East Bay Rehabilitation Center

Based on observations, interviews, and record review, the facility failed to ensure a clean, sanitary and maintained kitchen space to include: 1. Broken/missing trash receptacles at two of two hand washing stations; 2. A walk in freezer unit observed with heavy frosting crystallization on food items, shelving, and boxes of food items; 3. Overhead ceiling vents and ceiling tiles located above food prep and food service stations with dust and debris, 4. Various rusted areas near washed/sanitized cups and eating ware; and 5. Staff not wearing hair/beard covers appropriately while at food preparation and food service stations during three of four days observed, (2/12/2024, 2/13/2024, 2/14/2024). Findings included: 1. On 2/12/2024 at 9:07 a.m., the facility's kitchen was entered and toured with the Certified Dietary Manager (CDM). The hand washing sink was in a room next to the dish washing machine. The CDM stated he had only been back at the facility for two weeks, but has been employed at the facility about four years. A foot pedal operated trash receptacle was positioned at the right…

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 observations, interviews, and record review, the facility failed to implement interventions in the comprehensive care plan one resident (#90) of three resident sampled. Findings included: A review of the admission record showed Resident #90 was admitted to the facility on [DATE] with diagnoses including disorder of the skin and subcutaneous tissue, adult failure to thrive, cachexia (unintentional weight loss), and abnormal weight loss. A review of the active orders, as of February 2024, showed the following: -Bilateral heel elevation boots when in bed every shift. Remove for skin checks, hygiene and all cares as needed. Start date 4/5/23. A review of Resident #90's quarterly Minimum Data Set (MDS), dated [DATE], revealed the following: -Section C-Cognitive Patterns: Brief Interview for Mental Status (BIMS) score of 7, indicating severe cognitive impairment. -Section M M1200-Skin Conditions: requires pressure relieving devices while in bed and requires substantial/ maximal assistance (helper does more…

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 observations, interviews, and record review, the facility failed to ensure one resident (#98), who was dependent on staff for eating assistance, received eating assistance in a manor to promote a safe and comfortable eating experience out of forty-seven sampled residents during one observed meal (12/12/2024) of one meal observed. Findings included: On 2/12/2024 at 11:55 a.m. an observation in the main dining room during the lunch meal was conducted. There were two sections of the dining room. A large section with ten tables where residents who dine and eat without eating assistance, and a smaller section with six tables where residents were assisted with their meals. Residents who dine in the small assistive dining room, require forms of assistance to include cueing, supervision or assistance with eating activities. Resident #158 was observed seated in a wheelchair at a table along with Resident #98, who was lying back in a reclined Geri chair. Resident #98 was observed with sheets covering her entire…

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 observations, interviews, and record review, the facility failed to provide quality care and services related to wound care for one resident (#88) out of 5 sampled residents. Findings included: Review of Resident #88's admission Record revealed he was admitted to the facility on [DATE] from an acute care hospital. His diagnoses included weakness, altered mental status, need for assistance with personal care, cognitive communication deficit, muscle weakness, and a history of falling. An observation was conducted on 02/12/24 at 10:02 AM. Resident #88 was observed to have a bandage on his right shin which was not dated and was soiled with brownish yellowish drainage. Resident #88 said the bandage had been changed a few days ago. He said he can't remember how he got the wound. (Photographic evidence obtained) An interview was conducted on 02/12/24 at 12:28 PM with Resident #88's family member. The family said Resident #88 gets skin tears very easily. The family member said he was at the facility on…

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 observations, interviews, and record review the facility failed to ensure 1) Medication pill splitters were maintained in a clean and sanitary manner in two of four medication carts, and 2) discontinued resident medications were disposed of within thirty days in two of two medication rooms. Findings included: On [DATE] beginning at 8:10 a.m. the Medication Storage facility task was conducted with Staff J, LPN Unit Manager, (LPM, UM). The following observations were noted: -In two of the facility's two medication storage rooms resident medications were stores in cardboard boxes labeled personal (Photographic Evidence Obtained). The boxes contained medication containers without a resident's name or the contents. -A clear amber pill bottle without a resident's name and the word Pepcid written on the lid, contained three different pill shapes and sizes (a capsule, a white round tablet, a white oblong tablet). (Photographic Evidence Obtained). - A three-section amber pill organizer was also in the box.…

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 observations, interviews, and record review, the facility failed to follow infection control guidelines related to hand hygiene during two of six medication administration observations. Findings Included: On 2/13 /2024 at 8:30 a.m. Staff M, Registered Nurse (RN) was observed during medication administration for Resident #37. Staff M did not perform hand hygiene before beginning the procedure. Staff M, RN prepared seven medications for the resident and administered them as ordered. An interview was conducted with Staff M and she stated she did not perform hand hygiene prior to her medication administration. Staff M stated she did not follow the hand hygiene policy. On 2/13/2024 at 8:50 a.m. Staff N, RN was observed during medication administration for Resident #358. Staff N, RN did not perform hand hygiene before beginning the procedure. Staff N, RN prepared twelve medications for the resident and administered them as ordered. An interview was conducted with Staff N and she stated she did not perform hand hygiene prior to her medication administration. Staff N stated she did…

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 observations, record reviews, and interviews, the facility failed to store, distribute, and prepare food in accordance with professional standards for food service safety related to food stored underneath vents with an excessive amount of black build up in the mechanical room, a window blind with an excessive amount of dust and black build up directly behind food in the mechanical room, water stored on the floor in the mechanical room, a broken foot petal device on the trash can at the hand washing sink, inappropriate storage of utensils, and black buildup on the ice machine. Findings included: On 11/02/21 at 9:47 a.m., the Kitchen Manager reported that the hurricane supply was stored in the mechanical rooms, and he would have to get a key to open the door. At 9:49 a.m., the Kitchen Manager returned with the key and escorted the surveyor to the mechanical room next to the conference room near the 200 unit. The vent above cases of mashed potatoes, graham crackers, canned tuna, and juices was observed with an excessive amount of black build up. The window blind behind cans 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to promote and honor resident rights for three (Residents #96, #106, and #20) of 15 sampled residents, related to ensuring that dignity was maintained related to urinary drainage bags. Findings included: 1) A review of Resident #96's admission record revealed that she was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included severe sepsis with septic shock, urinary tract infection, and acute cystitis without hematuria. A review of Resident #96's most recent Minimum Data Set (MDS) dated [DATE], documented in Section C (Cognitive Patterns) that Resident #96's cognition was intact with a Brief Interview for Mental Status (BIMS) score of 15. Review of Section G (Functional Status) reflected that Resident #96 required physical assistance with toileting, bed mobility, and supervision with eating. Section H (Bladder and Bowel) indicated that she had an indwelling catheter. On 11/02/21 at 11:18 a.m.,…

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 observations, staff interviews, and medical record review, the facility failed to ensure care plans were followed related to checking for incontinence and repositioning for one (Resident #89) of fifty one sampled residents. Findings included: On 11/4/2021 from 7:20 a.m. -10:22 a.m., Resident #89 was observed seated in a fully reclined [Brand name] chair, positioned in the [NAME] unit television/activity lounge, which was directly across from the nurses' station. Resident #89 was positioned in the lounge and in front of the television. She was observed lying in a manner where she could watch the television. She was observed in the same position and without staff checking on her or interacting with her from at least 7:20 a.m. through to 10:22 a.m., which was over three (3) hours. During this period, staff did not speak with her, offer her hydration, nor repositioned her. Resident #89 was noted as dressed for the day and had a blanket over most of her body up to her neckline. She was observed with padding…

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 medical record review the facility failed to honor the bathing preference of a shower for one resident (#75) of forty nine sampled residents. Findings included: On 2/17/2020 at 9:35 a.m. a family member was observed at the 100-unit nursing station asking the nurse, Is my father going to get his shower this morning. She then asked the nurse for towels as she was heard saying my father has food in his beard. At 10:37 a.m. an interview was conducted with Resident #75's daughter and she said that she had concerns with her father getting his weekly showers since he had been admitted . Resident #75's daughter stated, My father is supposed to get two showers a week and that has not been happening. The daughter was asked if she had told anyone about her concerns, she stated, I told his nurse today. I went to the desk this morning and had to ask for towels. My father had food in his beard this morning when I got here. I know he didn't get his shower this morning. Resident# 75's…

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 upon observation, interviews, and record review the facility failed to appropriately secure medications in two medication carts (#2 East Hall, #1 [NAME] Hall) of four medication carts sampled. Findings included: A review of the facility policy titled, Medication Storage in the Facility, Page 48, with a revision date of August 2014, reads under Procedures: A. The provider pharmacy dispenses medications in containers that meet regulatory requirements, including standards set forth by the United States (USP). Medications are kept in these containers. C. All Medications dispensed by the Pharmacy are stored in the container with the pharmacy label. On 02/20/2020 at 11:25 a.m., an observation of the East Hall Medication Cart #2 was conducted. The second drawer from the top of the medication cart contained a one-half (½) loose orange tablet, and in the back of the drawer it was observed that one-half (½) of a pink tablet was also loose amongst the punch cards in the drawer. Staff D, Registered Nurse (RN) confirmed the presence of the unsecured tablets. (Photographic Evidence…

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 review of the Centers for Disease Control and Prevention guidelines, the facility failed to ensure that direct caregivers (Staff G, Staff I and a Therapy Tech) followed standard infection control precautions related to artificial nails and nail length. Findings included: On 2/17/20 at 12:15 p.m. lunch trays were being distributed to residents in the 100-hallway. Staff G, Certified Nursing Assistant (CNA) was observed delivering meal trays to multiple resident rooms. She was observed to have fingernails approximately one inch in length from the nail bed. She was observed to use a hand sanitizer as she rubbed the front and back of her hands with no care to the front or under sides of her fingernails. On 2/17/20 at 2:00 p.m. Staff G, CNA was observed leaving a resident room in the 100-hallway. She was carrying a clear colored plastic bag that contained an incontinent product. She went to the soiled utility room as she disposed of the bag. She was observed to have fingernails approximately one inch in length from the nail bed. She was…

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.