Hayward Hills Health Care Center

In the surveyor’s words

From the most serious findings on record at Hayward Hills Health Care Center, in the surveyor’s own words.

• Actual harm, isolatedF689Jul 18, 2024

  Based on observation, interview, and record review, the facility failed to implement measures to safely transfer one of two sampled residents (Resident 1) when a staff transferred Resident 1 from bed to a shower chair using a Hoyer lift (mechanical device that lifts a resident for transfer, the resident will be suspended in the air in a sling while being move from a bed to a chair) without assistance from another staff member. This failure resulted in Resident 1 falling and sustaining multiple injuries: Multiple rib fractures (broken ribs), Trace Right-Sided Pneumothorax (presence of air in the space between the lung and chest wall leading to breathing difficulty and chest pain), Left Femur Peri-Prosthetic Fracture (broken bone around the artificial joint of the left thigh); and caused… […]

• No harm, potential for more than minimal, widespreadF756Aug 16, 2024

  Based on interviews and record reviews the facility failed to ensure the Pharmacy Consultant (PC) provided the Medical Regimen Review (MRR) recommendations and Executive Summary to the facility within the timeframes established in the facility's policies and procedures for four out of four months and the facility did not act on the reports within 30 days for five of 10 sampled residents (Residents 56, 26, 2, 66, and 54). This failure had the potential to result in Residents not receiving therapeutic recommendation on drug therapies. Findings: During a telephone interview on 8/15/24 at 9:19 a.m., with PC and Regional Supervisor (RS), PC stated that PC visits the facility once a month and completes the MRR for the month and submits the report within 48 hours. […]

• No harm, potential for more than minimal, widespreadF908Aug 16, 2024

  Based on observation, interview, and record review, the facility failed to clean dishes in a safe and sanitary method when the dishwasher did not reach the required temperature. This failure had the potential to result in 65 residents being served food on dishes that were not sanitized, which could lead to the spread of disease. Findings: During an observation on 8/13/24 at 10:41 a.m. in the kitchen, the highest temperature reached by the dishwasher was 110 degrees ( ) Fahrenheit (F, a unit to measure temperature). During a second observation on 8/13/24 at 10:44 a.m., the highest temperature reached by the dishwasher was 110 F. During a concurrent observation and interview on 8/13/24 at 11:11 a.m. […]

• No harm, potential for more than minimal, patternF658Jun 11, 2026

  Based on observation, interview and record review, the facility failed to meet professional standards of quality for one of two sampled Residents (Resident 7) when nursing staff did not follow the physician's order for Resident 7's oxygen therapy. This failure had the potential to cause health complications to Resident 7. Findings: During a review of Resident 7's face sheet, undated, indicated Resident 7 was admitted to the facility on [DATE].During a review of Resident 7's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 4/20/26, indicated Resident 7 had a Brief Interview for Mental Status (BIMS- assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 2 out of 15. […]

• No harm, potential for more than minimal, patternF684Jun 11, 2026

  Based on interview and record review, the facility failed to ensure two of two sampled residents (Resident 27 and 80) received treatment and care in accordance with professional standards of practice when:1. Direct Care Staff did not follow physician's orders to assess Resident 27 for bleeding and did not follow up with Resident 27's physician regarding her orders to hold or to restart Eliquis (an anticoagulant medication used to prevent and treat blood clots, and lower stroke risk in patients with atrial fibrillation, an irregular and often very rapid heart rhythm) for a period of over six months. […]