West Shore Post Acute

Inspectors wroteBased on interview and record review, for two of five sampled residents (Resident 2 and Resident 3) the facility failed to provide a variety of fresh fruit options when only bananas were available for residents who requested fruits. This failure had the potential to result in not meeting the nutritional needs and compromising the nutritional status of the residents. A review of Resident 2's admission Record, printed on 6/1/26, indicated Resident 2 was admitted to the facility with diagnoses that included fracture of the left femur (a break on the thighbone), dislocation of the right hip, depression, and anxiety disorder. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide maintenance services in two of seven shower rooms (Shower Room E and Shower Room F) when both shower rooms were found unclean and not well maintained. These failures resulted in the lack of comfortable sanitary environment for the residents of the facility who used Shower Rooms E and/or F.During an interview on 6/1/26, at 11:30 a.m., with Housekeeping 1 (Hskg 1), Hskg 1 stated shower rooms were routinely cleaned by the janitors usually during the afternoon (PM) shift. During a concurrent observation and interview on 6/1/26, at 11:45 a.m., with Janitor 1 (J 1), inside Shower Room F, J 1 stated scattered areas of the floor and walls had grouts that were moldy and with brown-colored stains. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain an effective Pest Control Program (measures to eradicate and contain common household pests [e.g., bed bugs, lice, cockroaches [roaches], ants, mosquitos, flies, mice, and rats]) when there were continuous multiple sightings of roaches in the different parts of the facility despite scheduled weekly services from Pest Control Company. This failure created a nuisance for residents and had the potential to result in transfer of diseases such as salmonella, e. coli (bacteria known to cause food-borne illness), and other pathogens (microorganisms that can cause diseases). During an interview on 6/1/26, at 10:55 a.m., with Resident 3, inside resident's room, Resident 3 stated she had seen roaches twice since her admission to the facility two weeks ago. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure the Registered Dietitian (RD) and Dietary Services Manager (DSM) carried out the functions of the dietetic services in the food & nutrition services department when multiple issues in food safety, sanitation, and clinical nutrition care for residents with weight loss or weight gain were identified, according to facility policy and standards of practice. This failure had the potential to expose residents to unsafe contaminated food and unsanitary equipment and utensils, leading to foodborne illness and altered nutrition status among 114 residents who consume food from the kitchen. Cross reference F802, F803, F804, and F812

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the kitchen staff competently carried out the functions of the food and nutrition services department according to facility policy and standards of practice when: 1. Two Cooks (CK 1 and CK 2) did not properly verbalize or demonstrate the correct two-step cool down process used to prevent contamination in a cooked beef pot roast. 2. A Diet Aide (DA 1) did not know how to correctly calibrate a food thermometer. 3. A Diet Aide (DA 3) did not know how to test the sanitizer concentration in a red bucket. These failures had the potential to expose residents to bacterial contamination, that could result in food borne illnesses for all residents who consume food from the kitchen. The census was 114.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food safety and sanitation measures were maintained in the kitchen according to standards of practice and facility policy when: 1. An ice machine had pinkish gray slime debris on the drain panel and ice tray, and brown discoloration stains and debris inside the ice making grid, chute and on the right and left walls of the ice machine. 2. The kitchen did not have a three (3)-compartment sink station to wash, rinse, and sanitize dishes in the event of an emergency, if the dish machine was nonoperational. 3. Fourteen white colored plates on a dish rack had blackish dark gray stains on them. 4. Three cutting boards had deep cuts, and large white patches were used during food preparation in the kitchen. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain two out of two sampled clothes dryers according to the facility's policy when facility staff documented lint trap (help to reduce the lint and fabric particles that can build up and clog the exhaust hose) was cleaned prior to scheduled time. This failure had the potential for the clothes dryer to be in an unsafe operating condition.

Inspectors wroteBased on interview and record review, the facility failed to ensure the residents' medical records were updated to show documentation that advanced directives (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), were discussed with the residents and/or responsible parties for three out of 25 final sampled residents (Residents 4, 47 and 94). This had potential for the facility to provide treatment and services against the residents' wishes.

Inspectors wroteBased on observation, interview, record review, the facility failed to maintain a safe, clean, comfortable and homelike environment when: 1. The linoleum flooring in Resident 112's bathroom was discolored with areas of black stains that looked like dirt. 2. The toilet seat and toilet cover had multiple gray and black linear scratch marks, and the linoleum flooring was discolored with areas of black stains that looked like dirt in Resident 113's bathroom. This failure placed Residents 112 and 113 at risk for safety and may negatively impact the residents' psychological health when they had to use an unmaintained bathroom that was not homelike.

Inspectors wroteBased on observation interview and record review the facility failed to ensure two of 25 sampled residents were free from physical restraints when the facility staff installed bed foam bolsters to Residents 63 and 77's bilateral bedrails, which inhibited the residents' freedom to get in and out of their beds (Bed foam bolsters are elongated foam that are designed to prevent residents from falling off the bed). This deficient practice had the potential to cause injury and decline in the residents' quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two of 25 sampled residents (Residents 47 and 370), received the necessary services of bathing when the residents were not offered a shower as scheduled. This failure had the potential to affect the residents' dignity and their quality of life.

Inspectors wroteBased on observation, interview and record review , the facility failed to provide an ongoing program of activities to meet the interests and psychosocial well-being for two of 25 sampled residents (Residents 112 and 115). These deficient practices had the potential to affect the quality of life of the residents by placing the residents at risk of sensory deprivation and social isolation.

Inspectors wroteBased on observation interview and record review the facility failed to provide care and services to six of 25 sampled residents who were dependent on the staff for their care when their call lights were not answered by the facility staff on a timely manner (Residents 4,8, 48,88,113 and 370). This deficient practice had the potential to negatively affect the residents' physical comfort and psychosocial well-being

Inspectors wroteBased on observation, interview, and record review, for one of three sampled residents (Resident 45), the facility failed to developed and implement adequate person-centered interventions to prevent Resident 45 with dementia from wandering into the rooms of other residents. Dementia is a general term to describe a group of symptoms related to loss of memory, judgment, language, complex motor skills, and other intellectual function, caused by the permanent damage or death of the brain's nerve cells, or neurons. However, dementia is not a specific disease. There are many types and causes of dementia with varying symptom and rates of progression. (Adapted from: About Dementia. Alzheimer's Foundation of America. 30). This failure cause Resident 45 falls, injuries, and had the potential to cause residents increased confusion and emotional distress.

Inspectors wroteBased on observations, interviews, and record reviews, the facility did not ensure the standardized recipes for the regular diet were followed as printed, in accordance with menu guidance and facility policy. This failure had the potential to alter the palatability and nutritional value of the food, which could decrease food intake and compromise the nutritional status of the facility residents. The facility census was 114.

Inspectors wroteBased on observation, interview, and record review the facility staff did not follow their infection control prevention policy and standards of practice during med pass for (two of twenty-five residents,) Resident 50 and Resident 86, when: 1. The facility staff did not clean and sanitize the medication cart in between resident's care, (Resident 50 and Resident 86), after placing soiled medication cup used by Resident 50, into the medication cart. 2. An uncapped and exposed lancet (a small needle used to poke the skin, [usually on a finger for Residents with diabetes] to get a small drop of blood) was left in med storage room B with no name or identifier. 3. The facility staff did not keep medication pill crusher (used to crush medications during medication administration), on the medication cart, clean and sanitized. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one sampled resident (Resident 45), Minimum Data Set (MDS-Resident Assessment and Care Screening tool used to guide care), was accurate when Resident 45 MDS section E was not coded accurately to reflect Resident 45's wandering behavior. This failure had the potential for residents to not received appropriate care.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide wound care treatment and services for one of 25 sampled residents, Resident 80's left heel deep tissue injury (DTI, serious type of pressure ulcer where the underlying tissue is damaged), not following the Physician orders and not consistent with the facility's policy and professional standards of practice. This failure has the potential for Resident 80 to develop worsening of his wound, increase deep pressure ulcer, slow wound healing process, pain, infection and possibly hospitalization. During a review of Resident 80's Face sheet (FC), the FC indicated Resident 80 is [AGE] years old newly admitted to the facility, less than 30 days. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to manage, label and store medications for one of one sampled resident, Resident 90, in an accurate, secure, and safe manner according to their facility's policy and procedures and standards of practice, when: 1. facility staff administered Amlodipine Besylate (drug used to treat high blood pressure) to Resident 90 from a medication package that was inaccurately labeled as Amlodipine Besylate 2.5 M instead of administering Amlodipine Besylate 2.5 mg as per physician orders. 2. Facility staff left one loose pill exposed in one of the drawers in medication storage room [ROOM NUMBER]. Findings 1: During a review of Resident 90's face sheet (FC), the FC indicated Resident 90 is [AGE] years old, admitted to the facility in 2023. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the vegetarian menu was followed in accordance with the menu guidance and facility policy. This failure had the potential to decrease the food intake of three unsampled residents (50, 38, and 26) on vegetarian diets, which could further compromise their nutritional status.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Arbitration Agreement (a binding agreement by the parties to submit to arbitration (a private process where disputing parties agree that one or several other individuals can make a decision about the dispute after receiving evidence and hearing arguments) all or certain disputes which have arisen or may arise between them in respect of a defined legal relationship, whether contractual or not. The decision is final, can be enforced by a court, and can only be appealed on very narrow grounds.) was explained in a manner that one of three sampled residents (Resident 520) understood. This failure resulted in Resident 520 signing the facility's arbitration agreement without full understanding.

Inspectors wroteBased on observation , interview and record review, the facility failed to protect one of three sampled residents (Resident 2) the right to be free of physical abuse, when Resident 1 slapped Resident 2's in the face. This failure caused repeated resident to resident altercations, emotional distress and potential to result in injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Resident 1 was free from physical abuse when: 1) Resident 1 was hit by another resident and sustained a bloody right lower lip, 2) Resident 1 was touched on the face by another resident (Resident 2) while in Activity room. This failure resulted to Resident 1 being the recipient of physical abuse which affected Resident 1's physical and psychosocial well-being.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure one of three sampled residents (Resident 1) had at least two staff members to assist Resident 1 when Certified Nursing Assistant 1 (CNA 1) performed incontinence care by themselves which resulted in Resident 1 falling from their bed. This failure resulted in Resident 1 falling from their bed sustaining a left arm and left leg fracture. Resident 1 was not suitable for surgery to repair the fractures and had to enter hospice care due to the injuries sustained in the fall.

Inspectors wroteBased on interview and record review, the facility failed to provide a written notice of rights and services prior to or upon admission for three of three sampled residents (Resident 1, Resident 2 and Resident 3), when: - For Resident 1, the admission agreement was provided more than nine months after Resident 1's admission to the facility. - For Resident 2 and Resident 3, there was no admission agreement provided during the residents' stay. This failure had the potential to result in Residents 1, 2 and 3 ' s lack of information and awareness of their rights and how to use them as residents of the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) or Resident Representative (RR), was provided written information that specified the duration of the state bed-hold policy (Bed-hold, holding or reserving a resident's bed while the resident is absent from the facility for therapeutic leave or hospitalization), how reserve bed payments would be made (if applicable), and the conditions upon which the resident would return to the facility. This failure had the potential to result in the lack of awareness of Resident 1's right to hold a bed during hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident environment was safe and comfortable when the patio area had refrigerator parts, a circular concrete pad approximately two feet across, two pieces of broken concrete, and two leaking water hoses puddling water by two resident patio doors. The failure to maintain the facility patio without clutter and hose-generated puddles had potential to cause ambulatory residents using the patio to trip and fall.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two sampled residents (Resident 2) received the correct medications and instructions upon discharge. The failure to follow discharge orders for medications had the potential to result in Resident 2 attempting to self-administer an injectable medication for prevention of blood clots without instruction on side effects or administration. This had the potential to result in injury and excessive bleeding.

Inspectors wroteBased on interview and record review, the facility failed to provide assistance for one (Resident 1) of two sampled residents who made reports of lost items. The failure to investigate or assist with replacement of the reported loss of Resident 1 ' s hearing aids resulted in Resident 1 not having use of hearing aids, potentially causing difficulties with medical and social interactions.

Inspectors wroteBased on interview and record review, the facility failed to ensure the treatment for scabies (a contagious, itchy skin rash caused by a tiny burrowing mite called Sarcoptes scabiei.) for one of two sampled residents (Resident 1) was carried out according to the physician order and instructions when Permethrin topical cream (used to treat scabies) was washed off two hours after application. There was no evidence the medication error was reported to the physician. This failure had the potential for Resident 1's scabies treatment to be ineffective and could lead to spread of Scabies to other residents and staff at the facility.

Inspectors wroteThe facility failed to ensure a Certified Nursing Assistant (CNA) 1 followed infection control protocols for one of one sampled Resident (Resident 1) when CNA 1 did not perform hand hygiene prior to feeding lunch to Resident 1. This failure had the potential for contaminating Resident 1's food with pathogens from a variety of dirty sources.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow infection prevention and control procedures when Certified Nursing Assistant (CNA) 1, did not wear Personal Protective Equipment (PPE, protective items or garments worn to protect the body or clothing from hazards that can cause injury and to prevent the transmission of infectious agents from one person to another, also known as cross-contamination) while providing care to Resident 1 who was on contact isolation). This failure had the potential to result in spread of infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the Registered Dietitian (RD) and/or Dietary Manager (DM) were competent to comprehensively evaluate and manage the food service operation for 118 of 118 residents, as evidenced by: 1. Lack of guidance and oversight of the DM. 2. Staff competency did not meet professional standards for food safety related to: (a) Time/Temperature Control Foods. (b) Recording refrigerator temperature readings. (c) [NAME] bucket with cleaning solution contained dirty cloth. 3. Nutritional values of food and menu not evaluated and approved by RD. 4. Lack of oversight of dietetic services physical environment. This failure put residents at risk for compromised nutritional status and potential transmission of food borne illness.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff were competent to meet professional standards for food safety for 118 of 118 residents when Dietary Aide (DA2): 1. Did not cool down a cucumber salad according to established time/temperature control guidelines or record it neither in the cool down log nor the tray line temperature record. 2. Did not record internal temperature readings for the reach-in refrigerator. 3. [NAME] bucket with cleaning solution contained dirty cloth. This failure put the facility at increased risk for food contamination and foodborne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store and prepare food in accordance with professional standards for safety when: 1. A resident food refrigerator contained items that were not labeled and/or dated. 2. Stored equipment and utensils that were dirty. 3. Food items in dry storage were left open. These failures put the facility at increased risk for food contamination and foodborne illness for 118 residents who received food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the outside garbage storage area was maintained in a sanitary condition when refuse and dark liquid waste was found on the ground surrounding the garbage receptacles. This failure put the facility at increased risk for attracting pests and potentially causing pest related disease in 118 of 118 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the following kitchen equipment was maintained in good repair when: 1. Reach-in refrigerator: the rubber gasket (a rubber piece that surrounds the inside perimeter of the door to help keep the cold air in) around the interior perimeter of all three the doors was torn or peeled away from the doors. 2. Reach-in freezer: the bottom right side of the rubber gasket on the left door was torn and peeled away from the door. 3. Chest freezer: the lid was broken off the hinges, the rubber gasket was torn across the top of the lid and there was ice buildup on the inside walls. [...]

Inspectors wroteBased on interview, and record review, the facility failed to complete and submit quarterly Minimum Data Set (MDS- an assessment tool used to plan care) assessments for nine of nine (9) sampled residents (Residents 25, 57, 65, 14, 18, 73, 60, 21 and 78). This failure placed Residents 25, 57, 65, 18, 73, 60, 21 and 78 at risk for unidentified changes in health conditions and potentially outdated plans of care for over a three (3) month period.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide nail care services to four of ten residents (Resident 50, Resident 54, Resident 199 and Resident 400 ). This deficient practice had the potential to result in complications related to a nail infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: ensure the removal of expired biological supplies that were stored in a medication room. This failure had the potential to result in resident using the expired testing supplies.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 400) was provided with facial hair care when Resident 400 had long, uneven (in length), white facial hair. This failure resulted in Resident 400 feeling unclean and not presentable.

Inspectors wroteBased on interview and record review, the facility failed to complete a performance review for two of three CNA's (Certified Nurse Assistant) at least once every 12 months. This failure had the potential to result in inadequate care and services provided to residents.

Inspectors wroteBased on observation, interview and record review, for five of 27 sampled residents, the facility failed to: 1. a. For Resident 276, there was no care plan developed to address purplish skin discoloration on the dialysis site. This failure had the potential to result in delayed management. b. For Resident 276, fall care plan was not implemented when bathroom floor was left wet with a puddle of fluid. This failure had the potential to result in fall accidents. 2. For Resident 114, hearing care plan was not implemented when audiology consult was not provided. This failure had the potential to result in decreased social interaction. 3. For Resident 81, smoking care plan was not implemented when supervision was not provided. This failure had the potential to result in burn and fire hazards. 4. [...]

Inspectors wroteBased on observation, interview and record review, for one of one sampled resident (Resident 114) who had difficulty hearing, the facility failed to provide treatment to maintain hearing abilities when facility did not arrange audiology consult as indicated. For Resident 114, this failure resulted in the inability to hear telephone conversations with family members had also the potential to result in social isolation while in the facility.

Inspectors wrote1. Review of the Dental Progress Notes, on 11/21/19 at 9:30 a.m., indicated Resident 178 was seen by the dentist (DDS) on 8/13/19. The progress note showed submitting for relines. During an interview, on 11/21/19 at 1:15 p.m., the Social Services Director (SSD) explained Resident 178's dentures were not properly aligned. In a telephone interview, on 11/21/19 at 1:20 p.m., the Dentists' office manager (DOM) stated the DDS received approval from Medi-Cal in mid-August to do the reline work for Resident 178's dentures. During an interview, on 11/22/19 at 3 p.m., the SSD stated she would get a copy of the dentist's visit with the residents. She stated sometimes it would take three to six weeks for denture reline work. [...]

Inspectors wroteBased on interview and record review, the facility failed to employ a qualified social worker on a full time basis. This deficient practice resulted in the residents' inability to attain or maintain their mental and psychosocial health by failing to identify the required services needed by the residents and ensure that these services were provided.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain infection control practices when: 1. Manufacturer's directions were not followed for the disinfection of three of three glucometers. 2. Resident 57's personal cup was placed on Resident 80's tray table during lunch. 3. Resident 50 was served meals on Resident 54's over bed table. These failures had the potential for the spread of germs and infections.

Inspectors wroteBased on observation, interview and document review, for one of three residents (Resident 80), the facility failed to provide a dignified dining experience when Certified Nursing Assistant (CNA) 1 remained standing while assisting Resident 80 with eating. This failure did not promote respect or dignity in dining for Resident 80 who required assistance during a meal.

Inspectors wroteBased on observation, interview, and record review, for one of two sampled residents (Resident 275), the facility failed to inventory all of Resident 275's personal belongings upon readmission to the facility. For Resident 275, this failure had the potential to result in the unrecognized loss or theft of personal belongings.

Inspectors wroteBased on interview and record review, the facility failed to ensure comprehensive Minimum Data Set (MDS - an assessment tool used to direct resident care) assessments were completed accurately and within the regulated timeframes for one (Resident 179) of 27 sampled residents. Resident 179's annual MDS was not completed within 14 days of the Assessment Reference Date (ARD - the date the signifies the end of the look back period). For Resident 179, this deficient practice had the potential to result in unassessed and unmet care needs.

Inspectors wroteBased on interview and record review, the facility failed to transmit an Annual Minimum Data Set (MDS - an assessment tool used to direct care) Assessment within the regulated timeframes for one (Resident 178) of 27 sampled residents. Resident 178's Annual MDS was not transmitted within 14 days of completion. For Resident 178, this deficient practice had the potential to result in unassessed and unmet care needs.

Inspectors wroteBased on observation, interview and record review, for one of one sampled resident (Resident 276) who was on dialysis (process when a machine filters the blood of wastes when the kidneys are not healthy enough to do it), the facility failed to develop a baseline care plan to address presence of peritoneal catheter (a small flexible, hollow tube that is surgically placed in the lower abdomen to withdraw excess fluid, a small piece of the tubing if left outside of the body that can be covered when not in use). For Resident 2796, this failure had the potential to result in infection around the catheter site without appropriate intervention.

Inspectors wroteBased on observation, interview and record review, for one of six residents (Resident 275) who were at risk of developing pressure ulcers, the facility failed to provide preventive skin treatment for Resident 275 when licensed nurses did not apply Dermaseptine as ordered to Resident 275's skin as ordered by the physician. For Resident 275, this failure had the potential to result in skin breakdown.

Inspectors wroteBased on observation, interview and record review, for two of four sampled residents (Resident 81 and 175) who were investigated for accident hazards, the facility failed to provide safe environment when: 1. Resident 81 was allowed to smoke unsupervised with two oxygen tanks on the back of his wheelchair. 2. Resident 81 was found in the middle of the driveway at the facility's north side parking lot unsupervised. For Resident 81, these failures had the potential to result in injury from fire or motor vehicle accidents. 3. Resident 175 had O2 being administered at 2 liters per minute (lpm) via nasal cannula (nc - a plastic tube with prongs that is inserted into the nose to deliver oxygen), but there was no O2 sign at the resident's door.

Inspectors wroteBased on observation, interview and record review, for one (Resident 175) of two sampled residents who were observed receiving oxygen (O2), the facility failed to ensure Resident 175 received the necessary respiratory care in accordance with professional standards of practice when Resident 175's oxygen saturation (amount of oxygen in the bloodstream) level was measured while Resident 175 was receiving O2. This failure had the potential to result in Resident 175 receiving incorrect amounts of oxygen.

Inspectors wroteBased on interview and record review, the facility failed to ensure Residents 74 and 76 had their medication regimen reviewed monthly by the consulting pharmacist. This failure had the potential for missed opportunities to prevent, identify, report, and resolve medication-related problems, medication errors, or other irregularities for Residents 74 and 76.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a safe and sanitary environment when a bathroom floor had a puddle of fluid that had strong unpleasant odor. This failure had resulted in an unsanitary environment and had the potential to result in accidents from a wet floor.

Inspectors wroteBased on interview and document review, the facility failed to ensure medical records for one of 27 residents (Residents 80) contained accurately documented records when Resident 80 had a medical document of another resident in her chart. This failure had the potential to result in Resident 80 receiving the incorrect dietary order.