Bay Vista Healthcare & Wellness Centre, LP

Inspectors wroteBased on interview and record review, the facility failed to ensure its Payroll Based Journal (a mandated reporting system used by the Centers for Medicare & Medicaid Services (CMS) to collect auditable employee-level staffing data from long-term care facilities) was submitted for the first fiscal year quarter. This deficient practice resulted in the facility's failure to provide required information regarding staffing levels necessary to ensure the provision of safe and comprehensive care for all residents in accordance with federal regulations.

Inspectors wroteBased on interview and record review, the facility failed to ensure three of 12 sampled residents (Resident 5, 30 and 46) had completed Advance Directives ([AD]-written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) correctly in the medical records when:a. Failing to ensure Resident 5 had an AD acknowledgement form.b. Failing to ensure Resident 30 had an AD acknowledgement form.c. Failing to ensure Resident 46 had an advance directive acknowledgement form. These failures had the potential to result in care being provided that was inconsistent with the residents' wishes and could compromise the residents' rights to make decisions regarding their medical care during emergencies, end of life, and changes in condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure to store and handle food in a sanitary manner to prevent growth of microorganisms that could cause food borne illness (food poisoning: any illness resulting from the food spoilage of contaminated food, pathogenic bacteria, viruses, or parasites that contaminate food, as well as toxins) for 61 out of the 70 residents in the facility by failing to ensure: 1. There were no pests in the storage room.2. The dry storage room temperature was not above the appropriate range of 50 Fahrenheit ( F, temperature scale) - 70 F 3. Frozen food items were dated and ensure and accurately labeled.4. Food items in the residents' refrigerator were dated, had resident identifiers, and a log of when the refrigerator was cleaned. 5. The kitchen staff performed proper hand hygiene in-between tasks. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to:Ensure the padded bed side rails that were wrapped with porous foam were effectively disinfected for two of six sampled residents (Resident 1 and Resident 50). Complete the Infection Screening Evaluation form for one of five sampled residents (Resident 57), who was on the facility's Infection Prevention Surveillance Program for [DATE]. These failures had the potential to increase the risk of cross-contamination (the transfer of bacteria, viruses, microorganisms or other harmful substances from one surface to another through improper or unsanitary equipment, procedures, or products) and spreading infection for Resident 1 and Resident 50, and negatively impact the treatment for Resident 57.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide evidence that their ice machine was being serviced routinely to be maintained in a safe operating condition. This failure had the potential to result in a widespread foodborne illness with the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one of one sampled resident (Resident 5) was provided the opportunity to eat her meals at the same time as other residents during lunch at the dining room. This failure had the potential to diminish the resident's dignity, promote social isolation during mealtime, and result in an unsatisfactory dining experience.

Inspectors wroteBased on observation,interview and record review, the facility failed to ensure appropriate skin care plan for Resident 16 with dermatitis (inflammation of the skin, commonly causing red, itchy, and swollen skin) to address the resident's skin care needs for one of 1 sampled resident (Resident 16). This failure had the potential to result in unidentified care and delayed medical intervention.

Inspectors wroteBased on interview and record review, the facility failed to ensure Resident 4 received appropriate care when staff did not recognize and respond to:a) Resident 4's multiple episodes of loose stools while receiving Lactulose (a prescription laxative used to treat chronic constipation), and a physician's order to hold the medication for loose stools, for one of one sampled residents (Resident 4).b) Resident 3's change in condition following the initiation of anticoagulant therapy, without initiating a Change of Condition (COC), for one of one sampled residents (Resident 3). These failures have the potential to result in inconsistent care delivery, breakdowns in communication of resident specific interventions among interdisciplinary staff, unmet resident needs, and a decline in physical or psychosocial well being, ultimately reducing the quality of care.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two of five sampled residents selected for unnecessary medications (Resident 3 and Resident 46) were free from the use of unnecessary medications by:Failing to monitor and document Resident 3 who was receiving anticoagulant therapy (blood thinners to prevent harmful blood clots from forming or getting larger). Failing to provide an actual indication for the continued use of Ativan (a psychotropic [chemical substance that alters brain function that affects mood and behavior] medication used to treat anxiety) for Resident 46. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure Medical Director or designee attended the Quality Assessment and Assurance Committee (QAA committee, a group of people within an organization who are responsible for reviewing identifying and addressing quality issues) meeting held on 6/26/2026 as required QAA committee meetings. This failure had the potential to adversely affect the facility's quality assessment and performance improvement process by limiting clinical oversight and guidance.

Inspectors wroteBased on observation, interview and record review, the facility failed to offer the influenza (a highly contagious viral infection that attacks the nose, throat, and lungs) and pneumococcal (an illness caused by the Streptococcus bacteria [a common bacteria on the nose and throat] immunizations (the process of making your body immune to a specific disease) at the time of admission, for one of five sampled residents (Resident 56). This failure had the potential to result in the resident contracting influenza or pneumococcal and developing a life-threatening infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) whose Responsible Party (RP) 1 verbalized a complaint to facility staff, was informed of and helped in completing a Grievance/Complaint Investigation Report. This failure resulted in Resident 1 and RP 1 not receiving timely or formal communication regarding the outcome or resolution of the complaint, which led to distrust toward the facility. This failure had the potential to delay necessary care and services to Resident 1 and could negatively impact Resident 1's mental health and emotional well being.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), who had recommendations to have referrals and/or consultations with the cardiologist (medical doctor specializing in diseases of the heart) and neurologist (medical doctor specializing in diseases of the brain, spinal cord, nerves and muscles), were implemented. These failures resulted in Resident 1's referrals being delayed for more than nine months. These failures also had the potential to delay necessary specialty assessments, interrupted continuity of care, and increased the risk that changes in Resident 1's medical condition would go unrecognized which could affect Resident 1's health, safety, and overall, well being.

Inspectors wroteBased on interview and record review, the facility failed to ensure Restorative Nurse Assistant (RNA 1) accurately documented for one of three sampled residents (Resident 1), indicating Resident 1 received RNA services when there was no order and when those services were not provided. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure a Registered nurse (RN) worked eight consecutive hours a day seven days a week on 2/1/25, 2/2/25, 2/8/25, 2/9/25, 2/15/25, 2/23/25, 3/9/25 and 3/23/25. This failure had the potential to affect the residents' quality of care and not be able to provide advanced care activities such as resident assessments, developing and evaluating care plans, and consulting with physicians.

Inspectors wrote2. During a review of Resident 38's admission Record, the admission Record indicated Resident 38 was initially admitted on [DATE] and was readmitted on [DATE] to the facility with diagnoses including paranoid schizophrenia( a pattern of behavior where a person feels distrustful and suspicious of other people and acts accordingly), schizoaffective disorder bipolar type(a mental illness that can affect thoughts, mood, and behavior) depression( a serious mental health condition characterized by persistent sadness and a loss of interest in activities, impacting how a person feels, thinks and handles daily tasks), and anxiety disorder (intense, excessive, and persistent worry and fear about everyday situations). During a review of Resident 38's History and Physical (H&P) dated 2/8/2025, the H&P indicated Resident 38 can make needs known but cannot make medical decisions. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe and sanitary food storage and preparation practices when the facility failed to: 1. Ensure an open bag of frozen salisbury steak was stored in a sealed plastic bag in the freezer. 2. Ensure an open box of hot rice cereal was dated, labeled and stored in a sealed bag or container. These failures had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to food borne illness (illness caused by food contaminated with bacteria, viruses, parasites, or toxins ).

Inspectors wroteBased on interview and record review, the facility's Quality Assessment and Assurance Committee ([QAA] develop and implement appropriate plans of action to correct identified quality deficiencies) and the Quality Assurance Performance Improvement ([QAPI] a group who takes a systemic, interdisciplinary, comprehensive, and data driven approach to maintaining and improving safety and quality in nursing homes while involving residents and families) failed to ensure effective oversight of the facility and implementation of the facility's plan of correction (POC) of the deficient practices identified during the previous recertification survey. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents' medical records were updated to show documentation that advance directives (written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate) were discussed and written information was provided to the residents and/or responsible parties for two of six sampled residents (Resident 2 and 16). These deficient practices violated the residents' and/or the representatives' right to be fully informed of the option to formulate an advance directive and had the potential to cause conflict with the residents' wishes regarding health care.

Inspectors wroteBased on observation, interview , and record review, the facility failed to ensure one of four sampled residents (Resident 21) was free of chemical restraints (use of medication to control a patient's behavior or restrict the patient's movement and not required to treat the medical symptom) by failing to: 1. Ensure Resident 21 was provided non-pharmacological interventions (interventions that does not primarily use medicine ) before administering a as needed) (prn) psychotropic medication(any drugs that affects the brain activities associated with mental processes and behavior). This failure put Resident 21 at risk for adverse reactions (unintended, harmful events attributed to the use of medication) due to unnecessary prolonged use of psychotropic medication.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two sampled residents (Resident 22 and Resident 11) had a Level II Preadmission Screening and Resident Review (PASARR-a federal assessment requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are placed in facilities that can provide the appropriate care) assessment done when diagnosed with a mental illness prior to admission. This failure had the potential to result in Resident 22 and Resident 11 not receiving the necessary services and appropriate psychiatric( relating to mental illness or its treatment) level of treatment and evaluation in the facility.

Inspectors wroteBased on observation and interview, the facility failed to ensure one of two residents' (Resident 2) was provided with personal hygiene care. This deficient practice resulted in Resident 2's facial hair being too long to shave with a razor, requiring the use of an electrical razor and had the potential to affect Resident 2's dignity.

Inspectors wroteBased on interview and record review the facility failed to ensure two of two sampled residents (Resident 11 and Resident 60) were provided with a bowel and bladder retraining and/or toileting program (scheduled toileting, prompted voiding or bladder training [help to regain at least some control over patient's bladder]), to regain normal bowel and bladder function as much as possible and received appropriate treatment and services to restore continence. This failure had a potential risk for Resident 11 and Resident 60 to lose their ability to regain control of bowel and bladder function, which could result in loss of dignity.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of six sampled residents (Resident 48) received respiratory care (specialized healthcare field that focuses on the treatment , management and prevention of respiratory disorders) consistent with professional standards of care by failing to: 1. Ensure Resident 48 's nasal cannula (medical device used to deliver supplemental oxygen to a person's nose) was not left on the floor and oxygen concentrator ( medical device that provides a concentrated source of oxygen) were turned off when not in use. These failures had the potential to put Resident 48 for respiratory infection (an infection that affects respiratory tract which includes the nose, throat, and lungs caused by viruses or bacteria).

Inspectors wroteBased on observation, interview , and record review , the facility failed to provide necessary behavioral care and treatment on one of three sample residents ( Resident 167) by failing to: 1. Assess and monitor Resident 167's behavior after verbalization of wanting to die. 2. Follow up physician's notification about Resident's 167 suicidal ideation (thoughts of self-harm or ending one's life). 3. Provide psychiatric (study and treatment of mental, emotional, and behavioral disorders ) evaluation after Resident 167's verbalization of wanting to die. These failures had the potential to put Resident 167 at risk of committing suicide due to delays in care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a medication error rate of less than 5% (percent) during medication pass for one of the four sampled residents (Residents 46 ) The facility failed to: a. Administer Resident 46's Onglyza (medication for DM), Sitagliptin (medication for DM) and Risperdal (antipsychotic medication [used to treat schizophrenia and bi-polar]) within 60 minutes of its scheduled time as per facility's policy and procedure (P&P) titled, Medication Administration dated 1/1/2012. These deficient practices of medication administration error rate of 9.09% exceeded the five (5) percent threshold.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure one of four sampled residents (Resident 46) was free from significant medication errors by failing to administer Onglyza for diabetes mellitus 2 (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), Sitagliptin for DM 2 and Risperdal (antipsychotic medication) used to treat schizophrenia (a mental illness that is characterized by disturbances in thought) as prescribed by the physician. These failures had the potential to place Resident 46 at risk for hyperglycemia (high blood sugar) and angry outbursts.

Inspectors wroteThe facility failed to ensure transmission-based precautions (set of infection control measures designed to prevent the spread of infectious diseases in healthcare settings) were implemented for one of one sampled resident (Resident 22) who had an order to rule out Clostridium difficile (C. diff- a highly contagious bacteria that causes severe diarrhea) due to frequent diarrhea. This failure had the potential to expose other residents, staff and visitors to the spread of infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the resident, who had a history of banging her head on the wall, did not banged her head on the wall and sustained an injury for one of three sampled resident (Resident 1). The facility failed to: 1. Ensure a Certified Nursing Assistant (CNA) 1, who was assigned to provide Resident 1 with 1:1 (a constant observation provided by a care giver/sitter) supervision for safety, prevented Resident 1 from walking towards the wall and start banging her head on the wall. 2. Ensure CNA 1 was informed and had knowledge of Resident 1's behavior of banging her head on the wall. 3. Ensure the facility's policy and procedure (P&P) titled, Resident Safety, dated 4/15/25, which indicated, the purpose is to provide a safe and hazard free environment was followed. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of six sampled residents (Resident 1) was not physically assaulted by another resident (Resident 2). This deficient practice resulted in Resident 1 sustaining a laceration (a deep, jagged tear or cut in the skin, often caused by a sharp object or blunt trauma, resulting in an irregular wound that could bleed significantly) to his right hand between his right thumb and right pointer finger, that required eight sutures (a stitch or row of stitches holding together the edges of a wound or surgical incision) and abrasions (a minor injury to the skin that occurs when the skin is rubbed or scraped) to his right forearm, right knee and left knee.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident, who had anxiety (an emotional state that involves feelings of fear, dread and uneasiness), and had Ativan (a medication used to treat anxiety) 1 milligram ([mg] a unit of measurement) to control their anxiety, was provided antianxiety medication, for one of five sampled residents (Resident 1). The facility failed to: 1. Ensure licensed nurses ordered a refill of Ativan 1 mg for Resident 1 ' s anxiety before the medication ' s quantity was depleted. 2. Ensure Resident 1 received Ativan for anxiety, as ordered by Resident 1 ' s physician. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident, who lacked the capacity to make decisions, was supervised, and monitored to prevent one of three sampled residents (Resident 1) from eloping (leaving a secured institution without notice or permission) from the facility. Resident 1 was last seen in the facility on 12/12/2024 at approximately 10:30 p.m in his room. Resident 1 was noted missing on 12/12/2024 at approximately 11:30 p.m. As of 12/20/2024, Resident 1 has not been located. This deficient practice resulted in Resident 1 ' s eloping from the facility on 12/12/2024 and his whereabouts being unknown. This deficient practice had the potential for Resident 1 to be exposed to excessive drops in temperature, motor vehicle accidents, hunger, dehydration, and death. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the resident rights to be free from physical abuse for two of six sampled residents (Resident 2 and Resident 4). The facility failed to: 1. Ensure Certified Nursing Assistant (CNA 1) separated Resident 1 and Resident 2 immediately when the two residents were arguing over a wheelchair which resulted to Resident 1 throwing a coffee cup to Resident 2's right side of the head. Resident 1 had a recent history of resident-to-resident altercation last June 2024 and Resident 2 had a known aggressive behavior against staff and residents. 2. Protect and prevent Resident 3 from hitting Resident 4 on the face. These failures resulted in Resident 2 sustained a skin abrasion (superficial skin wound) on the right side of the head and Resident 4 getting hit on the face and fell on the floor.

Inspectors wroteBased on observation, interview and record review, the facility failed to: 1. Ensure Licensed Vocational Nurse (LVN) 5 documented medication as administered in the Medication Administration Record (MAR) immediately after administering Resident 20's Insulin Lispro (a short acting medication used to treat elevated blood sugar level). 2. Ensure LVN 5 verified Resident 20's identity with the MAR prior to medication administration. These deficient practices increased the risk of medication error, including Resident 20 not receiving the correct medication as ordered. 3. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: 1. Dusty fan was located near the dishwasher and a dusty radio was located near the kitchen prep table (workstation for food preparation). 2. Facility freezer and refrigerator were not in safe operating condition. 3. A green substance was observed on the spout of the ice dispenser These deficient practices had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (illnesses contracted from eating contaminated food or beverages) of residents who received food from the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure infection control practices was implemented. The facility failed to: 1. Ensure personal protective equipment (PPE- equipment used to prevent or minimize exposure to hazards) was easily accessible for direct patient care staff on residents with Enhanced Barrier Precaution (EBP- use of a gown and gloves for residents with wounds, and indwelling devices). These deficient practices had the potential for the spread and transmission of multidrug resistant organism (MDROs- microorganisms, predominantly bacteria that are resistant to one or more classes of antimicrobial agents) in the facility. 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure three freezers and one refrigerator in the facility's kitchen and food pantry were maintain in safe operating condition. This failure had the resident food items stored in an unsafe condition that could potentially place the residents at risk for food-borne illnesses (illness cause by food contaminated with bacteria, viruses, parasites, or toxins).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents receiving hemodialysis ([HD], a medical procedure to remove fluid and waste products from the body) provided necessary care and services for two of two sampled residents (Resident 47 and 26). The facility failed to: a. Ensure Resident 47's blood pressure check was not measured using the left arm with the arteriovenous shunt ([AV] a connection that was made between an artery and a vein for dialysis access). This deficient practice had the potential to interrupt the blood flow to the arm and may cause the AV shunt to stop working. b. Accurately measure Resident 47 and 26's intake and output when a full pitcher of water was left and within reach for Resident 47 and Resident 26. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to obtain informed consent (process by which a healthcare provider educates a resident about the risks and benefits, and alternatives of a given procedure or intervention) prior to the administration of psychotropic drugs (medication that affects brain activities associated with mental process and behavior) for two of four sampled residents (Resident 64 and Resident 41). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure its medication error rate was less than five percent (%). Two medication errors out of 27 opportunities contributed to an overall medication error rate of 7.14 % affecting one of four residents observed (Resident 33) during medication administration. The medication errors were as follows: 1. Calcitonin Salmon Nasal Solution (a medication used to treat osteoporosis [a disease which causes bones to weaken and break more easily]) 200 units ([U] the amount of a medication administered to a resident in a single dose) one spray was administered in Resident 33's right nostril (outer openings of the nose through which one breathes) instead of left nostrils as ordered by Resident 33 physician. 2. Omission of Calcitonin Salmon Nasal Solution 200 U one spray in Resident 33's left nostril. [...]

Inspectors wroteBased on interview and record review, the facility's Quality Assessment and Assurance committee ([QAA] a group of facility staff who identifies, evaluates, and implements measures to improve the quality of care and life for the residents in the facility) and Quality Assurance Performance Improvement ([QAPI] a group who takes a systemic, interdisciplinary, comprehensive, and data driven approach to maintaining and improving safety and quality in nursing homes while involving residents and families, and all nursing home caregivers in practical and creative problem solving) committee failed to ensure continued oversight of the facility's plan of correction (POC) of the deficient practices identified during the previous recertification survey (7/19/2021). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of one sampled resident (Resident 38) who had a history of post-traumatic stress disorder (PTSD- a mental health condition that triggered by a terrifying event either experiencing it or witnessing it), and depression (a depressed mood or loss of pleasure or interest in activities for long periods of time) was provided individualized plan of care to address potential trauma triggers This deficient practice has the potential not to provide resident centered behavioral health care services needed for Resident 38.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two sampled residents (Resident 27), who was prescribed with antipsychotic drug (a type of medication prescribed to treat mental health problem) and an anxiolytic drug (anti-anxiety medications, that treat anxiety symptoms and disorders) were monitored for behaviors of bipolar (a mental health condition that causes extreme mood swings) and anxiety episodes every shift. This deficient practice has the potential for Resident 27's behavior of psychosis and anxiety to be unmonitored and has the potential for an inaccurate information necessary for gradual dose reduction ([GDR] tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 30) Responsible Party (RP) was notified when the dentist recommended the need for dentures (an artificial placement of one or more teeth). This deficient practice had the potential to cause a delay in dental treatment for Resident 30.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) was not subjected to a physical abuse by Resident 2. The facility failed to: 1. Ensure Resident 1, who had a history of aggressive behavior toward residents and staff and was sent out to a general acute care hospital (GACH) on 5150 (temporary, involuntary psychiatric commitment of residents who present a danger to themselves or others due to signs of mental illness) hold on 4/18/2024, was not placed in the same room with Resident 2 upon re-admission to the facility on 4/26/2024. 2. Ensure staff followed Resident 2's care plan titled, Alleged altercation per another roommate on 4/11/2024, to prevent Resident 2 altercations with Resident 1 on 4/27/2024. 3. [...]

Inspectors wroteBased on interview, and record review, the facility failed to report an allegation of sexual abuse to the California Department of Health (CDPH) Licensing and Certification Program (L&C), State Long Term Care Ombudsman ([LTC] public advocate) and the local Police Department (PD) within the regulated time frame of two hours for one of five sampled residents (Resident 1). This deficient practice resulted in a delay in the investigation of the sexual abuse allegation and had the potential for pertinent data to be lost and/or forgotten.

Inspectors wroteBased on interview, and record review, the facility failed to complete one of one resident's (Resident 1) Preadmission Screening and Resident Review ([PASRR] a federal requirement to help ensure that individuals were not inappropriately placed in nursing homes for long term care), when Resident 1 was newly diagnosed with Schizophrenia (mental disorder affecting thoughts and perceptions) and started on Risperdal (medication used to treat Schizophrenia). This deficient practice has the potential to result in a lack of specialized care and services.

Inspectors wroteBased on interview, and record review, the facility failed to ensure the interdisciplinary team (IDT) was involved in developing a discharge plan for one of three sample residents (Resident 1), that reflects Resident 1's discharge concerns, needs, goals and treatment preferences. This deficient practice resulted in Resident 1 feeling angry and distrustful of the staff and the failures had the potential to result in an ineffective discharge planning leading to lack of necessary care and services for Resident 1 after discharge.