Bay Area Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify the physician of Resident 1's changes in condition when:1. Resident 1 developed warmth and tenderness on the left knee2. Resident 1 experienced episodes of respiratory distressThese failures could result in delayed medical evaluation by the physician including interventions that may be ordered by the physician on the resident.Findings:A review of resident 1's admission Record (AR), printed on 1/29/26, indicated, Resident 1 was admitted to the facility on [DATE].A review of Resident 1's Progress Note (PN), dated 6/2/25, indicated, that Resident 1 had diagnoses that included Hypertension (high blood pressure), Prediabetes, Atherosclerosis of Aorta (the main large blood vessel coming out of the heart becomes hardened and narrowed because fatty build up inside the blood vessel walls), a right distal humerus (elbow) fracture, and a frontal bone (facial bone) fracture resulting from an accidental fall.On 2/9/26 at 10:23 a.m., a record review of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, for one of two sampled residents (Resident 1), the facility failed to implement written policies and procedures when an abuse allegation was not reported to the State Survey Agency and to the Law Enforcement.This failure resulted in the abuse allegation not being formally investigated by the State Survey Agency.During a review of Resident 1's admission Record (AR) printed 1/29/26, the AR indicated Resident 1 was admitted to the facility in December 2019 with diagnoses that included dependence on respirator (ventilator, a life-support machine that breathes for patients unable to do so independently) status, unspecified intellectual disabilities, muscular dystrophy (progressive weakness and degeneration of skeletal muscles, often leading to reduced mobility and, in some types, heart or breathing issues) and myoneural disorder (progressive muscle weakness, wasting, spasms or fatigue).During a review of Resident 1's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 1/13/26, the MDS indicated a Brief Interview for Mental…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, for one of two sampled residents (Resident 2), the facility failed to ensure medical records were accurately documented.This failure had the potential to result in gaps in communication and uncoordinated care.During a review of Resident 2's admission Record (AR) printed 1/29/26, the AR indicated Resident 2 was admitted to the facility in on 11/3/25 with diagnoses that included type 2 diabetes mellitus (high blood sugar resulting from insulin resistance or insufficient insulin production), chronic kidney disease (a long-term condition characterized by a gradual loss of kidney function over months or years), and left hemiplegia (paralysis that affects only one side of the body).During a review of Resident 2's Weekly Pressure Ulcer Injury Record (WPUIR) dated 11/3/25, the WPUIR indicated Resident 2 had a Stage II pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, pressure ulcer is damage to skin and underlying tissue…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure 1 (Resident #6) of 1 resident reviewed for self-administration of medications was assessed to determine if they were clinically appropriate and safe to administer their own topical medications. Findings included: A facility policy titled, Self- Administration by Resident, dated 2007, revealed, Residents who desire to self-administer medications are permitted to do so with a prescriber's order and if the nursing care center's interdisciplinary team has determined that the practice would be safe, and the medications are appropriate and safe for self-administration. The policy also indicated, 1. If the resident desires to self-administer medications, an assessment is conducted by the interdisciplinary team of the resident's cognitive, physical, and visual ability to carry out this responsibility, during the care planning process. 2. The interdisciplinary team determines the resident's ability to self-administer medication by means of a skill assessment conducted as part of the care…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, record review, and facility document and policy review, the facility failed to dispose of expired medications that were stored on 1 of 5 medication carts. Findings included: A facility policy titled, Storage of Medications, dated 2007, revealed, 14. Outdated, contaminated, discontinued or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal. An undated facility document titled, Following Meds [medications] Expired After Opening revealed latanoprost eye drops expired 42 days after opening. A concurrent interview and observation of the Station 2 medication cart with Licensed Vocational Nurse (LVN) #7 on 02/26/2025 at 11:18 AM revealed two bottles of latanoprost eye drops. One bottle was labeled for Resident #16 and had an open date of 01/01/2025, and the other bottle was labeled for Resident #1 and had an open date of 01/08/2025. LVN #7 confirmed the bottles of latanoprost for Resident #16 and Resident #1 were…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interviews and record review, the facility failed to ensure storage of food under sanitary conditions when the following food items were not labeled and dated with use-by date in refrigerator: -Three gallons of milk opened not dated; - Bottle of pickle relish opened not dated; - One container of garlic spread opened not dated; - Bowl of cooked minestrone dated 4/23/23; - One container of low fat cottage cheese opened dated 4/21/23; - One bottle of horse Radish opened not dated ; - Bowl of crushed garlic not labeled or dated; - One container of low fat cottage cheese opened not dated; - One Med Pass 2.0 nutritional shake vanilla opened dated 2/3/23; - One bottle of yellow mustard opened dated 4/6/23; - One bottle of mayonnaise opened an dated 4/6/23; - One tray of dispensed cups with juice and milk beverage dated 4/25/23; - Two trays of dispensed cups of beverage not label or dated; - One bottle of caramel sauce opened and dated 12/2/22; - One can of peanut butter opened and dated 3/24/23; - Bowl of cooked yam dated 4/25/23; These failures had the potential to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure controlled medications (medications with high potential for abuse or addiction) were available and given according to the Physician's Order and fully accounted for, when: A random controlled medication use audit for three out of three residents (Residents 20, Resident 1 and Resident 19) indicated that Morphine (a potent medication for pain) was not administered as prescribed for Resident 20, and medications were documented as given to the Resident 1 and Resident 19 on the Medication Administration Records (MAR), but were not signed out of the Control Drug Record (CDR, an inventory sheet that keeps record of the usage of controlled medications). These failures resulted in Resident 20 enduring unnecessary pain, and had the potential to result in loss, misuse, and/or diversion of controlled prescription medications. Findings: During a random controlled drug audit, the CDRs of three residents (20, 1 and 19) were reviewed during the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure the medication error rate did not exceed 5% for 2 of 4 sampled residents (Resident 29 and Resident156) when: 1. Resident 29 was not administered Chlorhexidine solution (a prescription oral rinse that prevents the growth of bacteria in your mouth and reduces inflammation in gums) 15 ml (milliliter, unit of measurement) per manufacturer's guidelines. 2. Resident 156 was not administered oxycodone (a pain medication) 5 mg (milligram, unit of measurement) as prescribed by the physician. This failure resulted in 2 medication errors being identified out of 28 opportunities during an observation of medication administration which then resulted in the facility having a medication error rate of 7.14%. Findings: 1.During a review of Resident 29's admission Record, dated 5/2/23), the admission record indicated, Resident 36 was admitted to the facility in March of 2023 with multiple diagnoses including broken internal left hip prosthesis (an artificial body part) and left hip pain. During a medication pass…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure 1 resident in a census of 58 (Resident 156) was free from significant medication error when: For Resident 156, Oxycodone (a potent pain medication) was not administered as prescribed by the physician. This failure resulted in Resident 156 suffering from moderate to severe pain. Findings: During a review of Resident 156's admission Record dated 5/4/23, the admission Record indicated, Resident 156 was admitted to the facility in April of 2023 with multiple diagnosis including right femur (thigh bone) fracture, and chronic gout (painful swelling of the big toe joint). During an observation and interview on 5/02/23, at 9:04 a.m., with Licensed Vocational Nurse (LVN) 2 and Resident 156, Resident 156 stated, she wanted to do Rehab therapy (a care that can help you get back, keep, or improve abilities that you need for daily life) for pain management) time and that she was in severe pain every time she moved in bed. LVN 2 stated that she was unable to find her prescription pain medication in the medication…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure pharmaceutical products were stored and labeled correctly, when: 1a. One open and expired medication for Resident 356 was in the medication cart, which put residents 356 at risk of receiving expired medication, 1b. One expired can of test strip was in the medication cart, which put all residents at risk of receiving testing with expired test strips. 2a. One opened bottle of medication in the medication cart was not labeled, which put all residents at risk of receiving expired or outdated medication, 2b. Two expired medications were for Resident 28 and 44 were in the medication cart, which put residents 28 and 44 at risk for receiving expired medications. 2c. One expired medication was in the treatment cart, which put all residents at risk for receiving expired medications. 3a. One expired medication was in the medication cart, which put all residents at risk for receiving expired medications. 3b. One expired medication for Resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.