Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around November 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 Sage Post Acute during CMS and state inspections, most recent first.
A resident with impaired mental status eloped from the facility due to inadequate supervision and a faulty exit alarm on the sliding doors in their room. The resident, who used a wheelchair and had a low BIMS score, was found by a concerned citizen and taken to a police station. Maintenance staff did not keep records of alarm checks, and the charge nurse was aware of the resident's elopement risk. The resident's family had previously raised concerns about the sliding doors.
A facility failed to properly document and reconcile narcotic medications, as evidenced by a resident's hydrocodone-acetaminophen administration lacking proper time documentation and another instance of undocumented medication removal. Additionally, narcotic reconciliation counts were inconsistently completed, with multiple instances of missing signatures on count sheets. Staff interviews confirmed the importance of these procedures for accountability and safety.
The facility failed to implement Enhanced Barrier Precautions (EBP) and maintain proper catheter care for three residents with indwelling urinary catheters. Observations revealed catheter drainage bags were consistently found on the floor, contrary to facility policy and CDC guidelines. Staff, including CNAs and LVNs, were unaware of EBP requirements, and the Director of Nursing and Administrator acknowledged the infection control concerns but were not previously aware of the EBP requirements.
The facility failed to accurately code MDS assessments for two residents, one with a suprapubic catheter and another receiving Plavix, an antiplatelet medication. The MDS for the resident with a catheter did not reflect its presence, while the MDS for the resident on Plavix incorrectly indicated the use of an anticoagulant. These errors were acknowledged by the MDS Coordinator, DON, and Administrator, highlighting a lapse in accurate documentation of residents' medical conditions and treatments.
A facility failed to complete a baseline care plan within 48 hours for a resident with complex medical needs, including heart disease and renal failure. The care plan was marked 'In Progress' and lacked completion in key areas such as dietary status and therapy. Interviews with the DON and an LVN confirmed the oversight, acknowledging the care plan should have been completed within the required timeframe.
A facility failed to update care plans for a resident on anticoagulant medication and two residents with indwelling urinary catheters. Despite being on Eliquis, a resident's care plan lacked monitoring for anticoagulant use. Two other residents with catheters had no care plan updates reflecting their catheter use. The deficiency was due to the failure of admitting nurses and staff to update care plans according to facility policies.
Two residents with indwelling urinary catheters were not properly assessed or documented upon admission and readmission to the facility. Observations confirmed the presence of catheters, but there were no physician's orders or documentation in their care plans or medical records. Staff interviews revealed a lack of communication and documentation regarding catheter care, leading to deficiencies in catheter management.
A facility failed to monitor a resident for side effects of the anticoagulant Eliquis, despite policy requirements. The resident, with a history of pulmonary embolism and heart failure, received Eliquis without documented monitoring for complications like bruising or bleeding. Staff interviews confirmed the lack of monitoring, leading to a deficiency in medication management.
The facility exceeded the acceptable medication error rate, with errors affecting two residents. One resident received the wrong type of multivitamin, while another missed doses of metoprolol and Plavix due to unavailability. The LVNs involved failed to administer medications as prescribed and did not notify the physician of missed doses, as expected by the DON and Administrator.
A resident with hypertension did not receive a scheduled dose of metoprolol due to the medication being unavailable. The LVN contacted the pharmacy but did not inform the physician about the missed dose. The MAR and Progress Notes documented the omission, and interviews with staff highlighted the expectation to notify the physician and monitor the resident's condition.
A facility failed to document the administration of PRN pain medication for a resident, resulting in a deficiency. Despite a policy requiring immediate documentation on the MAR, two LVNs administered hydrocodone-acetaminophen without recording it on the MAR. The resident, admitted with hip pain, had an active order for the medication. Interviews confirmed the importance of timely documentation, which was not followed.
The facility did not meet the required minimum space of 80 square feet per resident in six multiple-resident rooms. Despite this, staff reported no issues in providing care, and residents had no complaints about room sizes. The DON was unaware of the specific requirements, while the Administrator acknowledged the importance of meeting them.
Resident Elopement Due to Inadequate Supervision and Faulty Exit Alarm
Penalty
Summary
The facility failed to ensure adequate supervision and safety for a resident with impaired mental status, resulting in the resident's elopement. The resident, who had a BIMS score indicating poorly impaired mental status and used a manual wheelchair, was able to leave the facility unsupervised. The resident was later found and brought to a police station by a concerned citizen. The facility's records indicated that the exit alarm on the sliding doors in the resident's room was loosely connected and not functioning at the time of the elopement. Interviews with facility staff revealed that the maintenance staff did not keep records of scheduled checks or maintenance of the exit door alarms, and the alarm string was found disconnected. The charge nurse on duty was aware of the resident's risk for elopement but was informed by another staff member that the resident was missing. The resident's family member had previously expressed concerns about the sliding doors in the resident's room. The facility's policy on safety and supervision emphasized making the environment as free from accident hazards as possible, yet this was not effectively implemented in this case.
Narcotic Documentation and Reconciliation Deficiencies
Penalty
Summary
The facility failed to ensure proper documentation and reconciliation of narcotic medications, as evidenced by the case of a resident who was admitted with a diagnosis of pain in the left hip. The resident had an active order for hydrocodone-acetaminophen to be administered as needed for pain. However, the facility's records showed discrepancies in the documentation of narcotic administration. Specifically, a Licensed Vocational Nurse (LVN) administered the medication but failed to record the time of administration, and another LVN did not document the removal and administration of a dose until prompted by a surveyor. This lack of documentation was acknowledged by the staff involved and highlighted during interviews with the Director of Nursing and the Administrator, who confirmed that staff should follow proper procedures for signing out narcotics. Additionally, the facility did not consistently complete narcotic reconciliation counts as required by their policy. The Controlled Drugs Count Records for a medication room and medication carts showed multiple instances where either no nurse or only one nurse documented the performance of drug counts during shift changes. Interviews with various staff members, including LVNs, the Infection Control Specialist, and the Pharmacist, revealed that the narcotic count sheets were intended to verify the accuracy of narcotic counts and ensure accountability. However, the presence of blank spaces on these sheets indicated that the counts were not consistently completed or verified, leaving the facility unable to prove that narcotics were accounted for. The Director of Nursing and the Administrator both acknowledged the importance of completing and signing narcotic count sheets to track narcotics and prevent unauthorized use. The failure to properly document and reconcile narcotic medications was a significant deficiency, as it compromised the facility's ability to ensure the safe and accurate administration of controlled substances to residents.
Failure to Implement Enhanced Barrier Precautions and Proper Catheter Care
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) and maintain proper catheter care for three residents with indwelling urinary catheters. Observations revealed that catheter drainage bags for Residents #13, #5, and #50 were consistently found resting on the floor, which is against the facility's policy and CDC guidelines. The facility's policy specifies that catheter drainage bags should be kept off the floor to prevent infection, yet this was not adhered to, posing a potential infection control issue. Resident #13 was observed with a catheter drainage bag on the floor multiple times, and there were no signs indicating the need for EBP. The resident's care plan did not address the presence of an indwelling urinary catheter, and staff, including a Licensed Vocational Nurse (LVN), did not take action to correct the situation. Similarly, Resident #5's catheter drainage bag was found on the floor, and staff only wore gloves during care, without implementing EBP. The resident's care plan and orders did not include directives for EBP, and staff were unaware of the requirement. Resident #50 also had a catheter drainage bag on the floor, and staff did not use appropriate PPE during care. Interviews with staff, including CNAs and LVNs, revealed a lack of awareness and education regarding EBP. The Director of Nursing (DON) and the Administrator acknowledged the infection control concerns but were not previously aware of the EBP requirements. This lack of awareness and implementation of EBP contributed to the deficiency in infection prevention and control.
Inaccurate MDS Assessments for Residents with Catheter and Antiplatelet Medication
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for two residents, leading to discrepancies in their medical records. For one resident with a history of urinary retention and a suprapubic catheter, the MDS was inaccurately coded, failing to reflect the presence of an indwelling urinary catheter. This error was acknowledged by the MDS Coordinator, Director of Nursing (DON), and the Administrator, who all confirmed that the MDS should have been coded to indicate the presence of the catheter. The resident's care plan and order summary clearly documented the use of a suprapubic catheter, yet the MDS assessment did not accurately capture this information. In another case, a resident with a history of cerebral infarction was receiving Plavix, an antiplatelet medication. However, the MDS was incorrectly coded to reflect the use of an anticoagulant instead of an antiplatelet medication. The MDS Coordinator admitted to the error, having mistakenly classified Plavix as an anticoagulant. The Administrator and DON both emphasized the importance of following the RAI manual instructions for accurate MDS coding. These inaccuracies in MDS assessments highlight a failure in the facility's processes to ensure accurate documentation of residents' medical conditions and treatments.
Failure to Complete Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to complete a baseline care plan within 48 hours of admission for a resident, as required by their policy. The policy, revised in December 2016, mandates that a baseline plan of care to meet the resident's immediate needs be developed within 48 hours of admission. The resident in question was admitted on May 12, 2024, with a medical history that included atherosclerotic heart disease, end-stage renal disease, dependence on renal dialysis, chronic pain syndrome, and insomnia. However, the baseline care plan for this resident was marked as 'In Progress' and lacked completion in several critical sections, including dietary/nutritional status, therapy, social services, comments and preferences, plan of care, and necessary signatures. Interviews with facility staff, including the Director of Nursing (DON) and a Licensed Vocational Nurse (LVN), confirmed that the baseline care plan was not completed within the required timeframe. The DON acknowledged that the care plan should have been completed within 48 hours of admission, and the LVN admitted that the staff had missed following up on the completion of the care plan. The facility's Administrator also stated that baseline care plans should be initiated at the time of admission and completed within the specified 48-hour period.
Failure to Update Care Plans for Anticoagulant Use and Urinary Catheters
Penalty
Summary
The facility failed to develop a care plan addressing the use of anticoagulant medications for a resident who was admitted with a history of pulmonary embolism and heart failure. Despite the resident being on Eliquis, an anticoagulant, since admission, the care plan did not include any focus area addressing the use of this medication. Interviews with the LVN and the DON confirmed that the care plan should have included monitoring for signs and symptoms of bruising and bleeding due to the anticoagulant use, but it was not updated accordingly. Additionally, the facility did not develop care plans for two residents with indwelling urinary catheters. One resident was readmitted from the hospital with renal failure and hospice services, and although observed with a catheter, the care plan did not reflect this. The DON confirmed that the catheter should have been included in the care plan upon readmission. Similarly, another resident with severe cognitive impairment was observed multiple times with an indwelling urinary catheter, yet the care plan lacked any mention of it. The MDS Coordinator and the DON acknowledged that the admitting nurse should have updated the care plan to include the catheter. The deficiency in care planning was attributed to the failure of the admitting nurses and other responsible staff to update the care plans to reflect the residents' current medical needs, such as anticoagulant use and the presence of urinary catheters. The facility's policies on anticoagulation and catheter care were not adhered to, resulting in incomplete care plans for the affected residents.
Deficiency in Catheter Care and Documentation
Penalty
Summary
The facility failed to ensure proper assessment and documentation for residents with indwelling urinary catheters, affecting two residents. Resident #50 was admitted and readmitted to the facility without any documentation or physician's orders for an indwelling urinary catheter, despite observations confirming its presence. The resident's care plan and medical records did not reflect the catheter, and staff interviews revealed a lack of communication and documentation regarding the catheter's presence and care requirements. Similarly, Resident #13 was readmitted to the facility with an indwelling urinary catheter, but there were no physician's orders or documentation in the resident's care plan or medical records. Observations confirmed the presence of the catheter, and staff interviews highlighted the absence of necessary orders and documentation to guide catheter care. The facility's policy required ongoing assessment and documentation of catheter use, but this was not followed for the affected residents. Interviews with staff, including CNAs, LVNs, the DON, and the Administrator, revealed a breakdown in communication and documentation processes, leading to the deficiency in catheter care and management.
Failure to Monitor Anticoagulant Side Effects
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications by not monitoring for potential side effects related to the use of a prescribed anticoagulant medication. The facility's policy on anticoagulation therapy required staff and physicians to monitor for complications such as excessive bruising, hematuria, hemoptysis, or other evidence of bleeding. However, the care plan for a resident admitted with a history of pulmonary embolism and heart failure did not include a focus area for monitoring the use of the anticoagulant Eliquis. The resident's medication administration records and progress notes lacked documentation of monitoring for side effects from Eliquis, despite the resident receiving the medication twice daily. Interviews with facility staff, including an LVN and the Director of Nursing, confirmed that monitoring should have been documented on the resident's MAR. The facility's failure to adhere to its anticoagulation monitoring policy resulted in a deficiency related to the resident's medication management.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a rate of 9.38% during a survey. This deficiency affected two residents during medication administration. One resident was given a multivitamin without added minerals, contrary to the prescribed order for a multivitamin with minerals. The Licensed Vocational Nurse (LVN) responsible for this error acknowledged the mistake during an interview, stating she did not realize the discrepancy at the time of administration. Another resident did not receive their prescribed doses of metoprolol tartrate and Plavix because the medications were unavailable. The LVN involved contacted the pharmacy but did not notify the resident's physician about the missed doses, as required. The Director of Nursing (DON) and the facility's Administrator both confirmed that the nurses were expected to administer medications as ordered and to notify physicians of any missed doses. The DON highlighted the potential risk of a hypertensive crisis due to the missed dose of metoprolol.
Failure to Administer Metoprolol Results in Medication Error
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically by not administering metoprolol to a resident with a history of hypertension. The resident was admitted to the facility with an active order for metoprolol tartrate, 100 mg, to be taken twice daily. During a medication administration observation, it was noted that the medication was not available, and the Licensed Vocational Nurse (LVN) did not administer the 9:00 AM dose. The LVN contacted the pharmacy, which required a new order, but did not notify the resident's physician about the missed dose. The Medication Administration Record (MAR) indicated the missed dose, and the Progress Notes confirmed that the pharmacy had not delivered the medication by the afternoon. Interviews with the LVN, the Director of Nursing (DON), and the physician revealed that the nurse should have monitored the resident's blood pressure and heart rate and informed the physician about the missed dose. The DON and the Administrator both stated that the nurse was expected to notify the physician and document the missed medication administration.
Failure to Document PRN Pain Medication Administration
Penalty
Summary
The facility failed to ensure proper documentation of the administration of as-needed (PRN) pain medication for a resident, leading to a deficiency in maintaining accurate medical records. The facility's policy required that the individual administering medication should initial the Medication Administration Record (MAR) immediately after giving each medication. However, for a resident admitted with a diagnosis of pain in the left hip, there was a lack of documentation on the MAR for doses of hydrocodone-acetaminophen administered on two separate occasions. The resident's care plan included instructions to administer analgesics as per physician's orders, and the resident had an active order for hydrocodone-acetaminophen to be given every four hours as needed for pain. The deficiency was identified when the Controlled Drug Record showed that two Licensed Vocational Nurses (LVNs) had signed for administering the medication, but the corresponding entries were missing from the MAR. LVN #6 admitted to failing to sign the MAR after administering the medication and acknowledged the importance of documenting the time of administration. Similarly, LVN #4 confirmed administering the medication but did not document it on the electronic MAR at the time of administration. Interviews with the Director of Nursing and the Administrator confirmed that staff were educated to document immediately after medication administration, highlighting a lapse in following established procedures.
Deficiency in Resident Room Size Requirements
Penalty
Summary
The facility failed to ensure that multiple-resident bedrooms met the required minimum space of 80 square feet per resident. This deficiency was identified in six rooms out of 45, where the space per resident ranged from 72.5 to 76.7 square feet. The facility's policy mandates that double rooms should provide at least 80 square feet per resident, and single rooms should provide at least 100 square feet. Despite the deficiency, there were no negative consequences or safety concerns noted, and residents were able to move freely around their rooms without obstruction from furniture or equipment. Interviews with staff, including CNAs and an LVN, revealed that the room sizes did not hinder their ability to provide care. The Director of Nursing was unaware of the specific room size requirements but expected rooms to be large enough for care provision and resident movement. The Administrator acknowledged the importance of meeting the 80 square feet per resident requirement to ensure adequate space for residents and staff. Despite the deficiency, no residents expressed concerns about their room sizes.
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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 |
| Hayward Gardens Post Acute | 0.2 mi | — | 4 | 0 |
| Canyon Creek Post-acute | 0.3 mi | — | 2 | 0 |
| Baywood Court Health Center | 0.6 mi | — | 0 | 0 |
| Vista Post Acute | 1.1 mi | — | 0 | 0 |
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