Hayward Gardens Post Acute
HAYWARD GARDENS POST ACUTE in HAYWARD, CA — inspection on April 30, 2026.
Found 3 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
medical appropriateness of potential residents.
Once a resident has been approved for admission,
a record review of facility staff sign in sheet titled, Nursing Staffing Assignment and Sign-in Sheet,
DHPPD, dated 1/17/25, 3/28/25, 5/3/25 and 7/4/25, the staff sign-in sheet indicated RNS/[DON] had signed as the Nursing Supervisor for all four dates.
The sign-in sheets dated 1/17/25, 5/3/25 and 7/4/25 indicated ADON was listed as the Director of Nursing.
The sign in sheet, dated 3/28/25, indicated ADON and RNS/[DON] were the Director of Nursing with RNS/[DON]'s name was handwritten on the sheet compared to typed names for other staff.
The facility staff ratio sheets dated 1/17/25 and 3/28/25, indicated there was both a Supervisor nurse (RN) and DON working on those dates.
The facility staff ratio sheets dated 5/3/25 and 7/4/25, indicated a Supervisor nurse (RN) working, but no DON was working on those dates.During a concurrent interview and record review on 8/6/25, at 2:11 p.m. with OA, RNS/[DON]'s human resources (HR) file titled View Worker [RNS/[DON]], dated 8/6/25, was reviewed. OA stated this was the current HR file for RNS/[DON] The HR file indicated ADON was the manager of RNS/[DON] and did not indicate RNS/[DON] was the facility Director of Nursing.
The file indicated a management structure listing ADON as the facility's Director of Nursing throughout the file.During an observation on 8/6/25, at 2:13 p.m., RNS/[DON] was in the Director of Nursing's office, during a general review of Resident 1's medical record, RNS/[DON] did not know how to view or print copies of Resident 1's past progress notes and care plans. RNS/[DON] needed to ask for assistance to find the information.
During an interview on 8/6/25, at 2:49 p.m., with RNS/[DON], an inquiry was made into RNS/[DON]'s function as the Director of Nursing. RNS/[DON] was unable to answer questions about the facility process of creating a quality assurance performance improvement (QAPI) plan and did not know of any current QAPI projects. RNS/[DON] was unable to describe what a QAPI plan was. RNS/[DON] was unable to describe AM's process for screening resident's appropriateness for the facility, and stated they only learned about resident after their records appear on the electronic medical record.During a phone interview on 8/6/26, at 7:44 p.m. ADON was on the phone with RNS/[DON] coaching RNS/[DON] to remain calm. ADON stated RNS/[DON] recalled having an interdisciplinary team (IDT) meeting regarding Resident 1's suicide attempt but did not write down or recall the exact date and did not recall details about the meeting. RNS/[DON] stated the IDT meeting might have been on 5/5/25 or 5/6/25 with Medical Doctor 1(MD1).During a phone interview on 8/6/26 at 7:46 p.m. with MD 1 and with ADON in the room, MD 1 stated there was no IDT meeting during week following Resident 1's suicide attempt.During a record review of facility Quality Assurance and Performance improvement (QAPI) meeting sign in sheet titled, Weekly IDT Meeting Sign Sheet Topic: QUAPI [DATE], dated 3/11/25 and Weekly IDT Meeting Sign Sheet Topic: QAPI May, dated 6/10/25, the QAPI sign in sheets indicated RNS/[DON] was not present for both meeting.
Both sheets indicated ADON was present for the QAPI meeting.During record review of facility policy and procedure (P&P) titled, Quality Assurance and Performance Improvement Program - Governance and Leadership, dated 3/2020, the P&P indicated the QAPI committee include the director of nursing services.During a record review of ADON's HR file titled, ADON: ADON, dated 8/6/25, the file indicated ADON was hired as Asst.
Director of Nursing (RN)-S.
The HR file indicated ADON had received discretionary monthly payments titled, DON monthly bonus from 11/2024 to 7/2025.During a phone interview on 8/11/25, at 8/11/25, at 1:49 p.m. with Administrator (ADM), the ADM stated they had hired and trained RNS/[DON] as the Director of Nursing on 12/24 but did not have any supporting documentation.During a record review of an email sent by ADM, dated 8/12/25, the email indicated they did not have records of RNS/[DON]'s training or job description as the DON and would be backdating documents when RNS/[DON] returned from vacation.During a phone interview on 8/21/25 at 11:11 a.m. with the Ombudsman (OM), the OM stated the ADON had introduced themselves as the DON and did not recall RNS/[DON] as the DON.
055434 04/30/2026
Hayward Gardens Post Acute 1628 B Street Hayward, CA 94541
inconsolably. Resident 1 was unable to answer questions verbally because of the crying and could
device in the room.
When asked if they still had thoughts of suicide, Resident 1 nodded and began to
in the room.
After Resident 1 stopped crying, Resident 1 stated they were not sent out for further evaluation, and the facility did not provide any follow up to the suicide attempt. Resident 1 stated they still wanted to get help and talk about the suicide attempt.During a concurrent interview and record review on 8/6/25, at 1:00 p.m., RNS/[DON] stated they were the Director of Nursing.
RNS/[DON] stated Resident 1's medical record did not have a care plan, change in condition documentation, interdisciplinary team (IDT) meeting or specific interventions ordered to address the 5/3/25 suicide ideation. RNS/[DON] stated as Director of Nursing, they expected staff to follow policy and procedure for suicide attempts.
During an interview on 8/6/25, at 3:00 p.m., with Medical Doctor (MD 1), MD stated they were notified of Resident 1's suicidal ideation twice during Resident 1's admission, once on 5/2/25 and once in June, but did not recall being informed of the suicide attempt. MD 1 stated they received one notification in May 2025 and one notification in June 2025. MD 1 stated they were not part of any IDT meeting regarding Resident 1's suicide attempt but expected staff to remove the strangulation implement and for Resident 1 to have a psychiatric consult.During an interview and record review on 8/6/25, at 7:30 p.m. with the Assistant Director of Nursing (ADON), Resident 1's medical record was reviewed. the ADON stated they were not previously informed of Resident 1's suicide attempt, did not have an IDT meeting about Resident 1's suicide attempt and did not have a care plan regarding Resident 1's suicide attempt.
During an interview on 10/30/25, at 11:45 a.m. with Medical Consultant (MC), MC stated suicide attempts were psychiatric emergencies similar to a heart attack and would expect staff to provide immediate treatment and evaluation.
Evaluation would include the provider and law enforcement to determine if there is danger to the resident.During a review of facility policy and procedure (P&P) titled, Response to Attempted Suicide and Suicide Attempts in Progress, dated 1/2025, the P&P indicated in response to suicide attempts staff must respond promptly, follow established procedures, and notify appropriate personnel, including the resident's physician, legal representative.and emergency service.
The P&P further indicated in response to a suicide attempt in progress staff dial 911 immediately and notify them of a psychiatric emergency in progress.notify the charge nurse and/or the Director of Nursing (DON) at once.arrange for a psychiatric or psychological evaluation as soon as possible.follow provider recommendations for treatment or transfer to a psychiatric facility.update the resident's care plan to reflect suicide risk and prevention measures.
Include behavioral management strategies and therapeutic interventions.Conduct a debriefing session with all staff involved.
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Hayward Gardens Post Acute 1628 B Street Hayward, CA 94541
dispensing and disposition of controlled substances includes the following: a.
Records of personnel
discontinued controlled substances are kept with the unused supply until it is destroyed or disposed
Discarding and Destroying Medications (November 2022), showed References, OBRA Regulatory Reference Numbers, S483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.