff members for ADLs, as indicated by their Minimum Data Set (MDS) assessment. During an observation, it was noted that the privacy curtain was not fully drawn, exposing the resident's body, brief, and legs while a Certified Nursing Assistant (CNA) was assisting with a bed bath and incontinent care. This lack of privacy was observed in a two-bed room where the resident's bed was located near the window, and staff members were seen walking past the window, potentially exposing the resident to public view. Interviews with the CNA and the Director of Nursing (DON) confirmed that the privacy curtains were not fully drawn during the care process, which was against the facility's policy. The facility's policy and procedure documents emphasize the importance of maintaining residents' privacy and dignity during care, including closing the room entrance door and ensuring privacy curtains are fully drawn. The failure to adhere to these guidelines resulted in a deficiency related to the resident's right to a dignified existence and privacy during care.
Failure to Provide Adequate Assistance for Dependent Resident
Penalty
Summary
The facility failed to provide necessary services for a resident who was totally dependent on two staff members for activities of daily living (ADLs). The resident, who had diagnoses including diabetes, generalized muscle weakness, lack of coordination, hypertension, and depression, was observed to be assisted by only one Certified Nursing Assistant (CNA) during a bed bath and incontinent care. Despite the resident's inability to assist in turning due to blindness and limited mobility, the CNA attempted to turn the resident alone, causing the resident to cry out in pain. The resident's skin was observed to be red with abrasions, and the resident had wounds on the right leg and left foot. Interviews with the CNA and Licensed Vocational Nurse (LVN) confirmed that the resident required two staff members for safe and comfortable repositioning, as indicated in the Minimum Data Set (MDS) and physician orders. The Director of Nursing (DON) and assistant DON acknowledged the requirement for two staff members for such dependent residents. A review of weekly summaries showed that only one person had been performing ADLs for the resident, contrary to the facility's policy and procedure, which specified the use of two people and a draw sheet to avoid shearing while turning or moving residents.
Failure to Notify Resident Representative and Physician of Change in Condition
Penalty
Summary
The facility failed to ensure the Resident Representative (RR) was notified of changes in condition and treatment for a resident who developed an unstageable pressure injury that progressed to a Stage IV pressure injury. The resident, who had severe cognitive impairment and multiple medical diagnoses, was admitted in July 2023. Despite the resident's condition worsening and requiring multiple wound debridements, the RR was not informed about the pressure injury or its progression during care conferences or through other communication channels. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed that there was no documentation or communication to the RR regarding the change in the resident's condition and treatment plan. Additionally, the facility failed to notify the resident's physician about the progression of the wound from a skin shear to a Stage IV pressure injury. The physician's notes indicated that the resident did not have the capacity to make decisions, and the Durable Power of Attorney (DPOA) was held by the resident's son. Despite this, the physician was not kept updated on the resident's condition, which prevented timely medical interventions. The facility's policy and procedure on Change of Condition required that both the resident's physician and family be notified of any significant changes, but this protocol was not followed. Interviews with the DON and ADON revealed that the facility had a binder system for communication updates on resident conditions to the attending physician, but this system was not effectively utilized. The treatment nurse also failed to notify the physician or nurse practitioner about the wound's progression. The facility's failure to communicate these critical changes prevented the RR from participating in the resident's care plan and left the physician unaware of the resident's deteriorating condition, which could have led to missed opportunities for necessary medical interventions.
Failure to Provide Proper Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to provide treatment consistent with professional standards to promote the healing of a pressure ulcer for one resident. The resident did not have a physician's order for wound treatment, and no wound treatments were documented on the treatment administration record from late January to late February. The resident's treatment administration record and physician orders were reviewed, and it was confirmed that there were no documented wound treatments during this period. The facility's policy and procedures indicated that topical medications used in treatments should be recorded on the resident's treatment record, which was not followed in this case. Additionally, the resident's surgical wound notes indicated specific dressings to be used, but these were not documented in the treatment administration record as required by the facility's policy. The facility also failed to complete and accurately document the resident's weekly skin assessments for multiple months. The Director of Nursing and Medical Records Director reviewed the resident's weekly nursing skin assessment records and found that several weekly assessments were missing between January and March. The facility's policy required weekly skin assessments to identify any skin issues and document them accurately, which was not adhered to in this case. The lack of consistent and accurate documentation of the resident's skin assessments placed the resident at risk for worsening existing pressure ulcers and slow healing of a stage IV pressure injury.
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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) |
|---|---|---|---|---|
| Emmanuel Post Acute Care - Hayward | 0.5 mi | ★★★★★ | 18 | 0 |
| Eden Healthcare Center | 0.9 mi | ★★★★★ | 5 | 0 |
| Serenethos Care Center, Llc | 1.4 mi | ★★★★★ | 0 | 0 |
| St Anthony Care Center | 1.8 mi | ★★★★★ | 0 | 0 |
| Bethesda Home | 1.9 mi | ★★★★★ | 0 | 0 |
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