Above average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Serenethos Care Center, Llc during CMS and state inspections, most recent first.
The facility did not ensure that the individual serving as the director of food and nutrition services met the required educational qualifications, as the person in the role only held a food handler certification and was also responsible for maintenance duties. The part-time RD was on site only once a month, and the Dietary Manager was temporarily covering while orienting the new supervisor.
A resident with major depressive disorder and an eating disorder did not have a required PASRR II assessment completed or accurately coded due to being placed in isolation, and facility staff were unaware of the missing assessment. Inconsistent documentation and lack of monitoring led to the resident not being properly assessed for care needs.
Nursing staff administered a 4% lidocaine patch to a resident's knees on two occasions instead of the lower back as ordered by the physician, resulting in two medication errors out of 27 opportunities and a medication error rate of 7.41%. The resident had diagnoses of heart failure, osteoarthritis, and a vertebral fracture. The nursing supervisor confirmed that changes in patch application sites require physician approval.
Expired medications, including insulin, vaccines, and emergency drugs, were found in the facility's storage areas. The medications had surpassed their expiration dates, indicating a failure in the facility's medication management practices. The Nursing Supervisor was unable to explain the presence of these expired medications.
A facility was found to have a 32% medication error rate due to several deficiencies. An LPN failed to use two identifiers for residents, did not provide water with oral medications, and left medications unsupervised with a confused resident. Additionally, acetaminophen was given routinely without assessing pain, and insulin injections were not administered per protocol.
The facility failed to maintain safe and sanitary food storage and preparation practices. An uncovered trash can, a dirty microwave, expired tortillas, and improperly stored sugar and salt were observed. These issues were confirmed by the RD and violated FDA Food Code and facility guidelines.
The facility's QAPI program failed to prevent a 32% medication error rate. LVNs did not follow protocols for resident identification, medication administration, and insulin injection procedures. The Quality Committee had not identified these issues or initiated improvement projects.
The facility failed to follow infection control policies for two residents, as their nebulization and CPAP masks were found undated, unlabeled, and exposed, increasing infection risk. An LVN and the Infection Preventionist confirmed the masks should have been stored in plastic bags to prevent bacterial growth.
The facility's dish machine consistently failed to reach the required minimum temperature of 120°F, as observed during multiple inspections. Staff confirmed the machine's inability to meet the necessary threshold for proper cleaning and sanitization, with temperatures ranging from 100 to 119°F. The manufacturer's guidelines and facility policies both specified the need for the machine to operate at a minimum of 120°F, yet the temperature logs documented persistent non-compliance.
The facility did not meet the required 80 square feet of space per resident for eight residents in four multi-bed rooms, each measuring 158.28 sq. ft. Despite this, observations showed sufficient space for care, no interference from heavy equipment, and no resident complaints or safety concerns.
The facility failed to maintain an effective pest control program, as flies were observed in the kitchen's dry goods storage, food preparation, and dishwashing areas. The RD confirmed the presence of flies and noted the absence of fly traps, attributing the issue to the door being left open during food delivery. This failure to adhere to the facility's pest control policy could potentially lead to foodborne illness.
A resident with moderately impaired cognition had a non-functional wall clock in her room, which displayed incorrect times and was not fixed over several days. The resident relied on the lobby clock for the correct time. LVNs and the DON acknowledged the importance of a working clock to prevent confusion, but the issue remained unresolved during the survey period.
Two residents in the facility did not receive proper nail care, leading to long and dirty fingernails. One resident, with impaired mental status, expressed a desire for clean nails but did not receive assistance. Another resident, with severe mental impairment and contractures, had nails digging into their palms. Staff confirmed the need for weekly nail trimming to prevent infections and injuries, as per facility policy.
A resident was given trihexyphenidyl for an incorrect indication of 'fall syndrome,' and the facility failed to act on the pharmacist's recommendation to clarify the medical diagnosis. Despite the policy requiring monthly medication reviews and timely action on recommendations, the facility did not address the issue within the allowed timeframe, leaving the resident on unnecessary medication.
Failure to Ensure Qualified Director of Food and Nutrition Services
Penalty
Summary
The facility failed to ensure that the individual designated as the director of food and nutrition services met the required federal and/or state educational qualifications for the position. The Dietary Manager stated she was not the dietary supervisor and was only covering temporarily while orienting a new supervisor. The newly identified Dietary Supervisor reported that he was responsible for both dietary and maintenance duties and only held a food handler certification, specifically a ServeSafe certificate from the National Restaurant Association, rather than the required qualifications for the director role. The Registered Dietitian worked part-time and was on site only once a month. These findings were confirmed through interviews and record review, indicating that the person serving as the director of food and nutrition services did not possess the necessary competencies and skill set as required.
Failure to Complete and Accurately Code PASRR Assessment
Penalty
Summary
The facility failed to ensure that the Preadmission Screening and Resident Review (PASRR) assessment was completed and accurately coded for a resident with diagnoses of major depressive disorder and an eating disorder. The resident's admission record indicated a positive PASRR I, but a PASRR II was not completed due to the resident being placed in isolation as a health or safety precaution. Despite this, the Minimum Data Set (MDS) Coordinator was unaware that the PASRR II had not been completed and had not seen the relevant letter from the Department of Health Care Services (DHCS) indicating the assessment was not done. The MDS documentation was inconsistent, with one section indicating the resident was considered by the state PASRR II process to have a serious mental illness, while another section indicated the opposite. Interviews with facility staff, including the MDS Coordinator and the Medical Director, revealed a lack of awareness and monitoring regarding the completion and coding of the PASRR II assessment. The Medical Director confirmed the importance of the PASRR II screening for ensuring appropriate care and stated he was not informed that the assessment had not been completed. The facility did not have a process in place to track or report the status of PASRR II assessments to the physician, resulting in the resident not being properly assessed for care and services appropriate to their needs.
Medication Error Rate Exceeds 5% Due to Improper Lidocaine Patch Administration
Penalty
Summary
Nursing staff failed to ensure the medication error rate remained below 5% when a 4% lidocaine patch was administered to a resident's knees on two separate occasions, rather than to the lower back as prescribed by the physician. Specifically, a registered nurse applied the patch to the resident's left knee during one medication pass, and a licensed vocational nurse applied the patch to the right knee during another medication pass. The physician's order clearly indicated the patch was to be applied to the lower back once daily for pain management. The nursing supervisor confirmed that any change in the application site required physician approval and a corresponding order change. These actions resulted in two medication errors out of 27 observed opportunities, leading to a medication error rate of 7.41%. The resident involved had a medical history including heart failure, osteoarthritis, and a current pathological vertebral fracture, and was admitted with these diagnoses. The errors were identified through observation, interview, and record review during the survey process.
Expired Medications Found in Facility
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident due to the presence of expired medications in the medication storage areas. During an observation, several expired medications were found in the medication cart, including Insulin Lispro and Novolog pens for two residents, which had been opened and stored at room temperature beyond the recommended 30 days. Additionally, an expired Pfizer Covid Vaccine was found in the refrigerated medication storage, which had surpassed its expiration date, potentially compromising its efficacy. Further inspection of the Emergency Drug Kit (E-kit) revealed multiple expired medications, including Atropine, Gentamycin, Naloxone, Hydralazine HCL, Haloperidol, GlucaGen Hypokit, Diphenhydramine, Chlorpromazine, and Atrovent. The E-kit had been last used several months prior, indicating a lack of regular checks and replacements of expired medications. During an interview, the Nursing Supervisor was unable to provide a clear explanation for the expired medications and expressed an intention to investigate the issue further.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in an observed error rate of 32% during a medication pass. This was due to several deficiencies in medication administration practices. Licensed Vocational Nurse 1 (LVN 1) did not use the required two distinct identifiers to verify resident identities before administering medications, relying instead on memory and occasionally checking photos. This practice was observed with three residents, potentially compromising patient safety and medication accuracy. Additionally, LVN 1 did not provide water with oral medications to a resident, who subsequently struggled to swallow multiple pills and had to request water. This oversight was contrary to the facility's policy, which requires offering at least 4 ounces of water with oral medications unless exceptions apply. Furthermore, LVN 1 left medications at the bedside of a confused resident without supervision, leading to the resident independently ingesting some pills, which raised concerns about medication safety and adherence to protocols. The report also highlighted that LVN 1 administered acetaminophen routinely to a resident without assessing their pain level, despite the medication being prescribed on an as-needed basis. Additionally, both LVN 1 and LVN 2 failed to hold the needle in place for the recommended five seconds after administering Insulin Lispro, potentially affecting the medication's absorption and effectiveness. These actions and inactions contributed to the high medication error rate observed during the survey.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure food was stored and prepared in a safe and sanitary manner, as observed during a survey. In the dishwashing area, a trash can was left uncovered, which was confirmed by the Registered Dietician (RD) to be against the FDA Food Code 2022, as it could attract insects and pests. Additionally, the microwave in the food preparation area was found to have black residue and greasy deposits, which were confirmed by the RD to be dirty and not in compliance with the FDA Food Code requirements for cleanliness of food-contact surfaces. Further observations revealed expired food items, including two unopened packs of corn tortillas and one opened pack, which were past their expiration dates according to the facility's guidelines. The RD confirmed these items were expired and could potentially cause foodborne illness. Additionally, a half-full bag of brown sugar and a bag of salt were found in their original paper sacks without proper storage in containers, as required by the facility's policy. The RD acknowledged that these items should have been stored in containers with tight-fitting lids to ensure their longevity.
Ineffective QAPI Program and Medication Administration Errors
Penalty
Summary
The facility's Quality Assessment Performance Improvement (QAPI) program was found to be ineffective in preventing medication administration errors, as evidenced by a 32% medication error rate observed during a survey. The facility's policy requires healthcare providers to use at least two distinct identifiers before administering medications, but this protocol was not followed by LVN 1 for three residents, who relied solely on memory for identification. Additionally, LVN 1 failed to offer water or an acceptable liquid with oral medications to Resident 30, resulting in difficulties swallowing the medications. Another error involved LVN 1 leaving medication unattended with a confused resident, who then self-administered two pills without supervision. Further issues were identified with the administration of medications. LVN 1 administered acetaminophen routinely to a resident, despite it being prescribed as needed for pain relief. Both LVN 1 and LVN 2 did not adhere to the manufacturer's instructions for administering insulin Lispro injections, as they did not hold the needle in place for the recommended five seconds after injection, potentially affecting proper insulin absorption and effectiveness. During an interview with the Quality Committee, it was revealed that they had not identified any issues related to medication pass observations and lacked ongoing performance improvement projects to address medication errors.
Infection Control Lapses with Resident Masks
Penalty
Summary
The facility failed to adhere to its infection prevention and control policy, resulting in potential infection risks for two residents. For Resident 30, a nebulization mask was found undated, unlabeled, and exposed in a bedside table drawer, in contact with other personal items and a dusty surface. This was observed during an interview with an LVN, who acknowledged that the mask should have been stored in a plastic bag, dated, and labeled to prevent bacterial growth and potential infection. Similarly, for Resident 8, both a nebulization mask and a CPAP mask were found undated, unlabeled, and exposed on a bedside table and in a drawer with other belongings. The LVN confirmed that these items should have been stored in plastic bags after use. The Infection Preventionist also stated that these masks should be cleaned and stored properly to prevent bacterial accumulation and infection risk. The facility's policies, revised in 2010 and 2014, require such equipment to be stored in a plastic bag with the resident's name and date, and changed regularly, which was not followed in these instances.
Dish Machine Temperature Deficiency
Penalty
Summary
The facility failed to maintain the dish machine in a safe operating condition, as observed during multiple inspections. On several occasions, the dish machine's temperature did not reach the required minimum of 120 degrees Fahrenheit, as specified by the manufacturer's guidelines. Observations on different days showed the machine's temperature ranging from 100 to 119 degrees Fahrenheit, consistently failing to meet the necessary threshold for proper cleaning and sanitization of food preparation and service utensils. Interviews with staff, including a dietary supervisor and maintenance supervisor, confirmed the machine's inability to reach the required temperature. The service contractor also verified that the manufacturer's instructions specified a minimum temperature of 120 degrees Fahrenheit. The facility's policy and procedures, as well as the dish machine's information plate, reiterated the need for the machine to operate within the manufacturer's recommended temperature range. Despite these guidelines, the facility's dish machine temperature logs for May 2024 documented temperatures below the required level, indicating a persistent issue with maintaining the dish machine in safe operating condition.
Deficiency in Resident Room Space Requirements
Penalty
Summary
The facility failed to provide the required 80 square feet of space per resident for eight residents occupying four multi-bed rooms. During an observation, it was noted that rooms 1, 5, 6, and 12 each measured 158.28 square feet and housed two beds, resulting in less than the required space per resident. Despite this, random observations of care and services indicated that there was sufficient space for the provision of care, and no heavy equipment was present that might interfere with residents' care. Each resident had adequate personal space and privacy, and there were no complaints from residents regarding insufficient space for their belongings. Additionally, there were no negative consequences or safety concerns attributed to the decreased space in these rooms.
Pest Control Deficiency in Kitchen
Penalty
Summary
The facility failed to ensure an effective pest control program, as evidenced by the presence of flies in the kitchen. During observations and interviews conducted on May 8, 2024, flies were seen in the dry goods storage area, food preparation area, and dishwashing area, with one fly on the back door screen. The Registered Dietitian (RD) confirmed the presence of five flies and mentioned that the door was left open for food delivery, which contributed to the issue. Additionally, the RD stated that there was no fly trap in the kitchen. The facility's pest control policy, dated 2008, indicated that the facility should maintain an effective pest control program to keep the building free of insects and rodents. However, the presence of flies in the kitchen demonstrated a failure to adhere to this policy, potentially leading to foodborne illness. The FDA Food Code 2022 also highlights the importance of insect control devices as a supplement to good sanitation practices in food establishments.
Non-Functional Clock in Resident's Room
Penalty
Summary
The facility failed to maintain a working wall clock in the room of a resident with moderately impaired cognition, as indicated by a Brief Interview of Mental Status (BIMS) score of 9 out of 15. During observations and interviews conducted over several days, it was noted that the wall clock in the resident's room consistently displayed incorrect times, such as 6:15 and 12:35, which could contribute to the resident's confusion and disorientation. The resident expressed reliance on the lobby clock to know the correct time, as the non-functional clock in her room was not useful. Licensed Vocational Nurses (LVN) and the Director of Nursing (DON) acknowledged the importance of having a working clock to prevent confusion among residents. However, the clock remained unfixed over the course of multiple observations. The LVNs admitted to not checking the residents' rooms and surroundings during their rounds, which contributed to the oversight. The DON also recognized the potential for confusion caused by an incorrect time display, yet the issue persisted without resolution during the survey period.
Failure to Provide Proper Nail Care for Residents
Penalty
Summary
The facility failed to provide proper grooming and nail care for two residents, Resident 20 and Resident 18, who were unable to perform these activities independently. Resident 20, who was admitted to the facility with impaired mental status and was dependent on staff for self-care, was observed with long fingernails containing black matter underneath. Despite expressing a preference for clean nails, Resident 20 did not receive the necessary assistance. Interviews with staff confirmed that nails should be trimmed weekly during showers to prevent potential infections and injuries. Similarly, Resident 18, who had severe mental impairment and contractures, was found with long, sharp fingernails digging into their palms. This resident was also dependent on staff for personal hygiene and was unable to cut their own nails. Staff acknowledged the risk of infection and injury due to the condition of the nails. The facility's policy stated that residents unable to perform activities of daily living independently should receive necessary services to maintain grooming and hygiene, which was not adhered to in these cases.
Failure to Act on Pharmacist's Recommendations for Medication Use
Penalty
Summary
The facility failed to act upon the consultant pharmacist's recommendations regarding the medication regimen of a resident, identified as Resident 12. The resident was receiving trihexyphenidyl, a medication typically used to improve muscle control and reduce stiffness in conditions like Parkinson's disease, for an incorrect indication of 'fall syndrome.' The consultant pharmacist had requested clarification of the medical diagnosis to support the use of this medication and recommended updating the facility records to reflect the rationale for its use. However, as of the date of the report, these recommendations had not been reviewed by the physician, and the resident continued to receive the medication without proper indication. Interviews and record reviews revealed that the facility's policy required the consultant pharmacist to review each resident's medication regimen monthly and communicate findings and recommendations to those with authority to implement them. Despite this policy, the facility did not act on the pharmacist's recommendations within the 30-day period typically allowed for such actions. The Registered Nurse involved acknowledged the importance of having the correct dosage, diagnosis, and medication to avoid misleading treatment, yet no documentation was found to indicate that the facility had addressed the pharmacist's concerns for Resident 12.
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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) |
|---|---|---|---|---|
| St Anthony Care Center | 0.4 mi | ★★★★★ | 0 | 0 |
| Bethesda Home | 0.5 mi | ★★★★★ | 0 | 0 |
| We Care Skilled Nursing Facility | 0.8 mi | ★★★★★ | 0 | 0 |
| Golden Harbor Healthcare Center | 0.8 mi | ★★★★★ | 60 | 0 |
| Morton Bakar Center | 1 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release June 2026) and official state health department websites.