Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at We Care Skilled Nursing Facility during CMS and state inspections, most recent first.
The facility did not create or implement individualized care plans for three residents with specific needs: one with a PICC line, another with significant weight loss and low oral intake, and a third with moderate hearing loss. Staff failed to document refusals, hold IDT meetings, or follow established policies for care planning and monitoring, resulting in unmet care needs for these residents.
Three medication administration errors were observed, resulting in a medication error rate of 12 percent. These included a resident receiving Metformin without food, a nurse failing to instruct a resident to press the inner canthus after eye drop administration, and a nurse not checking vital signs before, during, or after a nebulizer treatment. These actions did not follow physician orders, manufacturer guidelines, or facility policy.
The facility did not follow professional food safety standards, as frozen meats were thawed improperly above fresh milk and on food prep counters, and kitchen staff used incorrect test strips to check sanitizer concentrations for dishwashing and sinks. Staff were unable to explain proper testing procedures, and logs showed unclear documentation. Additionally, two kitchen staff did not wear proper hair coverings during food preparation, contrary to facility policy.
A resident with a history of adequate hearing experienced moderate hearing loss after a hospital stay, as documented in assessments and observed by staff. Despite this, no care plan was developed, and standard procedures such as notifying the physician or arranging audiology services were not followed, leaving the resident without needed hearing support.
A resident with chronic kidney disease, diabetes, and frequent urinary incontinence reported painful urination and was observed by a CNA to have foul-smelling urine. Although an LVN notified the physician and was instructed to collect a urine specimen and encourage the resident's compliance, no SBAR was completed, no written order was entered, and no care plan was initiated, resulting in a lack of follow-up and documentation as required by facility policy.
A resident with severe cognitive impairment and multiple health conditions was not adequately monitored or assisted with food and fluid intake, leading to significant weight loss and insufficient hydration. Staff were unaware of the resident's specific hydration needs and failed to implement recommendations from the RD, while required monitoring and care planning for weight loss were not completed.
A resident with a PICC line did not receive dressing changes as ordered, and required monitoring for complications was not performed or documented. There was no record of the resident's refusals for dressing changes or removal, and no care plan or IDT meeting addressed the PICC line care, contrary to facility policy and physician orders.
Two residents experienced unaddressed medication regimen irregularities when the consultant pharmacist failed to identify or follow up on issues during monthly reviews. One resident with ESRD continued to receive contraindicated laxatives despite repeated refusal of a phosphate binder, while another resident's recommended reduction in acetaminophen dosage was not communicated to the physician. Facility policy requiring timely reporting and documentation of medication irregularities was not followed.
A resident with heart failure and atrial fibrillation was prescribed apixaban, a medication with a black box warning, but did not receive the required monitoring for adverse effects such as bleeding. Facility policy and FDA guidance required close monitoring for this medication, but review of the MAR and staff interview confirmed that this monitoring was not performed.
A resident with COPD and difficulty chewing was served dry corn flakes cereal despite being on a mechanical soft, controlled carbohydrate diet and having a documented dislike for cereal. Staff interviews revealed that the wrong cereal was provided due to a request from a CNA, and the dietary manager acknowledged the error. The resident felt disregarded, and the facility's policy requires adherence to prescribed therapeutic diets and resident preferences.
Surveyors found seven expired IV administration sets and one expired PICC stabilizing device stored with ready-to-use supplies in the medication storage room. An LVN confirmed no unexpired IV kits or PICC devices were available, even though a resident could have needed them. The DON stated that monthly audits to remove expired supplies were required, but could not provide documentation that these audits were completed.
A facility failed to re-evaluate the use of Seroquel for a resident admitted from a hospital, as required by their policy. The resident, who had COPD and anxiety behaviors, was prescribed Seroquel for a mood disorder, but the MDS assessment showed no indicators of psychosis or aggressive behavior. Despite a pharmacist's recommendation to consider dose reduction or diagnosis clarification, the medication was continued without re-evaluation. Interviews with staff confirmed the lack of re-evaluation, and the DON acknowledged the oversight.
Failure to Develop and Implement Comprehensive Care Plans for Residents with Specialized Needs
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for three residents with specific needs. One resident was admitted with a peripherally inserted central catheter (PICC) line for cellulitis treatment but did not have a care plan addressing PICC line care. The resident had a history of refusing PICC line removal and dressing changes, yet there was no documentation of these refusals or any interdisciplinary team (IDT) meetings to address the situation. The last dressing change was performed over a month prior, and staff acknowledged that a care plan and IDT involvement were necessary to monitor for complications such as infection. Another resident experienced a significant weight loss of 2.4 pounds in one week, attributed to very low oral intake, consuming only 0-25% of meals. Staff recognized the resident's high risk for malnutrition and the need for assistance with feeding, but there was no care plan developed to address the weight loss or low intake. The facility did not hold IDT meetings or establish goals, benchmarks, or monitoring parameters for this resident, despite policy requirements for multidisciplinary care planning in cases of weight loss or impaired nutrition. A third resident had moderate hearing loss documented in multiple assessments, including the Minimum Data Set (MDS), and staff reported communication difficulties requiring written notes or speaking loudly. Despite these ongoing issues and a change in hearing status following a hospital stay, no comprehensive care plan was initiated to address the resident's hearing impairment. There was also no evidence of follow-up with audiology or investigation into the use of hearing aids, and standard procedures for addressing hearing changes were not implemented.
Medication Error Rate Exceeds Acceptable Threshold Due to Multiple Administration Failures
Penalty
Summary
The facility failed to maintain a medication error rate below 5 percent, as three medication errors were observed out of 25 opportunities, resulting in a 12 percent error rate. One incident involved a resident with Type II Diabetes Mellitus who was administered Metformin 850 mg orally without a snack or meal, contrary to the physician's order and manufacturer guidelines, which specify that Metformin should be given with food to prevent gastrointestinal upset. The nurse acknowledged administering the medication without food due to the timing of scheduled meals. Another error occurred when a nurse administered artificial tears to a resident for eye dryness but instructed the resident to rapidly blink after instillation, rather than slowly closing the eyes and pressing the inner canthus as per standard nursing practice and facility policy. Additionally, a resident receiving Ipratropium-Albuterol inhalation treatment did not have vital signs checked before, during, or after the nebulizer treatment, despite physician orders and facility policy requiring these assessments. The nurse confirmed the importance of monitoring vital signs to evaluate the effectiveness of the medication.
Failure to Follow Food Safety Standards in Food Storage, Preparation, and Sanitation
Penalty
Summary
The facility failed to adhere to professional standards of food service safety in several key areas. Observations revealed that frozen meats, including chicken and turkey, were thawed on top of ready-to-drink fresh milk inside a refrigerator due to lack of space, as stated by the Dietary Manager. Additionally, frozen chicken was left to thaw on the food preparation counter before cooking, and kitchen staff confirmed that the chicken was pulled from the freezer and left on the counter for lunch service. These practices were not in accordance with the facility's own policy, which requires thawing meat in a refrigerator on the bottom shelf below ready-to-eat foods or under running potable water. Multiple kitchen staff used incorrect test strips to check sanitizer concentrations for both the three-compartment sink and the dishwasher. Staff used pH test strips, which are intended for checking detergent concentration, instead of the appropriate chlorine or quaternary ammonium test strips for sanitizer concentration. Staff were unable to explain the correct procedures for testing sanitizer levels, and logs showed inconsistent and unclear documentation of sanitizer readings. The posted instructions for quat sanitizer testing were outdated and not aligned with current practices, and the logs had been altered to reflect different concentration ranges without clear rationale. Furthermore, two kitchen staff, including the Dietary Manager, were observed not wearing proper hair coverings during food preparation, contrary to the facility's dress code policy. The policy requires hats that completely cover the hair or hair nets for longer hair, but staff were seen with hair partially or completely uncovered while preparing food. These failures in food storage, preparation, sanitation, and personal hygiene had the potential to result in cross-contamination and food-borne illnesses, as noted in the findings.
Failure to Address Resident's Hearing Loss and Provide Access to Hearing Services
Penalty
Summary
The facility failed to ensure that a resident with a communication deficit received appropriate treatment to maintain hearing ability after a decline in hearing was identified. The resident was initially admitted with adequate hearing, but following a hospital stay and return to the facility, assessments indicated moderate difficulty hearing. Despite this documented change, no comprehensive care plan was initiated to address the resident's hearing loss, and there was no evidence that the facility followed its normal process for addressing such changes, which includes ear flushing, notifying the physician and responsible party, and arranging an audiology appointment. Multiple staff interviews confirmed that the resident had ongoing difficulty hearing, requiring others to speak loudly or write messages to communicate. The Social Services Director acknowledged being aware of the resident's hearing issues but did not follow up on whether the resident had hearing aids or if insurance could cover them, and could not provide documentation of communication with the nursing department regarding the change. Observations showed the resident struggling to participate in conversations and activities due to hearing loss, with no interventions in place to address these needs.
Failure to Follow-Up on Resident's Painful Urination and Initiate Required Documentation
Penalty
Summary
Staff failed to provide appropriate treatment and services to prevent a urinary tract infection for a resident who was frequently incontinent of urine and dependent on staff for toileting hygiene. The resident, who had chronic kidney disease, muscle weakness, and diabetes mellitus, reported experiencing painful urination. The resident's urine was also noted by a CNA to have a strange odor, and this information was communicated to an LVN. The LVN contacted the attending physician, who ordered a urine specimen collection, but the resident refused the procedure. The physician further instructed staff to continue encouraging the resident to comply with the urine collection. Despite these developments, there was no documentation in the clinical record regarding the resident's change in condition, no SBAR was completed, no written physician's order for urine collection was entered, and no care plan was initiated. The facility's policy required the use of SBAR for changes in resident condition and for communication among staff, but this protocol was not followed. As a result, there was no formal follow-up or monitoring of the resident's condition after the initial complaint.
Failure to Monitor and Maintain Adequate Food and Fluid Intake
Penalty
Summary
The facility failed to adequately monitor and assist a resident in maintaining sufficient food and fluid intake, resulting in unaddressed weight loss and insufficient hydration. The resident, who was admitted with multiple diagnoses including urinary tract infection and Parkinson's disease, had a BIMS score indicating severe cognitive impairment and required substantial assistance with eating and drinking. The care plan identified the resident as being at risk for dehydration or electrolyte imbalance due to dementia, but fluid intake records showed consistently low daily consumption, well below the recommended amount by the Registered Dietician (RD). Despite the RD's progress notes highlighting a notable weight loss of 2.4 lbs in one week and recommending a daily fluid intake between 1240ml-1485ml, staff interviews revealed a lack of awareness and follow-through regarding these recommendations. Certified Nurse Assistants and Licensed Vocational Nurses acknowledged the resident's need for direct feeding assistance and encouragement to eat and drink, but were not aware of the specific hydration goals or the extent of the resident's intake. The Director of Nursing was also unaware of the RD's recommendations and the resident's recent weight loss, and admitted that fluid intake was not being adequately maintained or monitored. Further, the Assistant Director of Nursing discontinued weekly weight monitoring by mistake and confirmed that no care plan was developed to address the resident's weight loss, despite the known high risk for malnutrition. Facility policies required monitoring and intervention for inadequate hydration and weight loss, but these were not followed, resulting in the resident's ongoing insufficient intake and unaddressed health risks.
Failure to Provide and Document PICC Line Care and Monitoring
Penalty
Summary
A resident admitted with cellulitis of both lower limbs had a peripherally inserted central catheter (PICC) in place, with physician orders for the PICC line dressing to be changed every seven days and as needed. Review of the Medication Administration Record showed that these dressing changes were not performed by a Registered Nurse as ordered. Observation confirmed the presence of the PICC line, and interviews with the Director of Nursing (DON) revealed that the last dressing change was performed in January, despite the ongoing order. The DON stated the resident had refused both PICC line removal and dressing changes multiple times, but there was no documentation of these refusals in the medical record. Further review with the Assistant Director of Nursing (ADON) found no documentation of refusals, no monitoring for PICC line complications, and no evidence that an Interdisciplinary Team (IDT) meeting or care plan addressing PICC line care had been developed. The DON also admitted that required measurements of the external catheter length and arm circumference, which are standard practice for monitoring PICC line placement and complications, were not performed or documented. Facility policies required regular dressing changes, monitoring, and documentation of all care and refusals, but these were not followed for this resident.
Failure to Identify and Address Medication Regimen Irregularities
Penalty
Summary
The facility failed to ensure that a licensed pharmacist performed an adequate monthly drug regimen review for two residents, resulting in missed identification and follow-up of medication irregularities. For one resident with end stage renal disease (ESRD), the medication regimen included milk of magnesia and fleet enema, both of which contain substances that should be avoided in renal patients due to the risk of electrolyte imbalance. Despite the resident's repeated refusal of a prescribed phosphate binder, these medications remained part of the bowel regimen, contrary to facility policy and best practices for renal patients. The consultant pharmacist acknowledged that this irregularity was not identified during the monthly review. Additionally, for another resident who transitioned from hospice to custodial care, the consultant pharmacist recommended reducing the daily dose of acetaminophen from 4 grams to 3 grams during a medication regimen review. However, this recommendation was not communicated to the prescribing physician, and no action was taken to adjust the medication order. The assistant director of nursing confirmed that the recommendation had not been followed up, and the consultant pharmacist noted that several recommendations from previous months remained unaddressed. Facility policies required the consultant pharmacist to provide written reports of non-life threatening medication irregularities to the attending physician within 24 hours, with documentation of review and action in the medical record. In both cases, these procedures were not followed, resulting in unaddressed medication regimen irregularities for the affected residents.
Failure to Monitor Resident on Apixaban with Black Box Warning
Penalty
Summary
A resident admitted with heart failure, atrial fibrillation, and mobility difficulties was prescribed apixaban, an anticoagulant with a black box warning (BBW) for significant risks such as bleeding and neurological impairment. The resident's Medication Administration Record (MAR) for two consecutive months was reviewed, and it was found that there was no documented monitoring for adverse effects associated with apixaban, despite facility policy and FDA recommendations requiring close monitoring for BBW medications. During an interview, the Assistant Director of Nursing confirmed that monitoring for adverse effects, such as bleeding, was not performed as indicated in the MAR. The facility's policy specifically required close monitoring for patients on BBW medications, and the manufacturer's insert for apixaban outlined the need for frequent monitoring for signs of bleeding and neurological compromise. The lack of monitoring constituted a failure to ensure the resident's drug regimen was free from unnecessary drugs and that adverse effects were adequately tracked.
Failure to Follow Therapeutic Diet and Food Preferences
Penalty
Summary
The facility failed to follow the prescribed therapeutic diet and food preferences for one resident. The resident, who was admitted with diagnoses including low back pain and chronic obstructive pulmonary disease (COPD), was ordered a controlled carbohydrate diet with mechanical soft texture due to difficulty chewing and swallowing hard foods. Despite clear documentation on the meal ticket indicating the resident's dislikes and dietary restrictions, the resident was served a bowl of dry corn flakes cereal, which she found hard to chew and stated could have caused her to choke. The resident expressed feeling disregarded because her food preferences and therapeutic diet were not followed. Interviews with staff revealed that the certified nursing assistant (CNA) acknowledged the error and attributed it to a mistake by the kitchen staff, who provided the wrong cereal. The dietary manager stated that the dry corn flakes were given because the CNA requested it, despite the resident's documented preferences and dietary needs. The director of nursing confirmed that meal tickets should have been checked before serving and that staff should have verified with a licensed nurse before making changes to the resident's diet. The facility's policy requires therapeutic diets to be prescribed and followed according to the resident's preferences and treatment goals.
Expired IV and PICC Supplies Found in Medication Storage Room
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices by storing seven expired intravenous (IV) administration sets and one expired peripherally inserted central catheter (PICC) stabilizing device in the medication storage room. These expired items were kept alongside other ready-to-use medication administration supplies. During an observation and interview, a licensed vocational nurse confirmed that there were no unexpired IV kits or PICC line stabilizing devices available at the facility, despite having an active resident who could have required these supplies. The Director of Nursing (DON) acknowledged the importance of discarding expired medication administration supplies to maintain sterility and stated that both night shift licensed nurses and the DON were responsible for conducting monthly audits of the medication storage room. However, the DON was unable to provide documentation showing that these audits were being completed. A posted notice in the medication room outlined responsibilities for changing and auditing IV and PICC line supplies, but there was no evidence that these procedures were being followed or documented.
Failure to Re-evaluate Antipsychotic Medication Use
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary drugs when the interdisciplinary team did not re-evaluate the use of Seroquel, an antipsychotic medication, at the time of admission or within two weeks for its appropriateness and indication for use. The resident was admitted from an acute care hospital with a prescription for Seroquel to manage a mood disorder manifested by yelling and hitting. However, the Minimum Data Set (MDS) assessment indicated no potential indicators of psychosis or behavioral symptoms directed towards others. Despite this, the medication was continued without re-evaluation, and the facility did not follow up on the pharmacist's recommendation to consider reducing the dose or clarifying the diagnosis. Interviews with facility staff, including CNAs and LVNs, revealed that the resident exhibited anxiety behaviors related to COPD and called out for help, but there was no documentation of aggressive behaviors that would justify the continued use of Seroquel. The Director of Nursing confirmed that the facility did not re-evaluate the medication use as per their policy, which requires an assessment of antipsychotic medication appropriateness at admission and within two weeks. The facility's policy also mandates that residents transferred from hospitals be evaluated for the appropriateness of antipsychotic medications, which was not adhered to in this case.
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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) |
|---|---|---|---|---|
| Bethesda Home | 0.3 mi | ★★★★★ | 0 | 0 |
| St Anthony Care Center | 0.4 mi | ★★★★★ | 0 | 0 |
| Morton Bakar Center | 0.6 mi | ★★★★★ | 0 | 0 |
| Golden Harbor Healthcare Center | 0.6 mi | ★★★★★ | 60 | 0 |
| Serenethos Care Center, Llc | 0.8 mi | ★★★★★ | 0 | 0 |
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