East Bay Post-Acute

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure, for Residents 1-10, the scheduled (controlled medication, narcotic) medication record system was complete (all documents available) and accurate (numbers match). The record system included Shipping Manifests (pharmacy delivery receipt), Controlled Substance (drug) Accountability Sheets (CDR, Controlled Drug Record), Medication Administration Records (MAR, record of medication administration), and destruction logs. The facility did not have complete records. The facility did not have accurate records. These failures resulted in the potential for undetected loss and diversion of scheduled medications. In addition, these failures resulted in the potential for avoidable medication errors.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the facility administrator was managed by a state licensed nursing home administrator (NHA) when the facility assigned the Operations Assistant (OA), who was not a state licensed nursing home administrator, as the administrator and posted Administrator 1's (ADM 1) license on the wall without assigning ADM 1 actual administrative duties. This failure resulting in the facility operations being managed by an unlicensed administrative staff for four months. A review of Resident 11's admission record indicated Resident 11 was originally admitted to the facility on [DATE] and discharged on 1/9/26. A review of Resident 12's medical record indicated Resident 12 was admitted for pressure ulcer care, diabetes and weakness. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to protect one of three sampled residents (Resident 1) from physical abuse when Resident 2 pushed Resident 1 on the ground, while Resident 1 was sitting in a wheelchair in facility's smoking area. Resident 1 fell on his back on the ground. This failure resulted in Resident 1 sustaining a skin tear on his right hand, and a transfer to Acute Care Hospital (ACH 1) requiring hospitalization for three consecutive days. It resulted in Resident 1 feeling scared of Resident 2. During a record review of Resident 1's admission Record dated 01/03/23, the record indicated Resident 1 had a diagnosis of major depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety disorder (nervousness). [...]

Inspectors wroteBased on interview and record review the facility did not report an alleged abuse incident involving Resident 1 and Resident 2, nor the investigation results, to the State Survey Agency for over three months. Furthermore, notification to the Long Term Care Ombudsman was also delayed nearly three weeks. Resident 2 pushed Resident 1 from a wheelchair, causing a fall, a skin tear on the right hand, and hospitalization at Acute Care Hospital (ACH 1). This failure resulted in facility not adhering to the abuse reporting timelines. During a record review of Resident 1's admission Record dated 01/03/23, the record indicated Resident 1 had a diagnosis of major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety disorder (nervousness). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure doors to enter the building were locked for all 84 of 84 sampled residents when the facility failed to ensure two doors (main entrance and rear exit) had functioning locks and failed to ensure staff kept the rear exit closed and supervised according to facility expectations while the doors locks were broken. The failure had the potential for unauthorized people to enter the facility building which had to potential to affect all residents' safety. During an observation on 11/8/25, at 5:02 a.m., in the parking lot at the back of the facility, the rear exit door of the facility was inspected. From 5:02 a.m. to 5:40 a.m., the rear exit door was propped open by a wet floor sign. Facility staff were exiting and reentering the building without closing the door. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to post the most recent Statement of Deficiencies (form CMS- 2567) results in a location where residents ( 14, 21, 36, 75, and 79), visitors, or other individuals had readily accessible access and did not have to ask to see the survey results. The resident council members felt their inability to access the survey results without asking fostered dependence on the staff and decreased their ability to act according to their own wishes. During an interview on 9/9/25 at 10:30 a.m. with the Resident Council members ( 14, 21, 36, 75, and 79) all members stated they did not know where the binder with the most recent survey results were located or if the results were available for their review without request. During a concurrent observation and interview on 09/09/2025 at 1:24 p.m. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure qualified, full-time oversight of Dietary Services when the Registered Dietitian (RD) did not work full time and the dietary manager (DM) was not qualified to supervise the kitchen for 19 weeks. These failures had the potential to compromise the safety and nutritional status of residents through potential transmission of foodborne illness and decreased quality of food for 81 residents who received food from the kitchen out of 85 residents in the facility. During a concurrent interview and record review on 9/9/25, at 4:13 p.m., with Dietary Manager (DM), DM's Safe-serv Food Manager certificate was reviewed. DM stated the Safe-serv Food Manager certificate was the only certificate they had. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the residents' medical records were updated to indicate information pertaining if an advanced directive (written statement of a person's wishes regarding the medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor), was offered and if the resident or responsible representative (RR) accepted or declined to create an advance directive, whether or not the resident had executed an advance directive, or the resident wishes for six / six sample residents (Residents 1, 2, 4, 7, 8, and 10). This had the potential for the facility to provide treatment and services against the residents' wishes. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two of 25 sampled residents (Resident 29 and 87)'s Minimum Data Set (MDS, an assessment used to plan care) assessment reflected accurate information when the following was noted: 1. Resident 29's MDS assessment inaccurately indicated use of antianxiety medications (chemical agents used to treat anxiety disorder), when Resident 29 was not taking any.2. Resident 87's discharge MDS assessment inaccurately indicated Resident 87 was discharged to an acute care hospital, when Resident 87 went home. This failure resulted in inaccurate reflection of Resident 29's clinical status and discharge disposition for Resident 87. 1. During an observation on 9/8/25 at 10:15 a.m., Resident 29 was sitting up in her bed. Resident 29 stated she was paralyzed from her waist down and had adapted to do her self care with both arms. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three of 20 sampled residents (Resident 75, 76, and 77) had physician orders followed promptly. This failure resulted in Resident 77 not being treated for promptly for pitting edema (swollen part of the body due to excess watery fluid that dimple or pit up to four millimeters when it's pressed for a few seconds) on both lower extremities. This failure resulted in Resident 77 feeling tightness and pain in both legs and frustration. It had the potential for Resident 77's both legs' edema to get worsened and to suffer from edema related complications such as fluid overload (a medical condition with excessive accumulation of fluids in the body's tissue and organs). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to prepare, distribute and serve food in a sanitary manner when:1. [NAME] 1 picked up Resident 11's meal ticket (printed tray ticket containing a resident's specific dietary needs, allergies, preferences, and even adaptive equipment requirements) from the floor and placed it on Resident 11's meal tray during meal tray food assembly.2. Two black oven mitts were dirty and in poor condition. These failures had the potential for cross contamination of food items and food borne illness for 81 residents who receive food in the kitchen.1. During an observation on 9/9/25 at 12:23 p.m., in the kitchen, [NAME] 1 took Resident 11's meal ticket from the second tray of station 2's meal cart to read the information. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow state regulations when:1. the facility did not have a qualified social worker to supervise, train and ensure the facility provided medically-related social services for nine months,2. the facility did not post the Centers for Medicare and Medic-aid Services (CMS) star rating in the facility. These failures resulted in1. Six residents did not have updated advanced directives (See Ftag 578), one resident did not have glasses because the facility failed to have trained staff conduct a vision test (See Ftag 685) and had the potential for all 85 residents to receive inadequate social services,2. and had the potential for residents and visitors to be uninformed about the overall quality of the facility.1. [...]

Inspectors wroteBased on interview and record review, facility failed to maintain accurate and complete medical records for four (Residents 6, 7, 75, and 76) out of twenty sampled residents. This deficient practice had the potential to cause inaccurate assessments of nutritional status, inappropriate care planning and unnecessary dietary restrictions, which could place residents at risk for unmet needs or avoidable decline. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one of two sampled residents ( Resident 35) was provided reading glasses as prescribed by the doctor. This failure resulted in Resident 35 to be unable to see things clearly, participate in activities fully and feeling frustrated. During a review of Resident 35's admission Record printed on 09/10/25, the record indicated Resident 35 was admitted to the facility on [DATE]. During a review of Resident 35's Minimum Data Set (MDS, an assessment used to guide care) assessment dated [DATE], the assessment indicated Resident 35 did not wear glasses at the time of assessment. The assessment indicated the Resident 35 was able to understand others and make her self understood. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents maintained adequate nutrition status in accordance with professional standards of practice and resident preferences for 2 out of 20 sampled residents (Resident 75 and 6). This deficient practice had the potential to result in unrecognized weight loss, inaccurate assessment of nutritional status, and failure to meet resident's dietary needs and preferences, placing residents at risk for avoidable weight loss and decline. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure least restrictive alternatives were attempted for a reasonable amount of time, prior to installing bedrails (adjustable metal or rigid plastic bars attached to the bed) for one of one samples residents (Resident 70) upon admission to the facility. This failure placed the Resident 70 at risk for injury, entrapment, psychosocial harm, up to and including death. During a review of Resident 70's admission Record printed on 9/10/25, the record indicated Resident 70 was admitted to the facility on [DATE]. During a review of Resident 70's Minimum Data Set (MDS, an assessment used to plan care) assessment dated [DATE], the assessment indicated Resident 70's Brief Interview for Mental Status (BIMS) score was six out of 15, indicating severe cognitive impairment. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain procedures to ensure accurate accountability and replacement of drugs in the emergency intravenous (IV) kit for 1 of 1 kits reviewed. This deficient practice resulted in the lack of documentation, missing medications, and failure to follow required procedures for notifying the pharmacy, which placed residents at risk of not having necessary emergency medications available when needed. During an observation on 09/08/2025 at 11:15 AM of the emergency IV kit, it was noted that the kit was missing normal saline. When asked when the kit was last opened, LVN 4 stated that typically a form is left inside the kit and faxed to the pharmacy; however, no such documentation was present. LVN 4 stated she could not determine when the kit had last been opened. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were administered in accordance with manufacturer instructions and accepted standards of clinical practice observed during medication pass. These failures included the administration of an expired inhaler and improper inhaler technique and potentially contaminating a syringe of Lispro prior to administration. As a result, 2 medication errors were identified out of 25 opportunities, resulting in a medication error rate of 8%. This placed residents at risk of reduced potency, diminished therapeutic benefit, and compromised clinical outcomes.1. During an observation on 09/08/2025 at 10:07 AM of medication administration by LVN 4 to Resident 79, LVN 4 administered Breo Ellipta inhaler, but failed to instruct the resident to fully exhale prior to inhaling the dose. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were labeled and stored in accordance with accepted professional principles and manufacturer instructions for 3 of 4 medication carts observed. This deficient practice resulted in the presence of unidentifiable medications, expired drugs, and opened medications without required dating, which placed residents at risk of receiving unsafe or ineffective therapy. During a medication storage observation on 09/08/2025 at 11:00 AM, cart number 4, was reviewed. Multiple unidentifiable loose pills were observed in the cart. When asked if she was aware of what these pills were, LVN 4 stated she did not know and confirmed they should not have been present in the cart. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain infection prevention and control practices during a medication administration for 1 of 1 residents (Resident 93) when RN 2 prepared Lispro Subcutaneous injection and left it on an uncleaned overbed table. This failure had the potential to expose residents to contamination and increased risk of infection. During a medication pass observation on 09/09/25 at 8:15 AM, RN 2 was observed drawing up Lispro insulin into a syringe at the medication cart. Prior to administering the injection, RN 2 placed the uncapped insulin syringe directly onto Resident 93's overbed table. This surface was observed at other times during the survey to hold personal food items and beverages. The syringe remained in contact with the table for approximately 20 seconds before the nurse picked it up and administered the dose. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow physician ' s order of supervised feeding for one (Resident 1) of two residents. This failure resulted in Resident 1 potentially choking and aspirating (accidental inhalation of food or liquid into the lungs) when eating.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 1), received treatment and care for a non-pressure ulcer (open area that is not caused by shear or pressure but may be caused by poor circulation) when: 1. Resident 1 developed redness to abdominal folds which became worse. 2. Resident 1's Treatment Administration Record (TAR), had multiple dates without initials/documentation that showed assigned licensed nurses had performed the resident's ordered wound treatments. These failures resulted in Resident 1's avoidable abdominal wound dehiscence which reopened and led to infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one of two sampled residents (Resident 2) when: 1. Treatment Nurse 2 (TN 2) and Certified Nursing Assistant 1 (CNA 1) did not wear a disposable gown during Resident 2's wound dressing change. Failure to wear the necessary personal protective equipment (PPE such as gloves, gown, face shield, masks, etc.) had the potential to place residents, staff, and visitors at risk for infection. 2. TN 2 did not perform hand hygiene (handwash with soap and water or alcohol-based hand rub) in between glove change during the wound dressing change. [...]

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure garbage was stored properly when outside trash bins were leaking, over-filled, and the lids were open, letting waste spill onto the ground. This failure had the potential to attract insects, rodents, and other pests to the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow facility medication administration policy, provide pharmacy services and ensure controlled medication (those with high potential for abuse and addiction) were fully accounted for 11 of 57 sampled residents (Residents 1, 400, 69, 329, 42, 20, 70, 30, 41, 57 and 330) when: 1. Licensed Vocational Nurse 8 (LVN 8) gave Resident 400 and Resident 1 medications without verifying residents' identity and did not name the medications given to the residents. 2. Resident 69 did not take her medications for one hour after LVN 3 left medications on Resident 69's overbed table without watching administration. 3. Resident 329 did not receive scheduled medication for 44 hours because the medications had not been delivered. 4. [...]

Inspectors wroteBased on staff interviews and review of facility documents, the facility failed to comply with Federal regulations related to the oversight of food service operations when the facility did not have a full-time dietitian and the requirements were not met as specified in established standards (California Code, Health and Safety Code - HSC § 1265.4) for food service managers which required, employment of a full-time, qualified dietetic supervisor when the dietitian was not full time. The lack of qualified, full time person to supervise the Food and Nutrition Services Department had the potential to result in unsafe food practices and food borne illness for 69 residents eating facility prepared foods.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the menu was followed when: 1. An entrée on the menu was not prepared because an ingredient was not purchased. 2. Diet salad dressing was not purchased and was on the lunch menu for residents on a Heart Healthy diet. This failure had to the potential to result in resident dissatisfaction of meals and/or the residents not receiving the appropriate nutrients as set forth by the planned menu for 69 residents who received food from the kitchen.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure food was palatable when recipes were not followed and foods were bland, as well as over-seasoned. This deficient practice placed 69 residents who received food from the kitchen at risk for decreased nutrient intake leading to nutrition related medical complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and served in a safe and sanitary manner when: 1. A resident's (Resident 1) personal refrigerator was not monitored for temperature, food expiration dates, and cleanliness. 2. Unpasteurized (not heated to kill dangerous pathogens which can cause foodborne illness), undercooked eggs were served to a resident. 3. Two of two ice machines were not clean. 4. Prepared, leftover Time/Temperature Control for Safety (TCS) food (food requiring time and temperature controls to limit the growth of illness causing bacteria) was not monitored for cooldown. 5. Refrigerated TCS food was not labeled to show when it was to be used-by or discarded. 6. Frozen raw fish stored in the freezer was not covered and open to air. 7. A kitchen staff member did not follow hand hygiene practices. 8. [...]

Inspectors wroteBased on interview and document review, the facility failed to have a refrigerator to store perishable food brought into the facility for residents by families and visitors. This failure to store perishable food belonging to residents had the potential for a decreased intake of food preferred by residents for 69 residents who ate food by mouth.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Annual (comprehensive) Minimum Data Sets (MDS, an assessment tool used to guide resident care) were completed within the required time frames for four of 30 sampled residents (Resident 31, Resident 50, Resident 47, and Resident 53). Resident 31, Resident 50, Resident 47, and Resident 53's annual MDS' were not completed within 14 days of the Assessment Reference Date (ARD, a date set to establish a uniform look-back period for all the responses to MDS coding items). These deficient practices had the potential for Resident 31, Resident 50, Resident 47, and Resident 53 to not receive the appropriate care and services needed based on these residents' current health status.

Inspectors wroteBased on interview and record review, the facility failed to ensure the quarterly Minimum Data Sets (MDS, an assessment tool used to guide resident care) were completed within the required timeframes for four of 30 sampled residents (Resident 67, Resident 51, Resident 13, and Resident 30). Resident 67, Resident 51, Resident 13, and Resident 30's quarterly MDS' were not completed within 14 days of the Assessment Reference Date (ARD, a date set to establish a uniform look-back period for all the responses to MDS coding items). These deficient practices had the potential for Resident 67, Resident 51, Resident 13, and Resident 30 to not receive the appropriate care and services needed based on their current health status.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Sets (MDS, an assessment tool used to guide resident care) were completed and submitted to the Centers for Medicare and Medicaid Services (CMS) within the required time frames determined by the Assessment Reference Date (ARD, a date set to establish a uniform look-back period for all the responses to MDS coding items) when: 1. For four of 30 sampled residents (Resident 31, Resident 50, Resident 47, and Resident 53), Annual MDS' were not completed and transmitted within 14 days of the ARD. 2. For four of 30 sampled residents (Resident 67, Resident 51, Resident 13, and Resident 30), Quarterly MDS' were not completed and transmitted within 14 days of the ARD. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure its nursing staff was competent and knowledgeable about the proper disinfection of shared glucometers (medical equipment used to measure and display the amount of sugar [glucose] in the blood) according to the manufacturer's instructions and accepted professional standards of practice when: 1. Two out of three nurses observed during medication administration did not use appropriate disinfectant to clean and disinfect shared glucometers for two out of three sampled residents (Residents 24 and 52). 2. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure proper medication storage and labeling of medication for one of one sample medication room and two of two medication carts when: 1. A non-licensed staff had access to the main medication room; and 2. Multiple expired, unlabeled, and undated multi-dose vials, eye drops, and inhalers were identified. These failures had the potential for loss or diversion of medications; and residents to receive medication with unsafe and reduced potency from being used past their discard date.

Inspectors wroteBased on observation, interview and facility document review, the facility failed to ensure kitchen staff were competent regarding job duties when kitchen staff did not know the appropriate procedures for cleaning equipment and utensils using the three-compartment sink. This failure had the potential to result in contamination of kitchen equipment and/or utensils leading to illness caused by pathogens (harmful organisms) for 69 residents who received food from the kitchen.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to provide a food/drink substitute of similar nutritive value and/or provide an alternate means of meeting the residents' nutritional needs when: 1. Milk was indicated on the planned lunch menu and was not provided for 43 residents out of 69 residents who received food from the kitchen; and 2. An alternate of equal nutritional value was not provided during a lunch meal for residents who did not like chicken. These failures had the potential for residents who ate food from the kitchen to receive a diet that did not meet their nutritional needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when: 1. Two out of three nurses failed to disinfect the blood pressure (BP) cuff before and/or after use for two of three sampled residents (Residents 28 and 52), 2. Two out of three nurses during medication administration were observed not using the appropriate disinfectant to clean and disinfect shared glucometers for two out of three sampled residents (Residents 24 and 52), and 3. Resident 25's foley catheter (tube inserted thru the urethra to drain bladder) equipment was lying on the ground. These failures had the potential for the spread of infections and communicable diseases among residents and placed Resident 25 at risk of urinary tract infection (UTI, infection of the urinary tract).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure essential kitchen equipment was in operational working condition when: 1. The right hand side of double oven unit was not operational. 2. A plate warmer was not operational.

Inspectors wroteBased on observation, interview, and record review, for one of 30 sampled residents (Resident 32), the facility failed to provide the resident with an appropriate facility gown to wear according to her size and preference. This failure resulted in Resident 32 wearing tight clothing, feeling uncomfortable, and restricted to both her upper arms and chest area.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide fingernail care to one of 30 sampled residents (Resident 13) when Resident 13's fingernails on both hands were long. This failure resulted in Resident 13 feeling bothered by the long fingernails and placed him at risk for scratching himself.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure care provided to a resident (Resident 27) was in accordance with professional standards of practice when a staff who was not a nursing staff provided resident care by helping the resident sit up in bed, and serving her lunch tray. This failure had the potential for one resident to receive food not appropriate for her diet resulting in a negative outcome such as an allergy reaction.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a timely evaluation of one resident's (Resident 72) severe weight loss. This failure had the potential to result in further unintentional and/or undesirable weight loss for one resident.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of one sampled resident (Resident 43) was free from unnecessary psychotropic medications (drugs that affect brain activities associated with mental process and behaviors). Resident 43 received aripiprazole (an antipsychotic medication, used to manage conditions such as psychosis) and sertraline (medication used to treat depression) without side effects and behavior monitoring. Resident 43's care plan did not have the correct side effect monitoring for the aripiprazole use. These failures resulted in inadequate monitoring for effectiveness and adverse effects of psychotropic medications.

Inspectors wroteBased on observation, interview and record review, the facility had a 7.41% error rate when two medication errors out of 27 opportunities were observed during the medication pass for two of six sampled residents (Residents 28 and 52 ). Resident 28 did not receive carvedilol (medication used to treat high blood pressure) as ordered and Resident 52 received a wrong calcium product. These failures resulted in medication not given in accordance with the prescriber's orders, which may negatively affect the resident's health.)

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately document entries for one of 30 sampled residents (Resident 24), when resident's current physician orders did not reflect oxygen (O2) and nebulizer (a device to take medication in the form of a mist that is inhaled into the lungs) use. This deficient practice resulted in incomplete and inaccurate records and had the potential for Resident 24 to not receive care, services, and treatments as needed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 30 sampled residents (Resident 34) had access to his call device. This failure resulted in Resident 34 not being able to get staff assistance when needed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staffing information was posted and readily available when the daily staffing ratio information was not posted for four consecutive days on 1/8/24 through 1/11/24 and the staffing data was not maintained for five months from August 2023 through the present time January 2024, for a minimum of 18 months. This deficient practice resulted in staffing information not being readily available to residents and visitors at any given time.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of two sampled residents (Resident 400) was free from significant medication errors when Licensed Vocational Nurse 8 (LVN 8) administered multiple doses of unprescribed medications, including opioid medications (a group of medications which are federally regulated substances used for pain control with a potential for physical or psychological dependence) to Resident 400. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to contact a physician for a significant change of condition for eight hours and 40 minutes for one of two (Resident 400) sampled residents after Licensed Vocational Nurse 8 (LVN 8) administered multiple doses of unprescribed medications, including opioid medications (a group of medications which are federally regulated substances used for pain control with a potential for physical or psychological dependence) to Resident 400. This failure resulted in Resident 400's hospitalization for excessive sedation and respiratory failure (inadequate breathing efforts) requiring mechanical ventilation (machine used to provide artificial breathing) from the opioid medications overdose.

Inspectors wroteBased on interview and record review, for one of two sampled residents (Resident 1), the facility failed to ensure Resident 1's representative was allowed to obtain a copy of the medical records within the required time frame. This failure had the potential to result in Resident 1's representative undue concern and anxiety on behalf of Resident 1.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the menu was followed for seven of seven residents when [NAME] 1 prepared white rice for residents on a pureed diet instead of the Spanish rice listed on the menu. This failure had the potential to result in less appetizing and nutritious food, and less food consumption, nutritional imbalance, and weight loss.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain kitchen cabinets in good repair when an undercounter cabinet had doors with chipped and peeling paint (interior and exterior sides), unpainted wooden interior walls were chipped and peeling, the cabinet floor had chips of paint and wood and irregular white, green, yellow, and black stains. The failure to maintain the cabinets in good repair and sanitary conditions had the potential to result in food contamination and food borne illness for any resident eating food.

Inspectors wroteBased on interview, and record review, the facility failed to arrange for a vision consult upon admission for one of 17 sampled residents (Resident 36). The failure to refer Resident 36 for eye care upon admission resulted in Resident 36 not receiving an eye exam on 3/30/22, during the routine eye care visit, with a subsequent delay in services for eleven additional weeks. This failure had the potential to result in impairment of Resident 36's vision.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the physician's orders to refer two of 17 sampled residents (Resident 2 and Resident 54) for podiatry (foot specialty) services. Resident 2 had no podiatry services for four months after one podiatry visit. Resident 54 had no referral for podiatry services for three weeks and three days following admission. These failures resulted in Resident 2 and Resident 54 developing long toenails which had the potential to result in skin breakdown/injury, infection, and amputation of toes and/or feet.

Inspectors wroteBased on interview and record review the facility failed to ensure one of eight sampled residents (Resident 39) received services to improve mobility and achieve maximum practicable independence when Resident 39 did not receive restorative nursing services for walking with a walker (an ambulation device with two to four wheeled legs, connected by handlebars to provide stability when walking). The failure to provide daily services to practice walking with a walker potentially contributed to muscle weakness and decreased mobility for ten weeks.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide appropriate pharmaceutical services for two of eight sampled residents (Resident 42 and Resident 10) when: 1. Resident 42's had four medications left unattended on her bedside table; the administration of the medications was delayed for one hour and fifty minutes past the scheduled administration time. This failure resulted in Resident 42 not receiving her medications timely, and Resident 10 receiving a more concentrated dose of medication. For Resident 42, the one hour and fifty minutes delay in administration of hydroxyzine (an anti-anxiety drug) resulted in potential stacking of doses as the next dose of hydroxyzine was due in one hour and ten minutes. Stacking of doses had the potential to result in adverse side effects such as seizures. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to arrange for a dental consult upon admission for one of 17 sampled residents (Resident 36). The failure to refer Resident 36 for a dental exam upon admission resulted in Resident 36 not receiving a dental exam on 3/30/22 or 3/31/22, during the routine dental care visit, with a subsequent delay in services for eleven additional weeks. This failure had the potential to result in difficulty eating and weight loss.

Inspectors wroteBased on observation, interview, and record review, for one of 8 sampled residents (Resident 16), the facility failed to ensure Treatment Nurse 1 (TN 1) performed hand hygiene (wash hands with soap and water or use an alcohol-based hand rub) on two occasions during a wound dressing change. The staff failure to change gloves during a wound treatment when moving from wound care (a dirty procedure) to application of a new dressing (a clean procedure), and to sanitize hands after removing gloves had the potential to result in infection and spread of infection.