Bayshire Riverwalk Post-Acute

Inspectors wroteBased on interview and record the facility failed to respond to resident call lights (primary purpose is to allow patients to request immediate assistance from nursing or care staff. It serves as a vital safety tool used for pain medication requests, toileting assistance, personal help, or alerting staff to medical emergencies) in a timely manner for 11 of 11 sampled residents (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, Resident 6, Resident 7, Resident 8, Resident 9, Resident 10, and Resident 11). This failure had the potential for care needs to not be met, injuries to occur, and other negative outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to:1. Follow the physical therapy (type of treatment that helps regain normal movement and ease pain after an injury, surgery, or a medical condition that limits the ability to function) recommendation for non-weight bearing status (limiting the amount of weight or pressure placed on a specific limb) on right upper extremity (RUE) for one of three sampled residents (Resident 1) when Certified Nursing Assistant (CNA 1) instructed Resident 1 to hold onto the grab bars with both hands while in the shower room.2. Ensure Resident 1 was sitting in the shower chair while being undressed in the shower room for one of three sampled residents (Resident 1).3. Ensure Resident 1 was standing on a dry non-slippery floor in the shower room for one of three sampled residents (Resident 1). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call lights were answered timely for three of four sampled residents (Resident 1, Resident 2, and Resident 3). This failure had the potential to result in Resident 1, Resident 2, and Resident 3's unmet care needs and emotional distress.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was free from physical abuse (any intentional act causing injury or trauma to another person through bodily contact) when Certified Nursing Assistant (CNA) 1 hit Resident 1 on the right side of his face while CNA 1 and CNA 2 were changing Resident 1's adult brief. This failure resulted in Resident 1 crying and having redness on his face.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the temperature was taken for a cup of soup prior to serving it to one of three sampled residents (Resident 1) after being heated up, by the nursing staff, in the microwave. This failure resulted in Resident 1 sustaining a second degree burn (damages the epidermis (surface of the skin)) and dermis (thick layer of living tissue below the epidermis containing blood vessels, nerve endings, sweat glands, hair follicles and other structures) layers of the skin and is characterized by blistering, deep redness, swelling, and intense pain) to his left-hand pointer finger.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all drugs and biologicals (a therapeutic substance, such as a vaccine or drug, derived from biological sources) were stored appropriately when: 1. Vaccines were not labeled after opening. 2. Expired medications were not disposed. These failures had the potential to result in residents being administered vaccines and medications that were expired and not receiving the intended therapeutic effect.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure professional standards for food service safety and sanitary kitchen conditions were followed when: 1a. Dry food items were not stored in airtight sealed containers.1b. Vegetables were retained that were not safe for consumption.1c. Cold food items were not covered to prevent spillage and cross-contamination.2a. Clean dishware was not covered to prevent debris contamination.2b. Clean Utensils were not covered to prevent contamination.3a. Pasta was not labeled with an opened date.3b. Dairy Creamer was not labeled with an opened date.3c. Individually pre-dished, cut-up fruit, vegetables, and baked desserts were not labeled with prepared and use-by dates. These failures had the potential to cause foodborne illnesses (illness caused by the ingestion of contaminated food or beverages) for residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement effective infection control practices when the facility failed to:1) Follow their policy and procedure (P&P) on Infection Prevention and Surveillance when the facility's Infection Control Surveillance (ICS) binder did not contain information on infection trend tracker, changes and resolution, analyzation of trends identified, and educational program based on prevention.2) Ensure three of three dirty linen containers were in good repair.3) Ensure floors were disinfected (cleaned with chemical to destroy bacteria which causes diseases).4) Follow their P&P titled, ISOLATION TRAYS for one of five sampled residents (Resident 128).5) Assist two of five sampled residents (Resident 37 and Resident 84) with hand hygiene. These failures had the potential to spread infection to residents, staff, and visitors.

Inspectors wroteBased on interview and record review, the facility failed to implement an effective antibiotic stewardship program (a systematic approach to educate and support health care professionals to follow evidence-based guidelines for prescribing and administering antibiotics/antimicrobials) for four of four sampled residents (Resident 10, Resident 134, Resident 135, and Resident 3). This failure had the potential for residents developing antibiotic resistance (bacteria evolve defenses, allowing them to survive drugs meant to kill them, making infections harder to treat, this happens when bacteria change due to antibiotic use, creating superbugs, leading to longer illnesses, higher costs, and increased mortality) with the use antibiotic and experiencing adverse health outcomes.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 133) right to refuse was respected. This failure resulted in a violation of Resident 133's right to be treated with respect and dignity.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light was easily accessible for three of 46 sampled residents (Resident 12, Resident 102, and Resident 62). This failure resulted in Resident 12, Resident 102, and Resident 62 being unable to call staff and to have unmet care needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of three sampled residents (Resident 47 and Resident 101) were provided with 72 hour written notification prior to receiving a new roommate. These failures resulted in a violation of residents' rights.

Inspectors wroteBased on interview and record review, the facility failed to implement their policy and procedure (P&P) titled, Abuse, Neglect & Exploitation Policy when allegations of abuse were not reported within 24 hours to the California Department of Public Health (CDPH-local state agency) and local ombudsman (representatives assist residents in long-term care facilities with issues related to day-to-day care, health, safety, and personal preferences) for one of three sampled residents (Resident 133). This failure resulted in Resident 133's allegation of abuse not being reported to CDPH and the local ombudsman timely.

Inspectors wroteBased on interview and record review, the facility failed follow their policy and procedure (P&P) titled, Abuse, Neglect & Exploitation Policy, when the facility failed to investigate and protect one of three sampled residents (Resident 133) when allegations of physical abuse were made. These failures had the potential for Resident 133's allegation not to be investigated timely and Resident 133 not to be protected from further abuse.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement a comprehensive care plan (CP) for one of 46 sampled residents (Resident 12). This failure had the potential to result in Resident 12 having an unrecognized change in condition and adverse health outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 46 sampled resident (Resident 119) had dentures in place and assisted with meals. This failure had the potential for Resident 119 not being assisted with activities of daily living and not meeting her nutritional needs.

Inspectors wroteBased on interview and record review, the facility failed to assess and complete the Skilled Nursing Dialysis Center Communication Form (SNDCCF - a communication tool to be completed by the nursing home and sent with each resident hemodialysis [a treatment that filters waste and excess fluid from your blood when your kidneys are failing] treatment) for one of two sampled residents (Resident 131). This failure had the potential for a change in condition to not be identified and delay in provision of care for Resident 131 who was receiving hemodialysis treatments.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a meal was served at a palatable and appetizing appearance for one of 30 sampled residents (Resident 74). This failure resulted in Resident 74 not eating her meals and potential for not meeting her nutritional needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a care plan (a detailed, written document created by facility staff that outlines all the medical, physical, emotional, and social care a resident will receive to improve or maintain their quality of life) for one of three sampled residents (Resident 1) with visual hallucinations (the experience of sensing something that is not actually there, even though it seems very real). This failure had the potential to result in Resident 1's care needs to not be met and/or result in psychological harm.

Inspectors wroteBased on interview and record review, the facility failed to implement their policy and procedure (P&P) titled, Abuse, Neglect & Exploitation Policy, when: 1. The allegation of psychological/mental abuse was not reported timely to the California Department of Public Health (CDPH the state survey and certification agency) and local ombudsman (representatives assist residents in long-term care facilities with issues related to day-to-day care, health, safety, and personal preferences) for one of three sampled residents (Resident 1). This failure had the potential for Resident 1 not to be protected from further abuse. 2. A 5-day investigation report (written report of the results of abuse investigation) was not sent to CDPH or local ombudsman within 5-days of the incident for one of three sampled residents (Resident 1). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the facility controlled medication (medications that have the potential for abuse and addiction and are therefore regulated by the government) drug record was accurate for one of three sampled residents (Resident 1). This failure had the potential for unaccounted for and/or diversion of controlled medications.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of abuse to the California Department of Public Health (CDPH-state agency) for one of three sampled residents (Resident 1). This failure resulted in delayed investigation of the allegation of abuse and potential for continued abuse towards Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement their policies for cleaning, drying, and storing clean dishes. This failure had the potential for contaminating food placing residents at risk for foodborne illnesses.

Inspectors wroteBased on observation and interview the facility failed to implement infection control practices when: 1. The facility's policy & procedure (P&P) for hand hygiene was not followed when two staff members did not perform hand hygiene before entering and after exiting residents' rooms. 2. The facility's P&P for laundry and bedding was not followed when the cover to the clean linen cart was ripped and unable to cover the clean linen completely for transport. 3. The facility's P&P for enhanced barrier precautions (EBP - measures to prevent infection which involves wearing gowns and gloves) was not followed for one of six sampled residents (resident 268) who had an indwelling foley catheter (flexible tubing that drains urine from the bladder into a collection bag). These failures had the potential to spread infectious diseases to residents, staff, and visitors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three of three sampled residents (Resident 364, Resident 33 and Resident 3) were assessed for self administration of medications. This failure had the potential for the facility not to identify and resolve any risks for self administration of medications for Resident 364, Resident 33, and Resident 3, and the potential to place mobile residents at risk for harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure proper accommodations were made for one of 25 sampled residents (Resident 269) when Resident 269 was given a call bell that could not be heard at the nurse's station. 2. Implement its policy and procedure (P&P) titled, Call System, Residents for 8 of 25 sampled residents (Resident 48, Resident 18, Resident 8, Resident 31, Resident 92, Resident 34, and Resident 67) when call lights were not answered within 5 minutes. These failures contributed to residents not being assisted timely which negatively affected their psychosocial and personal hygiene needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure four of six sampled residents (Resident 93, Resident 414, Resident 76, and Resident 164) had an Advance Directive (AD- a legal document that provides instructions for medical care and only go into effect if the individual is unable to make decisions for themselves) in the medical record. This failure had the potential for responsible parties and/or medical professionals to not honor resident's healthcare wishes and to not provide appropriate treatment in the event of an emergency medical situation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three of five medication carts did not contain controlled medications (medications with high potential for abuse and addiction) that were unaccounted for. This failure had the potential for drug diversion (illegal use of prescription drugs) and inaccurate documentation of controlled medication disposal.

Inspectors wroteBased on interview and record review, the facility failed to implement an effective antibiotic (range of powerful medications that kill bacterial infections) stewardship program (the practice of ensuring antibiotics are used appropriately and only when necessary) when antibiotic use was not monitored for three of three sampled residents (Resident 414, Resident 164, and Resident 57) . This failure had the potential for unnecessary use of antibiotics which could contribute to negative health outcome for residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three of three sampled resident's rooms (Resident 10, Resident 51, Resident 56) were maintained in good repair. This failure had the potential to impact residents' psychosocial needs and quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of 25 sampled residents (Resident 84) personal preference was honored when Certified Nurse Assistant (CNA) 2 was assigned to care for Resident 84 after Resident 84 requested CNA 2 not be assigned to her care. This failure resulted in Resident 84 experiencing emotional distress.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure care plans were developed and implemented for two of five sampled residents (Resident 18 and Resident 268). This failure resulted in Resident 18 and Resident 268 having unmet care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 25 sampled residents (Resident 1) received the necessary care and services to prevent the development and promote healing of pressure ulcers (open wounds caused by consistent pressure on the skin). This failure had the potential to cause Resident 1 to experience development or deterioration of pressure ulcers.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure for one of five sampled residents (Resident 48) fall precautions were in place. This failure had the potential for Resident 48 to fall and sustain injuries.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure titled, Medication and Treatment Orders to ensure the physician orders for two of two sampled residents (Resident 164 and Resident 57) included the clinical condition or symptoms for its use. This failure had the potential for residents to be taking unnecessary medications with potential for experiencing adverse health outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 25 sampled residents (Resident 87) was free from significant medication errors. This failure had the potential for Resident 87 to have adverse health outcomes.

Inspectors wroteBased on interview and record review the facility failed to: 1. Ensure dental services were provided for one of two sampled Residents (Resident 18). 2. Implement care plan interventions for one of two sampled Residents (Resident 18). This failure had the potential for Resident 18 to experience difficulty maintaining nutritional needs and could result in unintended weight loss. 1. During an interview on 11/05/24 at 12:23 p.m. with Resident 18, Resident 18 stated, my teeth are rotting in the back. I told them I needed to see a dentist at least 4 months ago. During an interview on 11/06/24 at 2:35 p.m. with Social Service Director (SSD), SSD stated Resident 18 had a dental consult sent on 9/12/24. No follow-up to this consult as of today (11/6/24). Resident 18 saw a dental hygienist on 9/4/24 for cleaning. She (Resident 18) gets referred to the dentist after a dental hygienist appointment. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 25 sampled resident's (Resident 269) meal tray ticket (MTT - guidance to staff on what to serve for a meal to a resident) was accurate and followed. This failure had the potential to result in a negative health outcome.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light system was working properly for one of 25 sampled residents (Resident 269). This failure resulted in delayed care and unmet needs of Resident 269.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure comprehensive care plan for one of three sampled residents (Resident 1) impaired skin integrity were developed and implemented. This failure had the potential for worsening of Resident 1's impaired skin integrity.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy and procedure (P&P) titled, Routine Clinical Documentation for one of three sampled residents (Resident 1). This failure had the potential not to meet the resident needs.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure (P&P) on weight management guidelines when one of four sampled residents (Resident 1's) weight was not monitored weekly as ordered. This failure had the potential for Resident 1 to continue losing weight due to weight changes not being monitored and addressed in a timely manner.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure the dry food storage room in the kitchen was maintained in a sanitary condition when lifeless roaches were found on the floor and the drain. 2. Ensure the clean water pitcher storage cabinets were cleaned and free from pest. These failures had the potential for contaminating the dry food and clean water pitchers, placing residents at risk for foodborne illnesses.

Inspectors wroteBased on interview and record review, the facility failed to ensure medications were administered according to the physician order(s) for one of four sampled residents (Resident 1) when: 1. Resident 1's Sodium Chloride (salt-based solution to provide hydration) Intravenous (IV-medication administration route into a vein of a person's body) solution was not administered as ordered. 2. Resident 1's Amiodarone (antiarrhythmic medication-prevents and treats a fast or irregular heartbeat [arrhythmia] by slowing down overactive electric signals in the heart, which stabilizes heart rate and rhythm [strong sound]) was not administered as ordered. These failures had the potential to cause adverse health outcomes.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Notify the physician of a change in condition and increasing oxygen administered for one of four sampled residents (Resident 1) when Resident 1 ' s oxygen saturation (oxygen level in the blood) went below normal, and staff increased the oxygen without a physician's order. This failure had the potential to contribute to Resident 1's decline in health condition. 2. Follow their policy and procedure on Neurological Checks (assessment of sensory and motor responses, especially reflexes, to determine whether the nervous system is impaired) for one of four sampled residents (Resident 1) when the neurological check results were inaccurately documented. This failure resulted in Resident 1 having inaccurate clinical records and potential for unidentified neurological decline.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure its policy and procedure (P&P) titled, Resident Call System and Door Alarm Response- EME-1 was followed for one of two sampled residents (Resident 2). This failure resulted in Resident 2 to have a delay in positioning of his therapeutic knee pillow.

Inspectors wroteBased on interview and record review, the facility failed to ensure pain medications were administered as ordered for one of two sampled residents (Resident 1). This failure resulted in Resident 1 ' s delay in receiving his pain medication.

Inspectors wroteBased on interview and record review, the facility failed to follow its policy and procedure (P&P) on Resident Grievance Procedure for one of three sampled residents (Resident 1). This failure had the potential for grievances to go unresolved and result in negative consequences.

Inspectors wroteBased on interview and record review, the facility failed to change one of three sampled residents (Resident 1) after an episode of urinary incontinence (inability to control urine or feces). This failure had the potential to result in infection, skin issues, wounds, and low self-esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a clean environment for one of three sampled residents (Resident 1). This failure had the potential for Resident 1 to feel undervalued, not cared for and have a negative effect on his self-respect.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure pain medications were administered according to physicians ' orders for six of nine sampled residents (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, and Resident 6). These failures had the potential for Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, and Resident 6 to have ineffective pain management.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pain management for six of nine sampled residents (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, and Resident 6). These failures had the potential for delay in the residents treatment and improper pain management causing discomfort to the residents.

Inspectors wroteBased on interview and record review, the facility failed to follow its policy and procedure (P&P) titled, Controlled Substances Policy, for six of nine sampled residents (Resident 2, Resident 3, Resident 4, Resident 5, Resident 6, and Resident 7). This failure had the potential for pain medications to be diverted and Resident 2, Resident 3, Resident 4, Resident 5, Resident 6, and Resident 7 ' s pain to be ineffectively managed.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) was promptly assisted with toileting. This failure resulted in Resident 1 not receiving timely assistance and not treated with dignity.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) pain medication was administered timely. This failure resulted in Resident 1's pain to not be treated effectively and timely. Findings. During an interview on 10/19/23 at 11:47 a.m. with Resident 1, Resident 1 stated pain medications can take anywhere from ten minutes to two hours to be administered. Resident 1 stated, Last night, I ring the bell informed the CNA [certified nursing assistant] and waited two hours, the Nurse stated the CNA never told her, so I don't know who dropped the ball on that one. During a review of Resident 1's Minimum Data Set, (MDS - an assessment tool) dated 10/20/23, the MDS indicated, Resident 1's BIMS (Brief Interview for Mental Status with a range of 0-15) score was 14 (a score of 13 to 15 suggests the resident is cognitively intact). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure pain management was effective for two of five sampled residents (Resident 2 and Resident 4) when: 1. Resident 2 was crying and waited for more than one hour for pain medication to be given. 2. Resident 4's pain was not followed up after administering pain medication. These failures had the potential for residents suffering in pain affecting their quality of life.

Inspectors wroteDuring an interview and record review, the facility failed to ensure one of five sampled residents (Resident 5) was free from a medication error when Resident 5 received a discontinued pain medication. This failure resulted in Resident 5 having sudden and unexpected inability to perform usual activities, onset of confusion, and hallucinations (perception of something not present) and potential for adverse unfavorable health consequences including death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services for one of three sampled residents (Resident 1) to ensure: 1. Physician's order was obtained for the left knee splint (LKS-device that hinders mobility causing atrophy [decrease in size of a body part] and range of motion [maximum amount of joint movement] loss) prior to applying on Resident 1's left knee. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy and procedure (P&P) titled, Supporting Activities of Daily Living to provide grooming, personal and oral hygiene assistance for two of 31 residents (Resident 190 and Resident 239). This failure resulted in physical and psychosocial distress for Resident 190 and Resident 239.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement their policy and procedure (P&P) for securing the medication cart and medication. This failure had the potential for unauthorized access to medications by residents, staff, and visitors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy and procedure (P&P) titled, Storage of Perishable Food when: 1. Condiments were not discarded by their use by date 2. All food was not covered in the refrigerator and freezer units 3. Opened products were not labeled with an opened date or a use by date 4. Refrigerator Temperature logs were not maintained. These failures had the potential to result in decreased food quality, loss of nutrients, and foodborne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three ice machines was maintained in a safe and sanitary condition. This failure had the potential to result in food-borne illness to residents and staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a call light was easily accessible for two of 31 sampled residents (Resident 239 and Resident 13). This failure resulted in Resident 239 and Resident 13 unable to call staff for assistance and unmet needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a homelike environment for one of 31 sampled residents (Resident 239) when drawers were missing in the chifforobe (closet-like piece of furniture over two drawers). This resulted in the potential for lack of storage for personal belongings and did not provide a homelike environment.

Inspectors wroteBased on interview and record review, the facility failed to provide vision screening for one of 31 sampled residents (Resident 36). This failure had the potential for Resident 36 to have worsening vision.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from a medication error rate of greater than five percent for one of four sampled residents (Resident 26) when two medication errors occurred within 30 opportunities for errors. This failure had the result of the facility medication error rate of 6.67 %.