F 0693
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and
provide appropriate care for a resident with a feeding tube.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview, and record review, the facility failed to develop new interventions to address the prevention of
displacement and clogging of one of one sampled resident's (Resident 1) nasogastric tube (NGT, a tube
that is inserted through the nose going down into the stomach) when Resident 1's NGT was displaced or
clogged five times between January to July 2024.
This deficient practice resulted in five transfers to the acute care hospital emergency department for NGT
reinsertion for Resident 1. This also had the potential of making Resident 1 feel discomfort and develop
infections.
Findings:
Review of the admission Record, indicated, Resident 1 was admitted to the facility on [DATE] with
diagnoses that included cerebrovascular disease (an interruption in the flow of blood to cells in the brain),
dysphagia (difficulty swallowing) and hemiplegia (paralysis that affects only one side of your body).
Review of Resident 1's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated
7/19/24 under Section C, indicated Resident 1's short- and long-term memory was impaired, and had
moderately impaired decision-making capacity (decisions poor, cues/supervision required).
Review of Resident 1's Physician's Orders (PO), dated 8/9/24, the PO indicated an active diet order of NPO
(nothing by mouth) dated 11/25/22 and an order of Glucerna (liquid food/nutrition) at a rate of 70 milliliters
(ml., a form of measurement) per hour for 16 hours a day thru NGT.
Review of Resident 1's Physical Therapy Evaluation and Treatment, dated 7/23/24, indicated the Resident 1
was able to move her left upper extremity (the region of the body that includes the left arm, forearm, left
wrist, and left hand).
Review of Resident 1's Situation, Background, Assessment, and Recommendation (SBAR, is a structured
communication framework that can help teams share information about a change in the condition of a
resident) notes dated 1/15/24, 1/27/24, 3/9/24 and 7/31/24, the SBAR indicated Resident 1 ' s NGT was
dislodged or was pulled out. The SBAR indicated Resident 1 was sent to the hospital ' s emergency
department on 1/15/24, 1/27/24, 3/9/24, and 7/31/24 for NGT reinsertion.
Review of Resident 1's SBARs dated 4/18/24 and 4/22/24 indicated Resident 1 ' s NGT was clogged.
SBAR indicated Resident 1 was sent to the emergency department on 4/18/24.
(continued on next page)
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
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
555398
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
555398
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/16/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Hayward Post Acute
25919 Gading Road
Hayward, CA 94544
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0693
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Review of Resident 1's PO dated 8/9/24, the PO indicated an order to transfer Resident 1 to the emergency
department for the replacement of NGT on 1/15/24, 1/27/24, 3/9/24, 4/18/24 and 7/31/24 for NGT
reinsertion.
During an interview with the Licensed Vocational Nurse (LVN) 1, on 8/16/24 at 1:18 p.m. , acknowledged
updating and revising the care plan to add new interventions to prevent dislodgement and clogging of NGT
and could have prevented some of Resident 1 ' s transfer to the emergency department for NGT
reinsertion. LVN further stated staff monitored Resident 1's NGT every 2 hours but was unable to provide
documentation.
During a concurrent interview and review of Resident 1's nutritional care plan dated with the Director of
Nursing (DON) and Assistant Director of Nursing (ADON) on 8/8/24 at 2:17 p.m., DON and ADON were not
able to find a care plan revision and new interventions to address how to prevent the clogging and
dislodgement of NGT after 1/15/24. DON stated the purpose of revising the care plan was to change the
interventions because the previous intervention did not work.
Review of facility's policy and procedure, titled care plan comprehensive, dated August 2021 indicated, . the
interdisciplinary team is responsible for evaluation and updating of care plans: a. When there has been a
significant change in the residence condition . c. When the resident has been readmitted to the facility from
a hospital stay and d. At least quarterly .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555398
If continuation sheet
Page 2 of 2
