Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Bay Marina Post Acute during CMS and state inspections, most recent first.
Nursing staff did not obtain timely dental services for a resident who was cognitively able to report symptoms and complained of toothache, burning gums, difficulty chewing, and ongoing pain, despite documented missing/broken teeth and irritated gums. An RN recorded significant oral findings and notified the physician, but the dental consult was not actually scheduled until seven days later. Key staff, including the RD and an RN caring for the resident, were unaware of the dental issues, while the DON confirmed ongoing oral discomfort managed only with pain medication. A later hospital CT showed numerous bilateral dental caries, and the consulting DDS stated he would have expected immediate notification and clearer communication from the facility when the resident first reported oral pain.
A resident with cognitive impairment, history of traumatic brain injury, ataxia, and repeated falls was discharged via Uber to an assisted living setting without documented pre-discharge planning or a discharge care plan, despite facility policy requiring early and coordinated discharge planning. Although a medication list was documented as sent to the next provider, it was not provided to the resident, and a home health RN later found the resident without discharge medications or a medication list and had to obtain this from the facility. The Discharge Planning Review Form was completed after the discharge and lacked the resident’s or family member’s signature, and there was no documented follow-up with the family member who had previously contacted the facility about discharge and financial benefit arrangements. Assisted living staff reported the resident’s unsafe wandering, unusual gait without a walker, and episodes of leaving and becoming homeless, while the assisted living owner noted uncertainty about who controlled the resident’s financial benefits.
A resident with end stage renal disease developed new skin discoloration on the face and hand, which was documented by staff but not reported to the charge nurse or investigated as required by facility policy. Interviews confirmed that nursing staff did not follow procedures for reporting and investigating changes in condition.
Two residents receiving dialysis did not receive their prescribed medications as ordered due to unavailability in the medication cart. Staff substituted medications with incorrect dosages or alternative products, including using medications labeled for other residents and lower doses than prescribed. The facility did not follow its policy to reorder medications in advance, resulting in missed or incorrect medication administration.
The facility did not ensure that a resident's transfer or discharge was conducted in a manner that met their needs and preferences, nor did it adequately prepare the resident for a safe transition.
A resident with a history of stroke experienced emotional distress after a CNA yelled, used profanity, and made derogatory remarks in response to a comment from the resident. The CNA's actions were in direct violation of the facility's abuse prevention policy, which prohibits verbal mistreatment.
A CNA verbally abused a resident with a history of stroke, and despite the facility's policy requiring immediate removal of staff accused of abuse, the CNA continued to provide direct care after the incident. Time records confirmed the CNA worked additional shifts before separation, contrary to established abuse reporting procedures.
A resident with hypertension and epilepsy, who was cognitively intact, was physically and verbally abused by a visitor who entered a shared room, accused the resident of theft, and slapped the resident in the face, causing an abrasion and pain that required emergency evaluation. Staff attempted to intervene, but the visitor continued the abusive behavior before eventually calming down.
A resident with a history of hypertension and epilepsy, who was cognitively intact, reported being physically assaulted by a visitor, resulting in a visible injury. The facility failed to thoroughly investigate the incident, did not interview all staff witnesses, and did not submit the required investigation summary to the State Survey Agency within five working days, as mandated by policy.
A resident's family member reported to staff that a nurse called the resident 'stupid,' but both an RN and a Medical Records staff member failed to notify CDPH or the Ombudsman or submit the required SOC 341 abuse report within the facility's mandated two-hour timeframe.
Two residents experienced deficiencies related to accident hazards and supervision: one resident with neurological and mobility impairments was provided a bed with wheels that did not lock, causing fear of falls, while another resident with a history of TBI and depression, assessed as at risk for elopement, was left unsupervised during smoking and left the facility undetected, with no care plan or investigation documented.
A resident with a history of hemiparesis and hemiplegia fell during a physical therapy session. The PTA guided the resident to the floor, but the LVN failed to assess the resident for injuries or notify the doctor, resulting in delayed treatment for a hip fracture. The facility's policy requires immediate assessment and notification following falls.
The facility failed to honor the dietary preferences of two residents, leading to a deficiency in resident self-determination. One resident, with a diagnosis of Adult Failure to Thrive, was served turkey salad despite disliking turkey, while another resident with Unspecified Protein-Calorie Malnutrition was given milk against their preference for juice. The facility's policy to provide meals consistent with residents' preferences was not followed.
A resident with end-stage renal disease felt upset and disrespected after a Rehabilitation Coordinator told him he was being kicked out of the facility. The incident, witnessed by an RN, was not handled according to the facility's policies on resident rights and discharge procedures. The Social Worker and Director of Nursing confirmed that the resident was not ready for discharge and that the RC's actions were inappropriate.
A resident with Neuralgia and Neuritis did not receive their prescribed Gabapentin on two occasions due to unavailability. The facility staff failed to notify the physician or obtain a new order to skip or delay the dose, contrary to the facility's medication administration policy.
A resident with dementia and delusional disorder threw a flower vase at her roommate, causing a lip wound and hospital transfer. The facility was aware of ongoing conflicts and previous aggressive behavior but failed to implement a care plan to prevent such incidents, violating their abuse prevention policy.
The facility failed to maintain proper food storage and preparation standards, with the walk-in fridge exceeding safe temperatures and beverages stored improperly. Ground beef was thawing without proper labeling or logs, and the kitchen environment was excessively hot, with an ineffective AC unit. These conditions risked food contamination for 90 residents.
A resident was moved to a different room without receiving the required written notification explaining the reason for the change. The resident, who was cognitively intact, was informed verbally on the day of the move, but the Social Service Director did not provide a written notice as required by the facility's policy.
A resident was denied re-admission to a facility after hospitalization, despite available beds. The resident, with a history of hemiplegia and other conditions, was discharged from a hospital following neurosurgery. Facility staff cited non-compliance as the reason for refusal, although the resident wished to return.
A resident with severe cognitive impairment showed signs of difficult breathing and tested positive for COVID-19, but the LVN failed to notify the physician or family. The LVN placed the resident on oxygen but did not report the condition change to another LVN during her break. Upon returning, the resident was found unresponsive, leading to a Code Blue. Facility policy requires immediate notification of such changes, which was not followed.
The facility failed to provide appropriate foot care for two residents, resulting in significant discomfort and potential health risks. Both residents had overgrown, discolored, and thickened toenails, and had not received podiatry services for over four months. Despite requests for nail care, the facility did not provide the necessary services, and records lacked documentation of any offers or declinations of toenail care.
Failure to Provide Timely Dental Consultation for Resident with Oral Pain
Penalty
Summary
Facility nursing staff failed to provide timely dental services after a resident reported significant oral pain. The resident, who had a history of hemiplegia following a stroke and documented missing or broken teeth, was cognitively able to report symptoms and did so, describing toothache, burning sensations in the upper and lower gums, difficulty chewing, and ongoing pain. An eInteract Change in Condition Evaluation completed by an RN on 3/9/2026 documented the resident’s report of toothache with burning gums, multiple missing and dark discolored teeth, cracked teeth, loss of lower teeth, and irritated gums. The physician was notified and a referral for a dental consultation was noted, and progress notes on 3/10/2026 indicated staff were monitoring the toothache and burning gum sensation, with gums described as slightly irritated and the resident continuing to report discomfort. Despite these findings and the facility’s Oral Healthcare & Dental Services policy stating that a consultant dentist would provide emergency dental care as needed, the actual dental consult was not scheduled until 3/16/2026, seven days after the initial complaint of oral pain. During interviews, the RD and an RN caring for the resident stated they were unaware of any issues with the resident’s teeth or chewing, and the DON confirmed the resident’s oral discomfort and that staff continued to administer pain medication. The DON acknowledged that nursing staff should have been more proactive in addressing the symptoms, which could indicate infection. A CT head and neck angiography performed at the hospital later showed numerous bilateral dental caries, and the dental consultant stated he would have expected immediate contact from staff upon the resident’s complaint of oral pain and emphasized the need for clear communication from the facility to his office. The resident reported still having pain during a subsequent interview.
Failure to Implement Effective Discharge Planning Leading to Post-Discharge Instability
Penalty
Summary
The facility failed to develop and implement an effective discharge planning process for a resident with multiple cognitive and physical impairments. The resident was admitted with diagnoses including cognitive communication deficit, a history of traumatic brain injury, ataxia, and repeated falls, and had a BIMS score of 12 indicating moderate cognitive impairment. The facility’s own policy required that discharge planning begin upon admission, with an initial discharge assessment within seven days and a discharge care plan developed by Social Services with the IDT. However, the Director of Nursing confirmed that the clinical record contained no evidence of discharge planning prior to the actual discharge date and no discharge care plan was developed. An IDT note documented that a family member had contacted the facility about discharge plans and was working on financial benefits, but there was no further documentation of coordination or follow-up with the family member regarding these plans. On the day of discharge, the resident was sent in an Uber to an assisted living facility with medications and a medication list documented as provided to the subsequent provider, but not to the resident. The Discharge Planning Review Form was completed and signed the day after discharge and lacked the resident’s or family member’s signature. Following discharge, a home health RN reported that when she assessed the resident for home health admission, the resident did not have a medication list or discharge medications, requiring the home health office to contact the facility for this information. Staff at the assisted living reported that the resident claimed to self-administer medications but did not show which medications, ambulated without a walker in an unusual manner, and frequently wandered off to an unknown shelter. The assisted living owner reported that the resident occasionally left the home, sometimes becoming dirty after being homeless for a few days, and that although the resident received financial benefits, they did not know who the payee was or who was receiving the money.
Failure to Report and Investigate Change in Resident Condition
Penalty
Summary
The facility failed to ensure that a change in a resident's condition was reported and properly investigated. A resident with multiple diagnoses, including end stage renal disease, was noted in progress notes to have new skin discoloration on the face and hand, and subsequently on the left eye and nose over several days. Despite these documented changes, nursing staff did not report the new skin discoloration to the charge nurse, and no investigation into the cause of the discoloration was initiated by the facility. Interviews with facility staff confirmed that nurses are expected to report any change in a resident's condition to the charge nurse for further investigation, as outlined in the facility's policy on unusual occurrence reporting. However, the responsible LVN admitted to not reporting the discoloration, and the Minimum Data Set Coordinator confirmed that no investigation was conducted. This failure to follow reporting and investigation procedures resulted in the deficiency.
Failure to Provide and Administer Prescribed Medications for Dialysis Residents
Penalty
Summary
The facility failed to ensure that routine medications were available and administered as ordered for two residents receiving dialysis. For one resident with end stage renal disease, hyperlipidemia, and gastro-esophageal reflux disease, several prescribed medications were not present in the medication cart, including atorvastatin, famotidine, Nephro-Vite Rx, sevelamer hydrochloride, and metoclopramide. Instead, staff administered alternative medications not matching the physician's orders, such as using a higher dose of famotidine labeled for another resident, substituting regular multivitamins for Nephro-Vite Rx, using sevelamer meant for a discharged resident, and giving a lower dose of metoclopramide than prescribed. For another resident with end stage renal disease and chronic pain syndrome, the required medications calcium carbonate 1250 mg and nortriptyline 75 mg were not available in the medication cart. Staff administered a lower dose of calcium carbonate than ordered. The facility's policy required medications to be reordered five days before they were needed, but this process was not followed, resulting in the unavailability of necessary medications for these residents.
Failure to Ensure Safe and Appropriate Transfer/Discharge
Penalty
Summary
The facility failed to ensure that the transfer or discharge process met the resident's needs and preferences, and did not adequately prepare the resident for a safe transfer or discharge. The report identifies that the necessary steps to assess and address the resident's individual requirements and preferences during the transfer or discharge process were not completed. There is no mention of specific residents, medical history, or conditions at the time of the deficiency.
Verbal Abuse by CNA Resulting in Resident Distress
Penalty
Summary
A resident with a history of stroke and no documented behavioral symptoms reported that a Certified Nursing Assistant (CNA) entered his room, yelled, and used profane language towards him. During an interview, the facility administrator confirmed that the CNA admitted to telling the resident, 'You are ugly too,' after the resident allegedly called her ugly. The resident stated that the CNA used to curse at him and that the situation caused him emotional distress. The facility's abuse prevention policy prohibits any form of resident abuse, including verbal mistreatment, but the CNA's actions violated this policy.
Failure to Immediately Remove Staff Following Alleged Verbal Abuse
Penalty
Summary
A certified nursing assistant (CNA) verbally abused a resident by yelling and cursing at them during the night. The resident, who had a history of stroke but no behavioral symptoms such as hallucinations or delusions, reported the incident to staff. The CNA admitted to responding to the resident with a derogatory comment after the resident made a remark about her appearance. The resident stated that the CNA had previously cursed at him and that the situation was upsetting. Despite the facility's policy requiring immediate suspension and removal of staff accused of abuse during an investigation, the CNA continued to provide direct care to residents following the reported incident. Time card records confirmed that the CNA worked additional shifts after the alleged abuse before her official separation from the facility. This failure to immediately remove the CNA from resident care did not align with the facility's established abuse reporting procedures.
Failure to Protect Resident from Abuse by Visitor
Penalty
Summary
A deficiency occurred when a family member (FM) of a resident entered a shared room and physically and verbally abused another resident. The FM, who was upset and accused staff of mistreating her sibling, began yelling, throwing objects, and then slapped the other resident in the face. The resident, who had a history of hypertension and epilepsy and was cognitively intact according to a recent BIMS assessment, sustained an abrasion on the left eyelid and complained of pain, which led to an emergency department evaluation. Multiple staff interviews confirmed that the FM was visibly upset, made threats, and accused the resident of stealing a TV remote. The FM physically attacked the resident, holding his arms and slapping him, while also calling him derogatory names. Staff, including a registered nurse and an infection preventionist, attempted to intervene and de-escalate the situation, but the FM continued to yell and refused to leave the room immediately. The resident appeared frightened and asked the FM to go away. Documentation in the resident's medical record, including an eINTERACT Change in Condition Evaluation and interdisciplinary team notes, confirmed the physical injury and the circumstances of the incident. The facility failed to protect the resident from abuse by a visitor, resulting in physical harm and emotional distress.
Failure to Investigate and Report Alleged Physical Abuse
Penalty
Summary
A deficiency occurred when the facility failed to thoroughly investigate an alleged incident of physical abuse involving a resident and a visitor, and did not report the results of the investigation to the State Survey Agency within the required five working days. The incident involved a resident with a history of hypertension and epilepsy, who was cognitively intact at the time, and who reported being physically assaulted by the sister of another resident. The visitor entered the room, accused staff of mistreatment, became agitated, and physically struck the resident, resulting in a scratch and discoloration on the resident's eyelid. This account was corroborated by a registered nurse who witnessed the aftermath and documented the injury. Despite the seriousness of the allegation and the visible injury, the facility administrator was unable to provide evidence that all staff who witnessed the incident were interviewed as part of the investigation. The administrator only provided a handwritten note from an interview with the alleged perpetrator, who denied the incident, and acknowledged that the investigation summary was not completed in a timely manner. Additionally, the administrator did not review or reconcile the nurse's documentation with the visitor's denial. The facility's policy required a written report of the results of all abuse investigations to be submitted to the California Department of Public Health Licensing and Certification within five working days of the reported allegation. However, the investigation summary was not completed or sent within this timeframe, and there was no evidence of a comprehensive investigation as required by policy.
Failure to Timely Report Alleged Abuse to Authorities
Penalty
Summary
The facility failed to follow its policy and procedure to immediately report an alleged abuse incident involving a resident. Specifically, the sister of a resident with a diagnosis of chronic pain informed both a Registered Nurse (RN) and a Medical Records (MR) staff member that an unknown nurse had called the resident 'stupid.' Both the RN and MR staff acknowledged that they did not complete or submit a Report of Suspected Dependent Adult/Elder Abuse (SOC 341) to the California Department of Public Health (CDPH) or the Ombudsman, nor did they notify these authorities of the alleged abuse as required. The facility's policy, revised in March 2018, mandates that the Administrator or designated representative notify CDPH, the Ombudsman, and Law Enforcement by telephone within two hours of an abuse allegation, and submit a written SOC 341 report within the same timeframe. Despite this, the initial notifications and required documentation were not completed by the staff members who first received the allegation, resulting in a delay in reporting the incident to the appropriate authorities.
Failure to Prevent Accident Hazards and Inadequate Supervision
Penalty
Summary
Two deficiencies were identified regarding the facility's failure to provide an environment free from accident hazards and to ensure adequate supervision of residents. For one resident with a history of epilepsy, hemiplegia, hemiparesis, right foot drop, and previous falls, the facility replaced her bed with one whose wheels did not lock. The resident, who was cognitively intact, reported that the bed moved whenever she repositioned herself, causing fear of falling. The Environmental Service Director confirmed the bed had been replaced two weeks prior but was unaware of any current issues with the bed. Another deficiency involved a resident with a history of myocardial infarction, depression, traumatic brain injury, and a need for assistance with personal care. This resident was assessed as being at risk for elopement upon admission, but the elopement evaluation lacked clinical suggestions or comments, and no baseline care plan was created to address the risk. Documentation showed that the resident was last seen after requesting to smoke and subsequently left the facility undetected. Multiple staff notes confirmed the resident's absence, and at the time of the survey, the facility did not know the resident's whereabouts. The facility's policy required assessment of elopement risk upon admission and documentation of preventative interventions, as well as specific actions to be taken if a resident was found missing. However, the clinical record did not indicate that these procedures were followed, and there was no documentation of an investigation or contact with the resident or family after the elopement.
Failure to Assess and Notify After Resident Fall
Penalty
Summary
The facility failed to ensure that their skilled nursing licensed staff provided care based on professional standards for a resident who experienced a fall. The resident, who had a history of hemiparesis and hemiplegia following a cerebral infarction, was participating in a physical therapy session aimed at strengthening her core. During the session, the resident leaned forward unexpectedly, and the Physical Therapy Assistant (PTA) guided her to the floor. Despite the fall, the licensed nurse did not immediately assess the resident for injuries or notify the doctor, which is a requirement according to the facility's Fall Management Program. The incident resulted in unnecessary pain and a delay in treatment for the resident, who was later found to have sustained a left hip fracture. The PTA reported the fall to the Licensed Vocational Nurse (LVN) and the Director of Rehabilitation, but there was no documentation indicating that the doctor was notified or that an immediate assessment was conducted. The LVN acknowledged the importance of assessing the resident and notifying the doctor following a fall, but failed to do so in this instance. The facility's policy requires that the Director of Nursing and/or the Administrator be notified of fall incidents as soon as possible, along with the resident's attending physician and responsible party.
Failure to Honor Resident Dietary Preferences
Penalty
Summary
The facility failed to honor the dietary preferences of two residents, leading to a deficiency in resident self-determination. Resident 1, who was admitted with a diagnosis of Adult Failure to Thrive, had a BIMS score of 15, indicating intact cognitive status. Despite this, Resident 1 was served a turkey salad for lunch, which was against their stated preference as indicated on their meal ticket. The Kitchen Director acknowledged that the staff should have adhered to the meal ticket, and the Assistant Director of Nursing emphasized the importance of respecting residents' food preferences to prevent them from feeling disrespected and potentially eating less. Similarly, Resident 2, admitted with Unspecified Protein-Calorie Malnutrition and a BIMS score of 13, was served milk with their lunch, contrary to their stated dislike. Resident 2 expressed a preference for juice instead. The Kitchen Director confirmed that milk should not have been provided. The facility's policy, which mandates that the Dietary Department provide meals consistent with residents' preferences and physician orders, was not followed in these instances, resulting in the deficiency.
Resident Disrespected by Rehabilitation Coordinator
Penalty
Summary
The facility failed to treat a resident with respect and dignity when the Rehabilitation Coordinator (RC) informed the resident that he was being kicked out of the facility. The resident, who had been living in the facility for about two and a half years, was diagnosed with end-stage renal disease and required dialysis three times a week. The resident reported feeling upset and disrespected after the RC told him that the Administrator wanted him out, which was witnessed by a Registered Nurse (RN). The RN confirmed witnessing the incident, noting that the RC's communication with the resident was not polite, leaving the resident visibly upset and stressed. The Social Worker (SW) stated that a care conference should have been held to discuss discharge plans, as the resident was not ready to be discharged due to his medical condition and lack of a place to go. The SW emphasized that discharging the resident without a home would have been unsafe. The Director of Nursing (DON) acknowledged that the RC should not have discussed discharge plans with the resident, as it was not within her responsibilities. The facility's policy and procedure on resident rights and discharge procedures were reviewed, indicating that residents should be treated with kindness, respect, and dignity, and that proper notice and procedures should be followed for discharge. The RC's actions were deemed unacceptable by the DON, as they did not align with the facility's policies.
Failure to Administer Gabapentin as Prescribed
Penalty
Summary
The facility failed to ensure that a resident received Gabapentin as prescribed by their physician, which had the potential to cause unnecessary pain. The resident was admitted with a diagnosis of Neuralgia and Neuritis and had a doctor's order for Gabapentin to be administered every evening for neuropathy pain. However, the medication was not available on two occasions, and the resident missed their doses on those days. The Assistant Director of Nursing (ADON) and a Registered Nurse (RN) confirmed that the missed doses were not communicated to the doctor, nor was a new order obtained to skip or delay the dose. The facility's policy required medications to be administered as prescribed, with a one-hour window before or after the scheduled time, but this was not adhered to in this case.
Failure to Prevent Resident Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse when another resident threw a flower vase at her, resulting in a wound on her lip and necessitating transfer to an acute care hospital for treatment. The incident occurred in the room shared by the two residents, where a disagreement over the room's sliding door shades escalated. The resident who committed the act had a history of dementia and delusional disorder, with documented physical and verbal behavior symptoms directed toward others. Prior to the incident, staff were aware of the ongoing conflict between the two residents but failed to take adequate measures to prevent the altercation. The facility's Director of Nursing acknowledged that there was a previous incident involving the same resident who exhibited aggressive behavior towards another resident, yet no care plan was developed to address these behaviors. The facility's policy on abuse prevention emphasizes the importance of care planning and monitoring for residents with behaviors that might lead to conflict, but this was not adhered to in this case. The lack of a care plan and failure to address the resident's aggressive behavior contributed to the incident, highlighting a deficiency in the facility's ability to ensure a safe environment for its residents.
Food Storage and Preparation Deficiencies
Penalty
Summary
The facility failed to maintain proper food storage and preparation standards, as observed during a survey. The walk-in fridge's temperature was recorded between 40-48 degrees Fahrenheit, exceeding the recommended maximum of 40 degrees. Beverages were stored without labels and at temperatures above 40 degrees. Additionally, four packages of ground beef were found thawing in the fridge without proper labeling or a thaw log, and the fridge's temperature was not conducive to safe thawing practices. The Dietary Manager acknowledged these issues, noting the absence of a thawing log and the inappropriate fridge temperature for thawing meat. The kitchen environment was also found to be excessively hot, with temperatures ranging from 85 to 98 degrees Fahrenheit, which could have affected the fridge's temperature. A temporary portable air conditioning unit was in place but was ineffective, blowing warm air and covered in lint, dust, and dirt, indicating it had not been cleaned in over a month. The Dietary Manager and Maintenance staff confirmed the AC unit's ineffectiveness and the kitchen's high temperatures, which should not exceed 80 degrees. These conditions posed a risk of food contamination, potentially leading to foodborne illness for the 90 residents in the facility.
Failure to Provide Written Notification for Room Change
Penalty
Summary
The facility failed to provide written notification to a resident before a room change, violating the resident's right to receive such notice. The resident, who was cognitively intact according to the Minimum Data Set (MDS) assessment, was informed verbally about the room change on the same day it occurred, without receiving a written explanation for the move. During an interview, the resident expressed feeling that insufficient time was given before the room change. The Social Service Director (SSD) acknowledged completing the Notification of Room Change form but admitted not providing a copy to the resident. The facility's policy and procedure, dated March 2018, requires that residents receive timely advance written notice, including reasons for room changes, which was not adhered to in this instance.
Facility Refusal to Readmit Resident Post-Hospitalization
Penalty
Summary
The facility failed to permit a resident to return after hospitalization, despite having available beds. The resident, who had been admitted with hemiplegia, hemiparesis, dysphagia, and chronic obstructive pulmonary disease, was transferred to an acute care hospital for a stroke and underwent neurosurgery. Upon discharge, the resident was ready to return to the facility, but the facility refused re-admission, citing non-compliance with daily care and facility rules. Interviews with facility staff, including the Director of Staff Development and the Charge Nurse, confirmed the decision not to allow the resident's return, despite the availability of three vacant male beds. The resident expressed a desire to return to the facility, as he had no other place to go. This refusal to readmit the resident after hospitalization was identified as a deficiency, with potential psychosocial distress implications for the resident.
Failure to Notify Physician and Family of Resident's Condition Change
Penalty
Summary
The facility failed to notify a resident's physician and representative of a significant change in the resident's health condition. The resident, who had a severe cognitive impairment, exhibited signs of difficult breathing and tested positive for COVID-19. Despite these changes, the responsible Licensed Vocational Nurse (LVN) did not inform the physician or the resident's representative. The LVN placed the resident on oxygen but did not report the change in condition to the other LVN on duty during her break. Upon returning from her break, the LVN found the resident unresponsive, leading to a Code Blue being called. Interviews with facility staff, including the LVN involved and another LVN, revealed that the facility's policy requires immediate notification of the physician and family in the event of a significant change in a resident's condition. The facility's administrator confirmed this requirement. However, the LVN admitted to not notifying the physician or the resident's representative, which could have delayed necessary medical intervention. The facility's policy on Change of Condition Notification emphasizes the importance of promptly informing relevant parties to ensure appropriate medical assessment and coordination.
Failure to Provide Podiatry Services
Penalty
Summary
The facility failed to provide appropriate foot care and treatment for two residents, resulting in significant discomfort and potential health risks. Resident 1, who was admitted with a diagnosis of diabetes, had not received podiatry services for over four months since her admission. Her toenails were observed to be dark brown, overgrown, curved, and thickened, causing her discomfort and preventing her from wearing socks or walking. Despite her requests for nail care, the facility did not provide the necessary podiatry services. The facility's records did not document any offers or declinations of toenail care for Resident 1 during this period. Similarly, Resident 2, who was admitted with severe protein-calorie malnutrition and deep vein blood clots, also had not received podiatry services. Her toenails were discolored, overgrown, curved, and thickened, causing discomfort from the sheets and blankets touching her feet. This discomfort made her feel sad and uncared for. The facility's records also lacked documentation of any offers or declinations of toenail care for Resident 2. The social worker responsible for arranging podiatry appointments was unable to find any records of referrals for both residents, despite the facility's policy stating that podiatry care should be offered to any resident requiring it.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Oakland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bellaken Skilled Nursing Center | 0 mi | ★★★★★ | 1 | 0 |
| Oakland Heights Nursing And Rehabilitation | 0.6 mi | ★★★★★ | 0 | 0 |
| Mercy Retirement & Care Center | 0.7 mi | ★★★★★ | 3 | 0 |
| Garfield Neurobehavioral Center | 1.1 mi | ★★★★★ | 0 | 0 |
| Fruitvale Healthcare Center | 1.1 mi | ★★★★★ | 1 | 0 |
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