Bay Marina Post Acute

Inspectors wroteBased on interview and record reviews the facility failed to ensure to identify and provide needed care and services that are resident centered, in accordance with the resident's preferences for two of seven sample selected residents (Resident 2 and 7) when licensed staff placed resident 2 and 7 on pureed diets not ordered by the physician. This resulted in unnecessary speech therapy evaluations and distress for residents.

Inspectors wroteBased on interview and record review, the facility's skilled licensed nursing staff did not provide timely dental assistance for one of three residents (Resident 1). Resident 1 complained of oral pain and had red gums and missing teeth; however, staff did not notify the dentist and scheduled a dental consult seven days after the resident's initial complaint of pain. This resulted in worsening dental status and unnecessary discomfort for Resident 1. During a review of Resident 1's document Face Sheet (FS), the FS indicated the facility admitted Resident 1 on 9/13/2025 with multiple medical diagnoses including hemiplegia (paralysis) on his left side due to a stroke. During a review of Resident 1's document Dietary Profile (DP) dated 3/11/2026, the DP indicated Resident 1 had missing or broken teeth. [...]

Inspectors wroteBased on interview and record review, for one of two sampled residents (Resident 1) who were discharged , the facility failed to develop and implement an effective discharge planning process for transition to post-discharge care. This failure resulted in Resident 1 suffering homelessness and had the potential to result in unnecessary re-admission to the hospitalDuring a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility in June 2025 with diagnoses that included cognitive communication deficit (impaired memory and attention affecting communication), personal history of traumatic brain injury (temporary issues with thinking, understanding, movement, and behavior due to an external force), ataxia (poor muscle control affecting movement and balance), and repeated falls. [...]

Inspectors wroteBased on interview and records review, the facility failed to ensure the change of resident's condition was reported and investigated properly for one of three sample selected residents (Resident 1), when Resident 1 was found with new skin discoloration on his face and the cause was not investigated by the facility. The failure to report and investigate a change in a Resident 1's condition could lead to Resident 1 experiencing delayed treatment, pain, and worsening health conditions. A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility with multiple diagnoses including end stage renal disease (the kidneys have lost nearly all their ability to function effectively, typically defined as having less than 10-15% of normal kidney function). A review of Resident 1's Progress Note, dated 3/20/25, indicated . Skin discoloration on his face and hand. [...]

Inspectors wroteBased on observation, interview and record review, for two of two sampled residents who received dialysis (Resident 1 and Resident 2), the facility failed to ensure routine medications were available for administration. This failure had the potential to result in medical complications not limited to elevated phosphorus, cholesterol, and worsening of symptoms. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a safe discharge to one sampled resident (Resident 1) when Resident 1 who had a physician order to be discharged to an assisted living (a type of housing designed that offers caregiver support and assistance with activities of daily living/ADL, including dressing, grooming, showering, moving around, and managing medication) was placed to an independent living housing (designed for people who are still active and require little to no support with the activities of daily living) instead. This deficient practice placed Resident 1 at risk for an unsafe discharge and re-hospitalization. [...]

Inspectors wroteBased on interviews and record reviews the skilled nursing facility did not ensure Residents were free from abuse for one of three sampled residents (Resident 1) when Resident 1 ' s Certified Nursing Assistant stated Resident 1 was Ugly. This resulted in unnecessary emotional distress for Resident 1.

Inspectors wroteBased on interviews and record reviews the Facility did not take the necessary steps to prevent abuse for one of three sampled Residents (Resident 1). Certified Nursing Assistant 1 (CNA 1) verbally abused Resident 1 and was not immediately removed from providing direct patient care. This resulted in the potential for further abuse.

Inspectors wroteBased on interview and record review, for one of two sampled residents (Resident 1), the facility failed to ensure Resident 1 was free from abuse when Family Member (FM) slapped Resident 1 in the face and called Resident 1 derogatory names. This failure resulted in Resident 1's abrasion on the left eyelid. Resident 1 was sent to the Emergency Department (ED) after complaining of left eye pain.

Inspectors wroteBased on interview and record review, for one of two sampled residents (Resident 1), the facility failed to have evidence that an alleged physical abuse was thoroughly investigated and failed to report the result of the investigation to the State Survey Agency within 5 working days of the incident. This failure had the potential to result in the inability to protect residents from further abuse.

Inspectors wroteBased on observation, interview and record review, for one of four sampled residents (Resident 87) reviewed for anticoagulant use, the facility failed to provide treatment and care in accordance with professional standards of care when licensed nurses did not administer medications, enoxaparin sodium (Lovenox, an anticoagulant for DVT [a condition that occurs when a blood clot forms in a vein deep inside a part of the body that could potentially travel to the lungs and cause pulmonary embolism] prophylaxis) and omeprazole oral capsule (Prilosec, an antacid, treats gastro-esophageal reflux disease) as ordered by the physician. This failure had resulted in Resident 87 experiencing heartburn (a burning sensation in the chest or upper abdomen caused by stomach acid backing up into the esophagus) and discomfort and had the potential to result in DVT from not receiving anticoagulant.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide pharmaceutical services which includes procedures that assure the accurate acquiring, receiving, dispensing, and administering of routine and emergency medications to meet the needs of three out of six sampled residents (Resident 12, 16 and 87) and to ensure controlled medication (those with high potential for abuse and addiction) were fully accounted for two out of three sampled residents (Resident 58 and 72) when: 1. Resident 12's Digoxin (medication to treat congestive heart failure [CHF, a condition where the heart muscle is weakened and cannot pump blood effectively]and heart rhythm problems), Furosemide (medication used to treat fluid build-up and swelling caused by CHF, . [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medication error rate was less than 5% when four medication errors out of 26 opportunities were observed during the medication administration for two out of five sampled residents (Resident 12 and 56). 1. Resident 12 did not receive Digoxin (medication to treat congestive heart failure (CHF, a condition where the heart muscle is weakened and cannot pump blood effectively) and heart rhythm problems), Furosemide (medication used to treat fluid build-up and swelling caused by CHF, . [...]

Inspectors wroteBased on observation, staff interview, and record review, the facility failed to store food in accordance with professional standards for safety when: 1. Unlabeled, undated food items were stored in the kitchen refrigerator. 2. A staff drink was stored in the kitchen freezer. 3. Beyond use by date food was stored in the kitchen dry storage. 4. Unlabeled, undated and beyond use by date food items were stored in the resident refrigerator. These failures had the potential for contamination of food resulting in food borne illness for 90 residents who received food from the kitchen.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to follow proper infection control techniques and did not follow their infection control policies and procedures for two of two sampled residents, Resident 6 and Resident 35, when: 1. Nursing staff did not don gloves when handling Resident 6's soiled bed linens and personal clothing. 2. Resident 35's mattress was worn out and soiled with urine and bodily fluids. 3. Staff in the laundry room did not separate clean linens from soiled linens in the laundry room. 4. Staff in the laundry room did not change gloves after loading soiled laundry and before handling clean linens. 5. Staff in the laundry room did not clean and sanitize washing machine's exterior after loading soiled laundry. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to allow two out of 27 Residents (Residents 45 and 70) to exercise their rights to self-determination when they were not provided nutrition in accordance with their preferences. These failures had the potential to result in Residents 45 and 70 feeling upset and disrespected.

Inspectors wroteBased on interview and record review, for one of six sampled residents (Resident 58) who were investigated for advance directives, the facility failed to ensure Resident 58 was afforded the right to formulate an advanced directive (a written instruction, such as a living will or durable power of attorney for health care, recognized under State law (whether statutory or as recognized by the courts of the State), relating to the provision of health care when the individual is incapacitated). This failure had the potential to result in Resident 58's wishes for life-sustaining treatment not documented and respected.

Inspectors wroteBased on interview and record review, the facility failed to follow its policy and procedure to immediately report alleged abuse allegations to the California Department of Public Health (CDPH) and the Ombudsman within two hours for one of 27 sampled residents (Resident 92), when Resident 92's sister alleged a Registered Nurse (RN) called Resident 92 stupid. These failures had the potential to cause a delay in investigations and affect physical and psychological well-being of residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide services to meet professional standards of quality for two of two sampled residents (Resident 12 and 37) when: 1. Licensed Vocational Nurse (LVN) 1 was not knowledgeable of the correct indication, dosage, and administration procedure of Resident 12's rivastigmine (medication used to treat mild, moderate, and severe dementia (memory loss and mental changes) associated with Alzheimer's disease (a brain condition that slowly damages your memory, thinking, learning and organizing skills) transdermal (the application of a medicine or drug through the skin, typically by using an adhesive patch, so that it is absorbed slowly into the body) patch. These failures resulted in Resident 12 to receive inadequate dosage of rivastigmine and not according to manufacturer's specification. 2. [...]

Inspectors wroteBased on observation, interviews, and record reviews, facility failed to provide assistant for one out of two sampled residents(Resident 193), when Resident 193 who is dependent on staff was not assisted with setting up his meal tray and given required assistant with eating during lunch period. This failure resulted in Resident 193 not being able to eat and enjoy his meals at his own desire time, had his meal cold, challenges eating with his left non-dominant hand, and potential to not maintain good nutritional status and poor quality of care.

Inspectors wroteBased on observation, interview and record review, for two of four sampled residents (Resident 8 and Resident 9) who were reviewed for range of motion/mobility needs, the facility failed to provide appropriate treatment and services to prevent further decrease in range of motion when Restorative Nursing Assistant (RNA) services ( RNA program, focuses on nursing interventions that help residents in long-term care maintain or regain their ability to perform activities of daily living (ADLs) and improve their overall well-being) was not provided as indicated in the comprehensive care plan. This failure had the potential to result in further decline in range of motion.

Inspectors wroteBased on observation, interview and record review, for two of 27 sampled residents (Resident 58 and Resident 90), the facility failed to ensure an environment that is free of accident hazards as possible, and that each resident receives adequate supervision when: 1. Resident 58's bed wheels did not lock. This failure had the potential to result in preventable falls. 2. Resident 90 was not supervised while out smoking. This failure had resulted in Resident 90 leaving the facility premises undetected. Resident 90's whereabouts remain unknown.

Inspectors wroteBased on observation, interview and record review, for one of eight sampled residents (Resident 87) reviewed for nutrition and hydration concerns, the facility failed to ensure Resident 87 maintained proper hydration status when fluid restriction was not followed as ordered. This failure had the potential to result in fluid retention and fluid overload.

Inspectors wroteBased on observations, interviews, record reviews for one of two residents( Resident 83), facility failed to follow their policy and procedure when nursing staff infused Resident's 83's Jevity tube feed at the correct rate and dose as per the Physician's order, stopped Resident 83's Percutaneous endoscopic gastrostomy (PEG[a tube that is passed into a patient's stomach sugically through the abdominal wall, most commonly to provide a means of feeding when oral intake is not adequate]) tube feedings without flushing the PEG immediately after, and left the tubing connected to Resident 83 for up to one hour after the infusion was completed. This failure has the potential for Resident 83's PEG tube to clog up, complications with PEG tube, infection, possible tube replacement, and hospitalization.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were free from significant medication error for one of five sampled residents (Resident 12) during medication administration observation when: 1. Resident 12 did not receive Digoxin (medication to treat congestive heart failure (CHF, a condition where the heart muscle is weakened and cannot pump blood effectively) and heart rhythm problems) and Furosemide (medication used to treat fluid build-up and swelling caused by CHF and treats high blood pressure) as ordered by the physician. 2. Resident 12's physician was not informed of the significant medication error. These failures resulted in Resident 12 to experience significant medication error from the omitted (a dose of medication that is ordered but not given) dose of digoxin and furosemide.

Inspectors wroteBased on observation, interview and record review, for one of six sampled residents (Resident 87), the facility failed to provide menus that meet residents' nutritional needs when Resident 87 was not provided double portion as ordered. This failure had the potential to result in weight loss.

Inspectors wroteBased on interview and record review, for one of eight residents (Resident 20) reviewed for concerns regarding food, the facility failed to provide nourishing bedtime snacks to Resident 20, a diabetic, consistent with plan of care and resident's request. This failure had the potential to result in hypoglycemia (abnormally low blood sugar level).

Inspectors wroteBased on interview and record review, the facility failed to operate and provide services in compliance with State regulations when an unusual occurrence of a successful elopement by a resident was not reported to the State Agency. This failure had the potential to result in the lack of oversight for resident safety.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide documentation for pneumococcal and influenza immunization screening (education, offered, and refusal of vaccine) for three of five sampled residents, Resident 14, Resident 67, and Resident 52. This failure has the potential for Resident 14, Resident 67, and Resident 52 to have infection, the spread of infection among other residents, hospitalization, and possibly death.

Inspectors wroteBased on interview and record review, the facility failed to develop and maintain an effective training program for all new and existing staff consistent with their expected roles based on the facility assessment when Licensed Vocational Nurse (LVN) 3 did not have annual competency training and two of three Certified Nursing Assistants (CNAs) did not have dementia training since hire date. This failure had the potential to result in providing poor quality and unsafe resident care.

Inspectors wroteBased on interview and record review, the facility's failed to ensure their skilled nursing licensed staff provided care based on professional standards for one of three sampled residents (Resident 1) when licensed nurse did not immediatelly assess and notify the doctor following Resident 1's fall. This failure resulted in unnecessary pain and a delay in treatment for Resident 1's fractured hip.

Inspectors wroteBased on observation, interview, and record review, the facility failed to allow two of four residents (Resident 1 and Resident 2) to exercise their rights to self-determination when they were not provided nutrition in accordance with their preferences. These failures had the potential to result in Residents 1 and 2 feeling upset and disrespected.

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat one of four sampled residents (Resident 1) with respect and dignity when the Rehabilitation Coordinator (RC) informed Resident 1 he was being kicked out from the facility. This failure resulted in Resident 1 feeling upset and disrespected.

Inspectors wroteBased on interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) received Gabapentin (a medication used to treat nerve pain) as ordered by their physician. This failure had the potential to cause Resident 1 unnecessary pain.

Inspectors wroteBased on interview and record review, the facility failed to ensure that one of three sampled residents (Resident 2) was free from physical abuse when Resident 1 threw a flower vase to her roommate Resident 2. This failure resulted in Resident 2 having a wound in her lip and transfer to an acute care hospital for treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored and prepared in clean and temperature-controlled environment, within standards for safety when: 1. Walk-in fridge temperature range was 40-48 degrees Fahrenheit (ºF), 2. Beverages not labeled or were being stored in temperatures above 40 ºF, 3. Four packages of ground beef where thawing in walk in cooler, not dated, with no thaw log, 4. Temperature of kitchen ranged 85 to 98 ºF and temporary portable air conditioner (AC) unit, placed in center of kitchen, was not cooling environment, and 5. Portable kitchen AC, placed in center of kitchen, had a grill covered in lint/dust/dirt and had not been cleaned in over a month. These failures had the potential to result in contamination of food leading to food borne illness, for 90 residents who resided in the facility.

Inspectors wroteBased on interview and record review, the facility failed to provide written notification before a room change to Resident 1 when the resident was moved to another room without a written notification of the reason of the move. This failure violated the right of Resident 1 to receive a written notice explaining the reason for the move before the room change.

Inspectors wroteBased on interview, and record review, the facility failed to ensure one of one sampled resident (Resident 1) was allowed to return to the facility after admission to the Acute Care Hospital 1 (ACH 1). This failure had the potential for Resident 1 to experience psychosocial distress regarding not being able to return to the facility.

Inspectors wroteBased on interview and record review, the facility failed to notify (Resident 1) Physician and representative of a significant change in Resident 1's health condition of one out of two sampled residents after Resident 1 exhibited signs of difficult breathing. This failure to report significant change in Resident 1's health condition may result in delay of treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that two of three sampled residents (Resident 1 and Resident 2) were provided foot care and treatment. Resident 1 and Resident 2 had dark brown colored long, curved, thick toenails on both feet. Resident 1 and Resident 2 did not receive podiatry services at least four months since their admission to the facility in 10/2023. This failure resulted in Resident 1 not being able to wear socks, unable to stand or walk due to discomfort from her toenails. This failure also resulted in Resident 2 experiencing discomfort from linen/sheets and blanket touching her long toenails which made Resident 2 feel depressed and uncared for, sad and uncomfortable.

Inspectors wroteBased on interview and record review, the facility failed to report the allegation of sexual abuse of 8/26/23 for one Resident (Resident 1) to the Adult Protective services, the local Ombudsman and California Department of Public Health (CDPH); and to the responsible party (RP) of Resident 1. The facility also failed to report the allegation of sexual abuse for Resident 1 within two hours to CDPH. The facility failed to report the results of all investigations of the allegations of sexual abuse for Resident 1 to California Department of Public Health within five working days. These failures could have resulted in further potential abuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure a safe environment for one resident (Resident 1) while the investigation of an alleged sexual abuse was in progress when Resident 2 was found in Resident 1's room on 9/1/23 at 4:30 a.m. There was no evidence that the facility thoroughly investigated first alleged sexual incident that occurred on 8/26/23 as there were no investigation records provided. These failures had the potential to have resulted in a further potential abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that adequate call light system was provided for five out of 19 sampled residents (Resident 1, 8, 28, 52, and 59) when: 1. Resident 1, 28, 52 and 59's call light was not within reach. 2. Resident 1's call light system was not functioning. 3. Resident 8 did not have a call light. This failure resulted in Resident 1, 8, 28, 52 and 59 not having direct access when seeking assistance from the staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled resident (Resident 31), was shaved in accordance with their preferences. This failure had the potential to result in Resident 31 feeling disrespected and upset.

Inspectors wroteBased on interviews and record reviews, it is evident that the facility has not successfully secured the services of a licensed pharmacist who can provide comprehensive consultation encompassing all facets of pharmacy services. This deficiency is notably reflected in the consistent occurrence of high medication error rates, surpassing the acceptable threshold of 5% during monthly medication passes. Additionally, no discernible plan has been established to rectify and reduce these concerning medication error rates.

Inspectors wroteBased on interview and record review, the facility failed to ensure that one of 19 sampled residents (Resident 36) drug regimen was free of unnecessary drugs when Resident 36 had a duplicate order for Aspirin (ASA-a non-steroidal anti-inflammatory medicine that is also used in the prevention of strokes.) This deficient practice resulted to Resident 36 receiving twice the prescribed dose of ASA and had the potential to put Resident 36 at increased risk for bleeding.

Inspectors wroteBased on the data gathered from observations, interviews, and record reviews, it was determined that the facility fell short of maintaining a medication error rate below 5%. Within the medication pass process, a total of three medication errors were witnessed out of twenty-five opportunities, resulting in a notable error rate of 12%.

Inspectors wroteBased on observations and interviews, it is evident that the facility fell short in ensuring the proper storage of refrigerated medications. This issue came to light when a malfunctioning refrigerator thermometer was discovered within the medication refrigerator.

Inspectors wroteBased on observation, interview, and record review, for one of 22 sampled residents (Resident 40), the facility failed to develop a care plan for the use of a hand mitt (soft fiber-filled mitten with tie wrist closure are indicated for patients who are prone to self-injury or who disrupt medical treatment). This failure had the potential to cause Resident 40 a decline in the physical functioning of her left hand or skin breakdown. Findings. A record review of Resident 40's admission Record indicated the resident was admitted to the facility with multiple diagnoses, including aphasia (loss of the ability to understand or express speech, caused by brain damage), and Non-Alzheimer's Dementia (impaired judgement. [...]

Inspectors wroteBased on observation, interview, and record review, the skilled nursing facility did not provide the necessary care for three of 22 sampled residents (Residents 5, 27 and 279). Resident 5 complained of shortness of breath which was not addressed. Patient 27's bed was not elevated to the prescribed level while being administered liquid medication into his Gastrostomy Tube (G Tube), a tube surgically placed into the abdomen to administer liquid food or medication), and Resident 279 complained of pain which was not treated in a timely manner. These failures resulted in unnecessary pain and difficulty breathing for Resident 5, delayed pain management for Resident 279, and the potential for aspiration (fluid into the lungs) for Resident 27.

Inspectors wroteBased on interview and record review, the facility failed to implement the Performance Evaluation policy and procedure when the Director of Staff Development (DSD) did not conduct the following: 1. A 90-day post probationary period performance evaluations for one of three Licensed Vocational Nurses (LVN 1) and, 2. An annual performance evaluation for one of two Registered Nurses (RN 1). This failure did not ensure the employees competency and skills were met to provide safe care.

Inspectors wroteBased on interview and record review, the facility failed to conduct a Certified Nursing Assistant (CNA) annual competency check for one (CNA 1) of one sampled employee. CNA 1 did not have the annual competency checks or complete a 12 hour/year in-service training as required. This failure did not ensure CNA 1 had the necessary skills and training needed to provide safe resident care.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure the medication for one (Resident 230) of 25 sampled residents was administered correctly and as prescribed. The nursing staff administered Resident 230's oral inhaler (medication used to improve breathing) without proper instructions. This failure resulted in Resident 230 not receiving the full dose and effectiveness of her inhaled respiratory medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the policy and procedure for infection control when nursing staff failed to perform hand hygiene between glove changes for one (Resident 78) of 22 sampled residents. This failure increased the potential for the transfer of germs and infection.