Hayward Gardens Post Acute

emotional distress and Resident 1's representative their right to be informed.

During a review of Resident 1's Minimum Data Set (MDS- a federally mandated resident assessment and care guide tool), dated 6/5/25, the MDS indicated Resident 1 had no skin problems but was at risk of developing pressure ulcers/injuries. Resident 1 was confined to bed and diagnoses included End-Stage Renal Disease (a condition in which the kidneys lose the ability to remove waste and balance fluids).During an interview on 7/28/25, at 11:10 a.m., with Resident 1's Family Member/representative (FM1), FM1 stated the facility did not notify FM1 of changes in Resident 1's skin condition. FM1 stated the facility did not inform FM1 that Resident 1 had a wound under her breast. FM1 stated that when Resident 1 was transferred to the hospital, FM1 stated the Emergency Department (ED) nurse informed FM1 that Resident 1 had a wound under her breast that was septic.During a review of Resident 1's change of condition note, dated 4/24/2025, the change of condition note indicated Resident 1 had rashes in multiple areas and Resident 1 had stated the rash was spreading.

The change of condition note also indicated Resident 1's representative was not notified.During a review of Resident 1's care plan, initiated 4/24/25, the care plan indicated Resident 1 had a rash on the right flank and between stomach folds; interventions included to monitor Resident 1's rash for increased spread or signs of infection.During a review of Resident 1's Treatment Administration Record (TAR), dated 4/1/25 to 4/30/25, and 5/1/25 to 5/31/25, the TARs indicated Resident 1's rash was not monitored for increase spread or signs of infection and skin conditions were also not monitored.During a review of Resident 1's ED notes, dated 6/16/25, the ED notes indicated Resident 1 had rashes noted to bilateral breast folds, more so on the left breast fold.

During a concurrent interview and record review on 9/23/25, at 11:15 a.m., with the Assistant Director of Nursing (ADON), Resident 1's change of condition note and care plan, dated 4/24/25, and Resident 1's TARs dated 4/1/25 to 4/30/25, and 5/1/25 to 5/31/25 were reviewed.

The change of condition note indicated Resident 1's representative was not notified of rash to breast. TARs indicated Resident 1's rash noted to bilateral breast fold were not monitored according to the care plan. ADON stated Resident 1's representative (FM1) was not notified of Resident 1's rash to bilateral breast fold and Resident 1's rash was not monitored.During a review of the facility's policy and procedure (P&P) titled, Change in Resident's Condition or Status, revised February 2021, the P&P indicated, Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.).

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE