Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
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 Hayward Gardens Post Acute during CMS and state inspections, most recent first.
The facility failed for an extended period to ensure that a qualified RN served as a competent DON, instead allowing an ADON without an RN license to function as DON while inconsistently designating an RN supervisor as DON without clear documentation or training. Staff rosters, HR files, sign-in sheets, and interviews showed the ADON was widely regarded and compensated as the DON, while the RN supervisor lacked knowledge of QAPI processes, could not effectively navigate the EMR, and did not participate in required QAPI meetings. This confusion and lack of qualified leadership contributed to nursing staff failing to provide adequate mental health services to a resident following a suicide attempt.
The facility failed to maintain complete and accurate records for controlled medications, including shipping manifests, Controlled Drug Records, and the Narcotic Take Back Log, for multiple residents. Staff described procedures for receiving, storing, transferring, and destroying narcotics, but record review showed missing nurse signatures, undated entries, and instances where a single nurse signed as both the nurse returning and the RN accepting discontinued controlled drugs. These documentation gaps involved various narcotic pain medications and conflicted with facility policies requiring detailed reconciliation of receipt, dispensing, and disposition of controlled substances, resulting in the potential for undetected loss and diversion.
A resident with hemiplegia, hemiparesis, chronic pain, and recent bereavement repeatedly expressed suicidal ideation and later attempted suicide by strangulation using wiring from an in-room circadia device. An RN supervisor found the resident with the cable around the neck, but there was no documented notification of the provider or police, no documented removal of the ligature risk from the room, and no care plan, change-in-condition note, or IDT meeting addressing the attempt. Subsequent psych consults did not specifically evaluate or treat the suicide attempt, the circadia device and wiring remained accessible at bedside, and key staff, including the ADON and MD, reported they were not informed of the attempt, while the resident reported no follow-up evaluation and ongoing suicidal thoughts.
A resident with End-Stage Renal Disease and confined to bed developed a spreading rash in the breast folds that was not monitored according to the care plan, and the resident's representative was not notified of the change in condition. The family only became aware of the wound after the resident was transferred to the hospital, where it was found to be septic. Facility policy requiring prompt notification and monitoring was not followed.
A resident's MDS was incorrectly coded, failing to reflect her dental issues, despite her dentures being loose and causing discomfort. This inaccuracy could delay proper care planning. The resident, with normal cognitive function, had financial concerns affecting her dental care, though reduced-price options were available.
A facility failed to refer a resident with bipolar disorder for a Level II PASARR due to an inaccurate Level I screening. The resident's cognitive function was intact, but the screening did not reflect their serious mental illness. Facility policy requires screening for mental disorders, but staff interviews revealed that inaccuracies could lead to residents not receiving necessary services.
A resident with end-stage kidney disease and other health issues did not receive necessary hygiene care due to the facility's failure to adjust her shower schedule, which conflicted with her dialysis days. Despite the resident's requests and the facility's policy allowing schedule changes, the showers were not rescheduled, and refusals were not properly documented. This led to unmet hygiene needs and a deficiency in care.
The facility failed to ensure the Director of Nursing (DON) was a registered nurse (RN) for seven months. The acting DON, an LVN, had not yet taken the NCLEX to become an RN, despite the facility's job description requiring the DON to be an RN. The administrator confirmed the acting DON had been in the position for over six months, and the staff roster listed them as the DON without indicating an acting position.
Unqualified and Inconsistent Nursing Leadership Resulting in Inadequate Oversight
Penalty
Summary
The deficiency involves the facility’s failure over approximately 15 months to ensure that a qualified and competent DON, holding a valid RN license, provided oversight of nursing services. Despite a prior citation and a plan of correction stating the facility would hire an RN for the DON position, records and interviews showed that the Assistant Director of Nursing (ADON), who did not hold an RN license, continued to function as the DON. The employee roster listed the ADON as the DON, and the ADON received monthly payments labeled as “DON monthly bonus.” Multiple staff, including a CNA, an occupational therapy assistant, the operations assistant, and the Ombudsman, identified or had been introduced to the ADON as the DON. State nursing board records confirmed that the ADON did not have an RN license. At the same time, the facility inconsistently represented the role of the RN Supervisor (RNS/[DON]). The RNS/[DON] stated they had been the DON for the past two years, but their badge identified them only as an RN supervisor, and their HR file listed the ADON as their manager and as the DON. Staffing sign-in sheets and staffing ratio forms showed the ADON listed as DON on multiple dates, with one sheet showing both the ADON and RNS/[DON] as DON, and some dates showing no DON on duty at all. The pharmacist consultant stated that RNS/[DON] was not the DON, and the admission manager described the ADON and Director of Staff Development as the individuals who reviewed potential residents for appropriateness, with the RNS/[DON] only seeing resident information after admission. During the survey entrance, the operations assistant initially introduced the ADON as the DON, then corrected themselves. The RNS/[DON], who was presented during the survey as the DON, demonstrated a lack of competence in key DON responsibilities. During review of a resident’s record, RNS/[DON] could not independently locate or print past progress notes and care plans in the EMR and required assistance. In an interview, RNS/[DON] was unable to describe the facility’s QAPI process, could not define a QAPI plan, and was unaware of any current QAPI projects, despite facility policy requiring the DON to be part of the QAPI committee. QAPI sign-in sheets showed the ADON, not RNS/[DON], attending QAPI meetings. Regarding a resident who had attempted suicide, RNS/[DON] stated they had notified the DON but then clarified they themselves were the DON, and they claimed there had been an IDT meeting about the incident, which the attending physician later denied. The administrator stated they had hired and trained RNS/[DON] as the DON but could not provide supporting documentation and later indicated they would backdate documents when RNS/[DON] returned from vacation. This pattern of misassignment and lack of documentation resulted in unqualified nursing leadership and contributed to staff failing to provide adequate mental health services to the resident after the suicide attempt.
Incomplete and Inaccurate Controlled Substance Accountability Records
Penalty
Summary
The facility failed to maintain a complete and accurate controlled medication record system for residents 1–11, involving documents such as pharmacy shipping manifests, Controlled Drug Records (CDRs), Medication Administration Records (MARs), and destruction logs (Narcotic Take Back Log). The Medical Records Director stated that shipping manifests and CDRs were scanned and retained electronically beginning 3/23, but surveyors found that the facility did not have complete or accurate records. A nurse (LVN 1) described receiving scheduled medications, signing the shipping manifest, placing medications in the cart, and filing the CDR at the cart, as well as transferring discontinued medications to the DON with both signing the CDR. The ADON described that unit nurses were to hand remaining medications and the CDR to the DON, document the amount transferred in the Narcotic Take Back Book, and have both the nurse and DON sign, with the DON and pharmacist later destroying the medications and signing the log. Record review with the ADON showed multiple deficiencies in documentation. For Resident 1, two CDRs with the same number for hydrocodone/APAP 5/325 mg tablets lacked the nurse’s signature, date, and number of doses received in the designated spaces. Review of the Narcotic Take Back Log (pages 6–22, total 137 line items) revealed 21 entries where one nurse signed as both the nurse giving back and the accepting RN for various residents’ controlled medications, and 79 entries were incomplete due to missing the “LN giving” signature. The ADON acknowledged these missing and improper signatures. The facility’s written policies on controlled substances and discarding/destroying medications required a system of reconciling receipt, dispensing, and disposition of controlled substances, including records of personnel access and usage, and required accountability records for discontinued controlled substances to be kept with the unused supply until destruction, in sufficient detail to enable accurate reconciliation. The report states these failures resulted in the potential for undetected loss and diversion (theft).
Failure to Ensure Safe Environment and Follow-Up After Resident Suicide Attempt
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate and timely mental health services and environmental safety for a resident with suicidal ideation and a suicide attempt. The resident was admitted with hemiplegia and hemiparesis following a cerebral infarction, along with low back pain, weakness, and a history of falls. On one evening, an LVN documented that the resident was repeatedly yelling "I want to kill myself" and could not be distracted from suicidal ideation, and the MD was notified. A police call report from that same night documented that the resident was threatening self-harm, was upset about a recent maternal death, and was experiencing back pain. The following morning, the RNS/DON found the resident with a circadia device wire around the neck after the resident had pulled the wiring from the wall and attempted strangulation. The RNS/DON’s progress note about the suicide attempt did not document that the police or the provider were contacted, and the RNS/DON could not recall if they had been notified. The RNS/DON was unable to find documentation that the circadia wire was removed from the room after the attempt. The physician order set included an order to monitor the resident every shift for suicidal ideation and listed two psych consults, but there were no orders to remove strangulation implements from the resident’s vicinity. Psychology notes from subsequent evaluations did not include any specific evaluation or treatment related to the suicide attempt. During a later room observation, the circadia device with wiring was still present next to the resident’s bed, and the resident confirmed by nodding that this device had been used in the suicide attempt. Interviews and record reviews showed that key facility staff and the provider were not fully informed of the suicide attempt and that no formal care planning or IDT process occurred in response. The RNS/DON stated the medical record did not contain a care plan, change in condition documentation, IDT meeting, or specific interventions addressing the suicide attempt. The MD reported being notified of suicidal ideation on two occasions but not of the actual suicide attempt and stated they were not part of any IDT meeting about it. The ADON stated they had not been informed of the suicide attempt and confirmed there was no IDT meeting or care plan related to it. The resident reported they were not sent out for further evaluation and that the facility did not provide follow-up to the suicide attempt, while also acknowledging ongoing suicidal thoughts and a desire to talk about the event. The facility’s own policy required immediate 911 activation, provider and DON notification, psychiatric/psychological evaluation, and care plan updates after a suicide attempt, but these steps were not documented as having been followed in this case.
Failure to Monitor and Communicate Resident's Spreading Rash
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards for a resident who was at risk for skin breakdown and confined to bed with a diagnosis of End-Stage Renal Disease. The resident developed a rash in multiple areas, including the bilateral breast folds, which was documented in the care plan with instructions to monitor for increased spread or signs of infection. However, the Treatment Administration Records (TARs) for the relevant months showed that the rash was not monitored as required, and there was no documentation of skin condition monitoring. Additionally, a change of condition note indicated the rash was spreading, but the resident's representative was not notified of this change. The resident's family member reported not being informed by the facility about the skin condition or the presence of a wound under the breast, only learning of it from hospital staff after the resident was transferred to the emergency department, where the wound was found to be septic. Review of facility policy confirmed that the facility was required to promptly notify the resident, physician, and representative of changes in condition, but this did not occur. The Assistant Director of Nursing confirmed that the required notifications and monitoring were not completed according to the care plan and facility policy.
Inaccurate MDS Coding for Dental Condition
Penalty
Summary
The facility failed to conduct an accurate assessment of a resident's functional capacity, specifically regarding the resident's dental condition. The Minimum Data Set (MDS) for the resident was incorrectly coded, indicating no oral or dental problems, despite the resident experiencing significant issues with her dentures. During an observation and interview, the resident reported that her dentures were loose and required removal to speak and eat effectively, causing discomfort and a desire for improvement. This discrepancy in the MDS coding had the potential to delay proper care planning and treatment for the resident. The resident, who was admitted with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), Aphasia following a cerebral infarction, and Hemiplegia, demonstrated normal cognitive function with a Brief Interview for Mental Status (BIMS) score of 14. However, the inaccurate assessment in MDS Section L overlooked her dental issues. Interviews with the Minimum Data Set Nurse Coordinator and the Social Services Director revealed that the incorrect MDS assessment could lead to inappropriate care planning and that financial concerns were affecting the resident's dental care, although reduced-price dental care options were available. The facility's policy indicated that the resident assessment coordinator is responsible for ensuring timely and appropriate assessments, which was not adhered to in this case.
Failure to Conduct Accurate PASARR Screening for Resident
Penalty
Summary
The facility failed to refer a resident with a serious mental disorder for a Level II Preadmission Screening and Resident Review (PASARR). This oversight occurred because the resident's Level I PASARR did not accurately reflect their diagnosed psychiatric condition, specifically bipolar disorder. The resident, who was admitted with diagnoses including paraplegia, generalized muscle weakness, and bipolar disorder, had a Brief Interview for Mental Status (BIMS) score indicating intact cognitive function. However, the Level I PASARR screening incorrectly indicated that the resident did not have a serious mental illness. The facility's policy requires that all new admissions be screened for mental disorders, intellectual disabilities, or related disorders as part of the PASARR process. During interviews, the Director of Nursing (DON) and the Minimum Data Set Nurse Coordinator (MDSC) acknowledged that an inaccurate PASARR screening could result in the resident not receiving all available services for psychiatric or developmental problems. The deficiency was identified during a record review and interviews with facility staff, highlighting a failure in the facility's admission and screening process.
Failure to Provide Adequate Hygiene Care for a Resident
Penalty
Summary
The facility failed to ensure that a resident received necessary services to maintain good grooming and personal hygiene. The resident, who was admitted with diagnoses including end-stage kidney disease, diabetes, and generalized muscle weakness, was scheduled to receive showers on Mondays and Fridays, which coincided with her dialysis days. The resident reported not having had a shower for several weeks and no bed baths were provided, despite her requests to change the shower schedule to non-dialysis days. The facility's documentation practices were inadequate, as reasons for the resident's refusals of showers were not documented, and there was no record of bed baths being provided when showers were refused. The Certified Nursing Assistant (CNA) and Registered Nurse Supervisor (RNS) acknowledged that refusals should be documented and communicated to the charge nurse or supervisor, but this was not consistently done. The Acting Director of Nursing (ADON) confirmed that shower schedules could be adjusted to accommodate residents' preferences, but this was not implemented for the resident in question. The facility's policies and procedures required documentation of reasons for shower or bed bath refusals and interventions taken, but these were not followed. The resident expressed her preference for shower days that did not coincide with dialysis, but her request was not accommodated, leading to unmet physical, physiological, and psychological needs. The facility's failure to adhere to its own policies and procedures contributed to the deficiency in care provided to the resident.
Unqualified Individual Serving as Director of Nursing
Penalty
Summary
The facility failed to ensure that the Director of Nursing (DON) was a registered nurse (RN) for a period of seven months. During an observation and interview, it was revealed that the individual serving as the DON was wearing a badge indicating their position but admitted to being an acting DON since March 2024. This individual had completed their schooling to become an RN but had not yet taken the National Clinical Licensure Examination (NCLEX) to obtain RN licensure. Consequently, the acting DON was not qualified as an RN, which is a requirement for the position according to the facility's job description. The facility's administrator confirmed that the job description for the DON required the individual to be a registered nurse in good standing with the State Board of Nursing. Despite this requirement, the acting DON was a Licensed Vocational Nurse (LVN) and had been in the position for over six months. The facility's staff roster and daily staffing sheet both listed the individual as the DON without indicating an acting position, further highlighting the discrepancy. This situation had the potential to result in inadequate supervision and management of the facility's residents and nursing staff due to the lack of a qualified RN in the DON role.
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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) |
|---|---|---|---|---|
| Hayward Hills Health Care Center | 0.1 mi | — | 0 | 0 |
| Sage Post Acute | 0.2 mi | — | 0 | 0 |
| Canyon Creek Post-acute | 0.5 mi | — | 2 | 0 |
| Baywood Court Health Center | 0.7 mi | — | 0 | 0 |
| Vista Post Acute | 1.1 mi | — | 0 | 0 |
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