Hayward Gardens Post Acute: Septic Wound Unreported - CA
The nursing home had known about the rash for nearly two months.
Inspectors at Hayward Gardens Post Acute documented the sequence in detail. On April 24, 2025, nurses wrote a change of condition note recording that the resident had rashes in multiple areas and that the resident herself said the rash was spreading. That same note included a line that inspectors would later flag: the resident's family representative had not been notified.
A care plan was opened that same day. It listed the rash on the right flank and between stomach folds and called for staff to monitor the rash for increased spread or signs of infection.
Nobody did.
Inspectors reviewed the treatment administration records for April and May 2025. Across both months, the rash was not monitored for increased spread or signs of infection. Skin conditions were not monitored either. The care plan sat on paper while the resident lay in bed, bedridden, her kidneys failing, her skin going unchecked.
On June 16, 2025, she was transferred to a hospital. The emergency department notes recorded rashes on both breast folds, worse on the left side. The ED nurse told the family what the nursing home had not: the wound was septic.
The family representative told inspectors she had never received a call from the facility about any change in the resident's skin condition. She said she had not been informed that there was a wound under her mother's breast. She learned all of it, she said, from the emergency room.
The Assistant Director of Nursing, interviewed alongside the records in September, confirmed what the documents showed. The family representative had not been notified of the rash to the bilateral breast fold. The rash had not been monitored according to the care plan. The ADON did not dispute either point.
The facility's own policy, revised in February 2021, states that the home promptly notifies the resident, the attending physician, and the resident representative of changes in the resident's medical or mental condition. Prompt notification did not happen. Neither did the monitoring the care plan required.
Inspectors cited the failure under the federal standard requiring that residents receive treatment and care in accordance with professional standards of practice. The level of harm was assessed as minimal harm or potential for actual harm — a designation that reflects where inspectors place the violation on a severity scale, not a conclusion about what the septic wound cost this woman or her family.
The facility's June 2025 assessment, the federally mandated resident assessment recorded just weeks before the hospitalization, had listed no skin problems for this resident. She was noted to be at risk for pressure injuries. She was bedbound. She had end-stage renal disease. The risk factors were documented. The follow-through was not.
Hayward Gardens Post Acute is disputing the citation.
The family representative spent months not knowing. The rash was spreading in April — the resident said so herself, and staff wrote it down. May passed. The care plan's instructions went unfollowed. In June, an ambulance took the resident to a hospital, and a nurse in the emergency department delivered the news that the nursing home had never called to share.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Hayward Gardens Post Acute from 2026-01-02 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 24, 2026 · Our methodology
HAYWARD GARDENS POST ACUTE in HAYWARD, CA was cited for violations during a health inspection on January 2, 2026.
The nursing home had known about the rash for nearly two months.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.