Inspection Reports for
Hayward Gardens Post Acute
1628 B St, Hayward, CA 94541, United States, CA, 94541
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
13.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
238% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
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20
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Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jan 2, 2026
Visit Reason
The inspection was conducted to assess the facility's compliance with professional standards of care related to treatment and monitoring of residents, specifically regarding Resident 1's skin condition and notification to the resident's representative.
Findings
The facility failed to monitor Resident 1's rash on bilateral breast folds for increased spread or signs of infection and did not promptly notify the resident's representative about the rash. These failures resulted in Resident 1 not receiving appropriate care and services, with potential emotional distress to the resident and their representative.
Deficiencies (1)
Facility did not monitor Resident 1's rash on bilateral breast fold for increased spread or signs of infection according to care plan and did not promptly notify Resident 1's representative of the rash.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | Interviewed regarding Resident 1's rash monitoring and notification failures |
Inspection Report
Deficiencies: 1
Date: Jan 2, 2026
Visit Reason
The inspection was conducted to assess compliance with professional standards of care related to treatment and care of residents, specifically focusing on monitoring and notification practices regarding changes in residents' skin conditions.
Findings
The facility failed to ensure one resident received appropriate treatment and care according to professional standards by not monitoring a rash for increased spread or signs of infection and failing to notify the resident's representative of the condition. These failures potentially caused emotional distress to the resident and denied the representative their right to be informed.
Deficiencies (1)
F 0684: The facility did not monitor Resident 1's rash on bilateral breast fold for increased spread or signs of infection according to the care plan. The facility also failed to promptly notify Resident 1's representative about the rash in multiple areas.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | Interviewed regarding Resident 1's care plan, change of condition notes, and treatment administration records. |
Inspection Report
Deficiencies: 3
Date: Dec 5, 2024
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident assessments, pre-admission screening, and provision of care and assistance with activities of daily living.
Findings
The facility failed to conduct an accurate assessment of a resident's functional capacity related to dental condition, failed to refer a resident with a serious mental disorder for appropriate PASARR Level II screening, and failed to ensure a resident received necessary grooming and hygiene services due to inconsistent shower scheduling and undocumented refusals.
Deficiencies (3)
F 0641: The facility failed to conduct an accurate assessment of Resident 42's functional capacity, incorrectly coding the Minimum Data Set for dental condition, potentially delaying proper care planning.
F 0644: The facility failed to refer Resident 57 for Level II PASARR screening despite a diagnosed psychiatric condition, risking inappropriate or ineffective care.
F 0677: The facility failed to ensure Resident 38 received necessary grooming and hygiene services, as shower schedules were not consistently followed and refusals were not documented or acted upon.
Report Facts
BIMS score: 14
BIMS score: 15
BIMS score: 15
Shower schedule frequency: 2
Refusals documented: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Minimum Data Set Nurse Coordinator | Discussed the importance of accurate MDS assessments and PASARR screening | |
| Social Services Director | Discussed Resident 42's financial concerns affecting dental care | |
| Administrator and Director of Nursing | Discussed PASARR screening process and corrections | |
| Certified Nursing Assistant 1 | Provided information on shower schedules and documentation | |
| Registered Nurse Supervisor 1 | Discussed documentation of showers and refusals | |
| Medical Records Director | Provided bathing checklist documentation | |
| Acting Director of Nursing | Reviewed shower and bathing documentation and policies | |
| Registered Nurse Supervisor 2 | Discussed Resident 38's shower refusals and scheduling difficulties |
Inspection Report
Deficiencies: 3
Date: Dec 5, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident assessments, pre-admission screening, and provision of care and assistance with activities of daily living at Hayward Gardens Post Acute.
Findings
The facility failed to conduct accurate assessments for residents, including incorrect coding of dental conditions and failure to refer a resident for appropriate PASARR level II screening. Additionally, the facility did not consistently follow shower schedules or document refusals for one resident, resulting in unmet physical, physiological, and psychological needs. These deficiencies had the potential to cause health decline and delay proper care planning and treatment.
Deficiencies (3)
Failed to conduct an accurate assessment of one resident's functional capacity, incorrectly coding dental condition in the Minimum Data Set.
Failed to refer one resident with a serious mental disorder for level II Preadmission Screening and Resident Review (PASARR) when Level 1 PASARR did not accurately show the resident's diagnosed psychiatric condition.
Failed to ensure one resident received necessary services to maintain grooming and personal hygiene; shower schedule was not consistently followed and refusals were not documented or acted upon.
Report Facts
BIMS score: 14
BIMS score: 15
BIMS score: 15
Shower schedule frequency: 2
Refusals documented: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Minimum Data Set Nurse Coordinator | MDS Nurse Coordinator | Interviewed regarding inaccurate MDS assessment and PASARR screening |
| Social Services Director | SSD | Interviewed regarding Resident 42's financial concerns affecting dental care |
| Administrator | ADM | Interviewed about PASARR process and resident assessments |
| Director of Nursing | DON | Interviewed about PASARR process and resident assessments |
| Certified Nursing Assistant 1 | CNA | Interviewed about shower schedules and documentation |
| Registered Nurse Supervisor 1 | RNS | Interviewed about shower refusals and documentation |
| Medical Records Director | MRD | Provided bathing checklist documentation |
| Registered Nurse Supervisor 2 | RNS | Interviewed about shower refusals and scheduling difficulties |
| Acting Director of Nursing | ADON | Interviewed about shower schedules, refusals, and resident rights |
Inspection Report
Enforcement
Deficiencies: 1
Date: Nov 25, 2024
Visit Reason
The inspection was conducted to assess compliance with staffing requirements, specifically to verify that the Director of Nursing (DON) was a registered nurse as required by regulations.
Findings
The facility failed to ensure the Director of Nursing was a registered nurse for seven months, resulting in an unqualified nurse being designated as the DON, which posed a potential risk for inadequate supervision and management of residents and nursing staff.
Deficiencies (1)
Facility failed to ensure the Director of Nursing was a registered nurse for seven months.
Report Facts
Duration of deficiency: 7
Inspection date: Nov 25, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Named as acting DON without RN license | |
| Administrator | Provided information on DON job description and staffing |
Inspection Report
Deficiencies: 1
Date: Nov 25, 2024
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements regarding the qualifications of the Director of Nursing (DON) at the facility.
Findings
The facility failed to ensure the Director of Nursing was a registered nurse for seven months, resulting in an unqualified nurse designated as DON, which posed potential risks for inadequate supervision and management of residents and nursing staff.
Deficiencies (1)
F 0727: The facility failed to have a registered nurse as the Director of Nursing for seven months. The acting DON was a Licensed Vocational Nurse who had not yet passed the RN licensure exam.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Aug 17, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding a fall incident involving Resident 1, who fell off the bed while being cared for by staff.
Complaint Details
The investigation was complaint-related, focusing on the fall of Resident 1 on 3/21/2022. The complaint was substantiated by interviews with CNA 1, RN 1, LVN 1, and the Assistant Director of Nursing, as well as review of Resident 1's Minimum Data Set, Progress Notes, History and Physical, and Orthopaedic Consultation Note.
Findings
The facility failed to ensure that Resident 1, who required two-person assistance for repositioning and brief changes, was properly assisted, resulting in Resident 1 falling off the bed and sustaining a right femur fracture. Staff interviews and record reviews confirmed that the brief was changed by one person instead of two, contrary to the care plan.
Deficiencies (1)
Failure to ensure one of three sampled resident's brief was changed with two people helping to turn Resident 1 in the bed, resulting in a fall and right femur fracture.
Report Facts
Date of fall: Mar 21, 2022
Date of survey completion: Aug 17, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 1 | Certified Nursing Assistant | Named in the finding for changing Resident 1's brief alone leading to fall |
| RN 1 | Registered Nurse | Assessed Resident 1 after fall and provided information about incident |
| LVN 1 | Licensed Vocational Nurse | Cared for Resident 1 on evening shift and reported on Resident 1's condition post-fall |
| ADON | Assistant Director of Nursing | Reviewed MDS and confirmed two-person assist requirement for Resident 1 |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Aug 17, 2023
Visit Reason
The inspection was conducted following a complaint investigation related to a resident fall incident involving inadequate assistance during brief changing.
Complaint Details
The investigation was triggered by a complaint regarding Resident 1's fall on 3/21/2022. The complaint was substantiated as the facility failed to follow the care plan requiring two-person assistance, leading to the fall and injury.
Findings
The facility failed to ensure that Resident 1 was assisted by two people as required when being turned in bed, resulting in Resident 1 falling off the bed and sustaining a right proximal femur fracture. Interviews and record reviews confirmed that staff regularly changed Resident 1's brief alone despite the care plan requiring two-person assistance.
Deficiencies (1)
F 0689: The facility failed to ensure one of three sampled residents was assisted by two people when being turned in bed, resulting in a fall and right femur fracture. Resident 1 was changed by one staff member alone contrary to the care plan requiring two-person assist.
Report Facts
Date of fall: Mar 21, 2022
Date of survey completion: Aug 17, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 1 | Certified Nursing Assistant | Named in the finding for changing Resident 1's brief alone leading to fall |
| RN 1 | Registered Nurse | Assessed Resident 1 after fall and provided information on incident |
| LVN 1 | Licensed Vocational Nurse | Cared for Resident 1 on evening shift when fall was reported |
| ADON | Assistant Director of Nursing | Reviewed care plan and confirmed two-person assist requirement |
Inspection Report
Routine
Deficiencies: 19
Date: Jun 9, 2023
Visit Reason
Routine inspection survey of Hayward Gardens Post Acute to assess compliance with healthcare facility regulations including resident rights, assessments, care planning, nutrition, medication management, and food service operations.
Findings
The facility had multiple deficiencies including failure to conduct monthly resident council meetings, untimely completion of resident assessments, incomplete baseline care plans, inadequate communication accommodations, lack of treatment for range of motion decline, significant unaddressed weight loss and nutrition issues, improper medication and antibiotic management, unsafe medication storage, insufficient food service oversight, poor food safety and sanitation practices, and malfunctioning equipment.
Deficiencies (19)
F0565: Facility failed to provide monthly Resident Council Meetings for April and May 2023 and did not address some resident concerns from prior meetings.
F0638: Facility failed to complete quarterly Minimum Data Set assessments timely for 10 of 12 sampled residents, delaying assessment of residents' needs and progress.
F0655: Facility failed to develop and implement baseline or comprehensive care plans within 48 hours of admission for two sampled residents.
F0676: Facility failed to provide consistent qualified interpreter services for a non-English speaking resident, causing communication barriers and emotional distress.
F0688: Facility failed to provide treatment services to address decline in range of motion for one resident due to insurance issues.
F0692: Facility failed to comprehensively assess and intervene for significant weight loss in one resident, resulting in continued severe weight loss and inadequate nutritional support.
F0693: Facility failed to ensure feeding tube orders were followed and dietitian recommendations acted upon for one resident.
F0697: Facility failed to assess and document pain characteristics and monitor side effects before administering PRN hydromorphone pain medication to one resident.
F0756: Facility failed to act on consultant pharmacist medication regimen review recommendations for two residents and lacked follow-up procedures.
F0761: Facility failed to ensure safe and secure medication storage when multiple loose pills were found in medication cart drawers.
F0801: Facility lacked full-time qualified dietetic services supervisor and competent oversight of food and nutrition services.
F0801: Facility failed to follow proper food safety and sanitation practices including improper food storage, use of leftovers without documentation, missing menu substitutions, dirty kitchen equipment, and inadequate cleaning schedules.
F0802: Facility staff lacked competency in food safety procedures including reading freezer thermometers, testing sanitizer strength, cleaning juice machine, and labeling chemicals.
F0803: Facility failed to provide milk as shown on the menu for 55 residents and served incorrect food portions to 10 residents on modified diets.
F0804: Facility served bland and inadequately heated food, compromising palatability and nutritional intake for residents.
F0806: Facility failed to provide gluten-free diet alternate for one resident with gluten allergy and failed to provide alternate for garlic bread for 61 residents.
F0812: Facility failed to maintain kitchen and food storage areas in a clean and sanitary condition including dirty equipment, dirty floors and vents, missing floor tiles, unlabeled food, dirty ice machine, and lack of airgap on food preparation sink drain.
F0881: Facility failed to monitor antibiotic use by not clarifying stop date for erythromycin eye ointment for one resident.
F0908: Facility failed to maintain reach-in freezer in safe operating condition with ice build-up and ripped door gaskets.
Report Facts
PRN Hydromorphone administrations: 80
PRN Hydromorphone administrations: 6
Weight loss: 39.6
Weight loss percentage: 23
Residents affected by milk omission: 55
Residents affected by garlic bread omission: 61
Residents affected by food safety issues: 61
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DM | Dietary Manager | Named in relation to food service deficiencies and lack of qualified dietetic supervision. |
| RD1 | Registered Dietitian | Named in relation to nutrition assessment and dietitian duties. |
| LVN 4 | PM Shift Supervisor | Named in relation to failure to follow up on pharmacist and dietitian recommendations. |
| DA1 | Dietary Aide | Named in relation to sanitizer testing and juice machine cleaning deficiencies. |
| C2 | Cook | Named in relation to food safety and sanitation deficiencies. |
| MS | Maintenance Supervisor | Named in relation to cleaning and maintenance deficiencies. |
| IP | Infection Preventionist | Named in relation to antibiotic stewardship deficiencies. |
| LVN 1 | Licensed Vocational Nurse | Named in relation to pain management deficiencies. |
| ADON | Assistant Director of Nursing | Named in relation to medication and pharmacist recommendation follow-up. |
Inspection Report
Routine
Deficiencies: 21
Date: Jun 9, 2023
Visit Reason
The inspection was a routine survey to assess compliance with regulatory requirements related to resident rights, assessments, care planning, communication, rehabilitation services, nutrition, medication management, food service, and equipment maintenance.
Findings
The facility had multiple deficiencies including failure to hold monthly resident council meetings, untimely completion of quarterly resident assessments, lack of baseline care plans within 48 hours of admission, inadequate communication accommodations for a non-English speaking resident, failure to provide treatment for a resident with limited range of motion, inadequate nutritional assessment and interventions for a resident with significant weight loss, failure to follow dietitian recommendations for tube feeding, inadequate pain assessment and documentation, failure to follow consultant pharmacist recommendations, unsafe medication storage, lack of full-time qualified dietitian oversight, food service deficiencies including unpalatable food, failure to provide diet accommodations for allergies, unsanitary kitchen conditions, improper food storage and handling, and failure to maintain essential kitchen equipment.
Deficiencies (21)
Failure to provide monthly Resident Council Meetings for April and May 2023 and failure to address resident concerns from prior meetings.
Failure to complete quarterly Minimum Data Set assessments in a timely manner for 10 of 12 sampled residents.
Failure to develop and implement baseline and/or comprehensive care plans within 48 hours of admission for two sampled residents.
Failure to provide appropriate communication accommodations for a non-English speaking resident, including lack of qualified interpreter and communication board.
Failure to provide treatment services to address decline in range of motion for a bedbound resident due to insurance issues.
Failure to comprehensively assess and implement nutritional interventions for a resident with significant weight loss, including failure to follow weight loss policy, provide adequate supplements, and conduct interdisciplinary team meetings.
Failure to follow dietitian recommendations to increase tube feeding rate for a resident with gastrostomy tube.
Failure to assess and document pain characteristics and side effects before and after administration of PRN hydromorphone pain medication for a resident.
Failure to act upon consultant pharmacist medication regimen review recommendations for two residents and lack of policy addressing follow-up.
Unsafe and unsecured medication storage with multiple loose pills found in medication cart drawers.
Lack of full-time qualified dietitian or competent dietary services supervisor to oversee food and nutrition services.
Failure to properly cool, store, substitute, and prepare food according to policy and professional standards, including use of leftovers, substitutions without documentation, and unpalatable food served at low temperatures.
Failure to provide gluten-free diet alternate for resident with gluten allergy and failure to provide alternate for garlic bread for all residents.
Unsanitary kitchen conditions including dirty blender lids, cutting boards, pans, can opener, and ice machine; dirty vents and floors; broken floor tiles; and lack of cleaning schedules.
Failure to properly test and maintain sanitizer solution strength and improper manual warewashing procedures.
Unauthorized personnel allowed in food preparation and storage areas.
Failure to label opened food containers with use-by dates and failure to date supplement shakes after thawing.
Failure to maintain ice machine according to manufacturer's instructions and use of improper cleaning chemicals.
Food preparation sink drain lacked an airgap to prevent backflow contamination.
Failure to provide milk as shown on the menu for 55 residents and incorrect food portion sizes served to 10 residents on therapeutic diets.
Failure to serve palatable food with appropriate temperature; pureed food was served barely warm and tasted bland.
Report Facts
Residents reviewed for assessments: 12
Residents with untimely assessments: 10
PRN Hydromorphone administrations: 80
PRN Hydromorphone administrations: 6
Weight loss: 39.6
Residents on diets allowing milk: 55
Residents receiving pureed/minced diets: 10
Temperatures recorded: 67
Freezer gasket damage: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident 19 | Interviewed about missing milk and meal preferences | |
| Resident 287 | Interviewed about missing milk and meal preferences | |
| Resident 12 | Interviewed about missing milk and meal preferences | |
| Social Services Director | DSD | Interviewed about missing Resident Council Meetings and nutritional supplements |
| Registered Dietitian 1 | RD1 | Part-time dietitian interviewed about nutritional assessments and menu substitutions |
| Dietary Manager | DM | Interviewed about food service management and kitchen sanitation |
| Licensed Vocational Nurse 4 | LVN 4 | PM shift supervisor interviewed about follow-up on pharmacist and dietitian recommendations |
| Licensed Vocational Nurse 2 | LVN 2 | Interviewed about feeding tube administration and medication cart loose pills |
| Dietary Aide 1 | DA1 | Interviewed about sanitizer testing and juice machine cleaning |
| Dietary Aide 2 | DA2 | Interviewed about sanitizer testing and juice machine cleaning |
| Maintenance Supervisor | MS | Interviewed about kitchen cleaning and ice machine maintenance |
| Assistant Director of Nursing | ADON | Interviewed about medication and dietitian recommendation follow-up |
| Infection Preventionist | IP | Interviewed about antibiotic use monitoring |
| Nurse Practitioner 1 | NP1 | Interviewed about resident weight loss and nutritional needs |
| Registered Nurse 1 | RN 1 | Interviewed about medication administration and pain management |
| Certified Nursing Assistant 3 | CNA 3 | Interviewed about communication with non-English speaking resident |
| Certified Nursing Assistant 2 | CNA 2 | Interviewed about communication with non-English speaking resident |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: May 30, 2019
Visit Reason
The inspection was conducted to assess compliance with the requirement that each resident's assessment is updated at least once every 3 months, specifically focusing on the completion of quarterly Minimum Data Set (MDS) assessments.
Findings
The facility failed to update quarterly MDS assessments for five of 21 sampled residents, resulting in these residents not having updated assessments to track their health status. The overdue assessments were confirmed during an interview with the MDS coordinator.
Deficiencies (1)
Failure to update quarterly MDS assessments for five residents (Resident 4, Resident 9, Resident 13, Resident 17, and Resident 10).
Report Facts
Residents sampled: 21
Residents with overdue assessments: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MDS coordinator | Confirmed overdue quarterly MDS assessments during interview |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: May 30, 2019
Visit Reason
The visit was conducted to assess compliance with federal guidelines regarding timely completion of quarterly Minimum Data Set (MDS) assessments for residents.
Findings
The facility failed to update quarterly MDS assessments for five of 21 sampled residents, resulting in those residents not having updated assessments to track their health status.
Deficiencies (1)
F 0638: The facility failed to update quarterly MDS assessments for five residents when the assessments were not completed timely as required by federal guidelines.
Report Facts
Residents with overdue MDS assessments: 5
Sampled residents: 21
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MDS coordinator | Confirmed overdue dates of quarterly MDS assessments during interview. |
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