How many inspection deficiencies does VISTA POST ACUTE have?

VISTA POST ACUTE has 31 deficiencies from recent inspections. None are at the Immediate Jeopardy level.

What are the staffing levels at VISTA POST ACUTE?

VISTA POST ACUTE has a four-star staffing rating from CMS with 0.37 RN hours per resident per day. This rating is based on registered nurse (RN), licensed practical nurse (LPN), and nurse aide staffing hours.

Where is VISTA POST ACUTE located?

VISTA POST ACUTE is located in HAYWARD, CA. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does VISTA POST ACUTE have?

VISTA POST ACUTE has 71 certified beds.

Who owns VISTA POST ACUTE?

VISTA POST ACUTE is a for profit - limited liability company facility and is part of the BVHC, LLC chain.

What questions should families ask when visiting VISTA POST ACUTE?

Families visiting VISTA POST ACUTE should ask about daily routines, communication with families, how they handle medical emergencies. Also ask to speak with current residents or families, tour during mealtime, and request a copy of the most recent inspection report.

How does VISTA POST ACUTE compare to other nursing homes?

VISTA POST ACUTE has a 4-star overall rating, placing it above average compared to other nursing homes in CA. Higher-rated facilities typically have better inspection results and staffing levels.

VISTA POST ACUTE

Name: VISTA POST ACUTE
Address: 3269 D STREET, HAYWARD, CA, 94541, US
Telephone: (510) 537-6700
Rating: 4.0

3269 D STREET, HAYWARD, CA 94541 · (510) 537-6700

For profit - Limited Liability company 71 Beds BVHC, LLC Data: November 2025

Trust Grade

70/100

#503 of 1155 in CA

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Last Inspection: January 2025

Within standard 12-15 month inspection cycle. Federal law requires annual inspections.

Overview

Vista Post Acute in Hayward, California, has a Trust Grade of B, indicating it is a good choice but not without some concerns. It ranks #503 out of 1,155 facilities in California, placing it in the top half, and #47 out of 69 in Alameda County, meaning only a few local options are better. Unfortunately, the facility is trending in a worsening direction, with issues increasing from 1 in 2024 to 6 in 2025. Staffing is generally a strength, with a 4 out of 5 stars rating and a turnover rate of 35%, which is better than the state average. While there have been no fines, some specific incidents raised concerns, such as medication errors affecting residents' treatment, unclean kitchen conditions that risk food safety, and lapses in infection control practices during medication administration. These factors suggest that while the facility has strengths, families should remain vigilant about certain risks.

Trust Score: B
In California: #503/1155
Safety Record: Low Risk
Inspections: Getting Worse
Staff Stability: 35% turnover. Near California's 48% average. Typical for the industry.
Penalties: No fines on record. Clean compliance history, better than most California facilities.
Skilled Nurses: Each resident gets only 22 minutes of Registered Nurse (RN) attention daily — below average for California. Fewer RN minutes means fewer trained eyes watching for problems.
Violations: 31 deficiencies on record. Higher than average. Multiple issues found across inspections.

★★★★☆

4.0

Overall Rating

★★★★☆

4.0

Staff Levels

★★★☆☆

3.0

Care Quality

★★★★☆

4.0

Inspection Score

↔

Stable

2024: 1 issues

2025: 6 issues

The Good

4-Star Staffing Rating · Above-average nurse staffing levels
Full Sprinkler Coverage · Fire safety systems throughout facility
No fines on record
Staff turnover below average (35%)
13 points below California average of 48%

Facility shows strength in staffing levels, fire safety.

The Bad

Staff Turnover: 35%

11pts below California avg (46%)

Typical for the industry

Chain: BVHC, LLC

Part of a multi-facility chain

Ask about local staffing decisions and management

The Ugly 31 deficiencies on record

Jan 2025 6 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Tube Feeding (Tag F0693)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to provide care according to facility policy and procedures (P&P) when the nursing staff did not check the tube placement and/or residual volume before medication administration for three of three residents (Residents 10, 37, and 61) who were receiving medications via the gastrostomy tube (aka G-tube, a tube inserted through the abdomen that delivers nutrition and medications directly to the stomach). The failure had the potential for complications related to enteral feeding such as aspiration (foreign material into the lungs) due to undetected tube displacement, nausea, vomiting, etc. Findings: a. During a medication administration observation on 1/27/25 at 10:02 a.m., Licensed Vocational Nurse (LVN) B was observed preparing a medication, doxazosin (medication to treat high blood pressure), for Resident 37. She crushed and diluted the medication with water. On 1/27/25 at 10:08 a.m., at the resident's bedside, LVN B was observed attaching the 60-milliliter (mL, unit of measurement) syringe to the resident's G-tube and pulling back on the plunger to see the residual volume, then she flushed the tube with about 30 mLs of water. After several minutes of manipulation to get the water to go down into the tube, LVN B poured the diluted medication into the tube. LVN B did not check the tube placement (to confirm the placement of the tube) before the medication administration. b. During a medication administration observation on 1/27/25 at 10:38 a.m., LVN B was observed preparing 5 medications for Resident 61. On 1/27/25 at 10:47 a.m., at Resident 61's bedside, LVN B was observed checking the residual volume but did not check the tube placement before the medication administration. During an interview on 1/27/25 at 10:55 a.m., when asked about the tube placement check before medication administration, LVN B stated, I just check residuals before medication administration. She stated she would not typically check the tube placement before medication administration. c. During a medication administration observation on 1/28/25 at 8:28 a.m. with RN C, she was observed preparing 2 medications for Resident 10. On 1/28/25 at at 8:36 a.m., at the resident's bedside, RN C turned off the resident's feeding pump, attached the syringe to the resident's tube, added about 50 mLs of water into the syringe, then poured each diluted medication into the tube with flushing of water in between the medications. RN C did not check the tube placement and the residual volume before administering the medications. During an interview on 1/28/25 at 8:45 a.m., RN C was asked about checking the tube placement and the residual volume. She stated, We usually do placement check with 30cc of air using the stethoscope, and check the residual first before administration. She stated she got nervous and forgot to do it. During an interview with the Director of Nursing on 1/28/25 at 11:35 a.m., she stated nurses should check the tube placement by injecting air into the stomach and listening for the sound with the stethoscope, and checking the residual volume, before medication administration. A review of the facility's policy and procedures titled Administering Medications through an Enteral Tube, dated 11/2018, indicated the staff verify placement of feeding tube before medication administration.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to ensure discontinued and unused controlled medications (medications that can be easily abused and are under strict government control) for three residents (65, 123, and 174) were promptly removed from one of three inspected medication carts. The failure had the potential for medication errors or loss/abuse of controlled medications. Findings: 1. During an inspection of the Station 1 medication cart with Licensed Vocational Nurse (LVN D) on 1/27/25 at 11:06 a.m., two opened bottles, one 180-milliliters (mL) and one 120-mL, of morphine (a potent narcotic medication for pain) 2 milligrams (mg) per mL for Resident 174 were identified in the locked compartment of the cart. The Controlled Drug Record (CDR or Count Sheet, an inventory sheet documenting the medication, count, date, time, amount given, the amount left, and the signature of the user) for each bottle was wrapped around the bottle with a rubber band. LVN D stated each bottle has zero count left, meaning the count on the CDR had zero (0) amount remaining but in reality there was some left-over amount in the bottle (an over-fill from the manufacturer). She stated the nursing staff did not count them during shift changes because the count on the CDRs was zero. She stated the bottles were supposed to be given to the DON for destruction. A review of two CDRs indicated one was zero'ed out on 1/14/24 (13 days before the survey); and the other reached zero count on 1/20/25 (7 days before the survey). On 1/28/25 at 1:12 p.m., at Station 1 medication cart with Registered Nurse C (RN C), the same two morphine bottles were observed inside the locked compartment of the cart. Further inspection of the bottles with RN C revealed the 180-mL bottle had about 12 mLs remaining; and the 120-mL bottle had about 10 mLs left. RN C verified this finding and stated they are there for the DON to pick up. 2. During the inspection of Station 1 medication cart on 1/28/25 at 1:12 p.m. with RN C also identified two blister cards (card that packages doses of medication within small, clear, or light-resistant amber-colored plastic bubbles or blisters) containing lacosamide (a controlled medication to treat seizures) 100 mg tablets. One had 30 tablets, and the other had 24 tablets. Their CDRs were wrapped around the cards. RN C stated they belonged to Resident 123 who left the facility. A review of Resident 123's clinical record indicated the resident requested to leave AMA [against medical advice] on 1/13/25 (or 15 days prior to the survey). 3. Inspection of the Station 1 medication cart with RN C on 1/28/25 at 1:18 p.m. also identified a bottle containing 8 tablets of lorazepam (a controlled medication to treat anxiety) 0.5 mg for Resident 65. RN C stated the lorazepam was discontinued. A review of Resident 65's clinical record indicated the lorazepam was discontinued on 1/14/25 (14 days before the survey). During an interview with the Director of Nursing on 01/28/25 at 1:57 p.m., she stated the nursing staff should remove the excess morphine liquid for Resident 174 as soon as possible. Regarding those discontinued medications for residents 65 and 123, she stated they should be given to her immediately after discontinued, to prevent loss. A review of the facility's policy and procedures titled Controlled Substances, revised 4/2019, indicated, Empty or discontinued medication containers, must be discarded with two nurses or given to Director of Nursing for proper destruction, and continued in narcotic count until discarded.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Medication Errors (Tag F0758)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to ensure one of 20 sampled residents (Resident 47) was free from unnecessary psychotropic medications (drugs that affects brain activities associated with mental processes and behavior). Resident 47 received quetiapine (Seroquel, an antipsychotic medication) for delusion (fixed, false beliefs that conflict with reality) without documented evidence of delusional symptoms, and without demonstration how these symptoms caused harm to the resident/others or caused significant distress to the resident. The failure had the potential for the resident to receive the antipsychotic medication unnecessarily, which had the potential for increased risks associated with psychotropic medication use that include but not limited to sedation, respiratory depression, falls, constipation, anxiety, agitation, abnormal involuntary movements, and memory loss. Findings: A review of Resident 47's clinical record indicated he was admitted to the facility with diagnoses including unspecified dementia (general term that describes a group of symptoms, such as loss of memory, judgment, language, complex motor skills and other intellectual functions due to permanent damage or death of the brain's nerve cells) and unspecified schizophrenia (a chronic, severe mental disorder that affects the way a person thinks, acts, expresses emotions, perceives reality, and relates to others). A review of Resident 47's Minimum Data Set (MDS, a care area assessment and screening tool), dated 12/9/24, indicated he had a BIMS score of 4 (Brief Interview for Mental Status, a test given by medical professionals that helps determine a patient's cognitive understanding that can be scored from 1 to 15), which indicated his cognitive condition was severely impaired. A review of Resident 47's clinical record indicated a physician's order, dated 10/21/24, for Seroquel 25 mg by mouth at bedtime related to OTHER SCHIZOPHRENIA .m/b [manifested by] Delusion. A review of Resident 47's January 2025 Medication Administration Record (MAR, where nursing staff documented the medication administration and behavioral symptom monitoring) indicated the staff had been monitoring for delusion associated with Seroquel use since 10/20/24. The MAR showed the resident had zero (0) episodes of delusion. A review of Resident 47's Care Plan, revised 11/15/24, indicated the resident was receiving Seroquel for other schizophrenia m/b Delusion. There was no documented evidence in the clinical record what specific behavioral symptoms related to delusion (such as thinking or believing something that is not there) the resident exhibited, or how these symptoms caused harm to the resident/others or caused significant distress to the resident. During an interview with Resident 47 on 1/29/25 at 11:21 a.m., he stated there was a person who has been bothering him and making him upset. He stated he has told about a dozen staff about this already but nothing has been done. He got up from the bed and started walking out of his room to look for that person. About 2 minutes later, he pointed at a resident (Resident 21) and stated she has been going to his room and bothering him. In an interview with Licensed Vocational Nurse (LVN) F, on 1/29/25 at 11:35 a.m., she stated Resident 47 had no behaviors except he gets irritable with noise and whenever Resident 21 comes into his room. She explained Resident 21 has dementia and does not know her surrounding; she often comes into Resident 47's room, thinking he is her son. LVN F stated she has been working in the facility for many months and has not known Resident 47 having any kind of delusion. During an interview with LVN D on 1/29/25 at 11:44 a.m., she stated Resident 47 is real calm, uses call light if he needs to. She explained that he gets angry when Resident 21 comes into his room, which she often does due to her thinking he is her son. When asked about the resident's delusion, LVN D stated, He doesn't have any delusion that I am aware of. He never had a day where he's delusional. During an interview with Certified Nursing Assistant (CNA) G on 1/29/25 at 11:52 a.m., she stated Resident 47 gets angry sometimes and he doesn't like it when [Resident 21] comes into the room. When asked if she has witnessed the resident having delusions, she stated, I don't know. Never seen him with delusions. In an interview with CNA H on 1/29/25 at 12:48 p.m., she stated, Sometimes he gets angry because [Resident 21] comes into room, sometime he wants medications. When asked if she has witnessed the resident having delusions, CNA H shook her head and said, No. During a concurrent interview and review of Resident 47's clinical record with the Director of Nursing (DON) on 1/29/25 at 12:55 p.m., the DON stated Resident 47 received Seroquel for delusion and sometimes he's paranoid. She was asked to provide any documentation showing Resident 47 had delusional symptoms and how they caused harm to him/others or caused significant distress to the resident. After the review, she stated, There's just delusion in the documentation. A review of the Psychiatric Visit Progress Reports, dated 8/12/24, 8/23/24, 10/10/24, and 12/19/24, with the DON indicated, under the Behavioral Observations, the writer of the reports wrote a No for Delusions in all four reports. A review of the facility's policy and procedures titled Antipsychotic Medication Use, revised 12/2016, indicated, Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective . The Attending Physician and other staff will gather and document information to clarify a resident's . behavior . specific symptoms, and risks to the resident and others . Diagnoses alone do not warrant the use of antipsychotic medication. In addition to the above criteria, the antipsychotic medications will generally be considered if the following conditions are also met . The behavioral symptoms present a danger to the resident or others .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Unnecessary Medications (Tag F0759)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility had a medication error rate of 13.79% when four medication errors occurred out of 29 opportunities during the medication administration observation for four out of nine residents (Residents 3, 8, 10, and 37). Resident 37 did not receive one medication as scheduled; Resident 8 received insulin with incorrect priming; and Residents 3 and 10 did not receive one medication as prescribed. The failures resulted in the residents not receiving the medications as prescribed and had the potential for complications of their medical conditions (such as high/low blood sugar or blood pressure). Findings: 1. During the medication administration observation on 1/27/25 at 10:02 a.m., Licensed Vocational Nurse B (LVN B) was observed preparing one medication, doxazosin (a medication to treat high blood pressure) for Resident 37. LVN B stated, I don't have chlorhexidine [an antiseptic mouthwash with broad-spectrum antimicrobial activity against bacteria, viruses, and fungi], will have to order from pharmacy. On 1/27/25 at 10:08 a.m., LVN B was observed going into Resident 37's room and informing the resident she did not have his mouthwash. During an interview on 1/27/25 at 10:59 a.m., LVN B confirmed the chlorhexidine was due this morning, but it was not available for administration. A review of Resident 37's clinical record indicated a physician's order, dated 7/29/2024, for chlorhexidine gluconate mouth/throat solution 0.12%, give 15 ml orally three times a day for oral care. The facility scheduled it to be administered at 9 a.m., 1 p.m., and 9 p.m. On 1/27/25 at 1:49 p.m., a review of Resident 37's January 2025 Medication Administration Record (MAR) indicated a 9 (meaning, Other/See Progress Notes) in the 1/27/25 9 a.m. entry for chlorhexidine administration. A review of the corresponding progress notes, charted by LVN B on 1/27/25 at 10:04 a.m., indicated: pending supply. A review of the facility's 4/2019 policy and procedures (P&P) titled Pharmacy Services Overview indicated, Residents have sufficient supply of their prescribed medications and receive medications (routine, emergency or as needed) in a timely manner. 2. During a medication administration observation on 1/27/25 at 12:08 p.m., with LVN D, she was observed preparing an insulin (medication to treat high blood sugar) injection for Resident 8. She stated the resident's blood sugar was 255. At the medication cart, LVN D removed Resident 37's Humalog Kwikpen (a pre-filled insulin pen containing a short acting insulin called insulin lispro) from the medication cart, cleaned the rubber seal (area connecting the insulin chamber to the needle), attached a needle on it, inverted the pen, and squeezed out some of the insulin drops. Then she removed the needle, cleaned the the rubber seal again, attached a second needle on the rubber seal, and then turned the dose dial to 8 units. On 1/27/25 at 12:13 p.m. LVN D was observed injecting the Humalog into Resident 8's left lower abdomen. During an interview on 1/27/25 at 12:15 p.m., LVN D stated she primed the insulin pen by placing a new needle, turning the dial to 1 unit, and pressing the pen to make sure it worked. Then she would take off the needle, put a new needle on, and turn the dial to the prescribed dose. She stated that is the way she has always done it, by making sure the pen works. A review of Resident 8's clinical record indicated a physician order, dated 12/11/2024, for insulin lispro solution, to inject per sliding scale (a set of instructions for administering insulin dosages based on specific blood glucose readings), to give 8 units for blood sugar between 251 - 300. During a follow-up interview with LVN D regarding insulin pen priming on 1/27/2025 at 2:21 p.m., she stated she learned only use one needle and to prime it (the needle) with 1 unit first to make sure the pen works before turning to the ordered dose. She verified she did not prime the insulin pen correctly before injecting it to Resident 8. During an interview on 01/28/25 at 11:35 a.m. conducted with the Director of Nursing (DON) regarding the priming of insulin pens, she stated to prime the needle before each medication administration. A review of the drug manufacturer's INSTRUCTIONS FOR USE HUMALOG ([NAME]-ma-log) KwikPen, dated 7/2023, indicated the following instructions for priming the pen: Prime before each injection, priming your Pen means removing the air from the Needle and Cartridge that may collect during normal use and ensures that the Pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin. To prime your Pen, turn the Dose Knob to select 2 units . Hold your Pen with the Needle pointing up. Tap the Cartridge Holder gently to collect air bubbles at the top . Continue holding your Pen with Needle pointing up. Push the Dose Knob in until it stops, and '0' is seen in the Dose Window . Turn the Dose Knob to select the number of units you need to inject . A review of the facility's P&P titled Administering Medications, dated 4/2019, indicated, insulin pen needles must be changed and primed between administration doses. 3. During the medication administration observation on 1/27/25 at 4:28 p.m., LVN E was observed administering two medications with water to Resident 3, one included metformin (used to treat diabetes) 1,000 milligrams (mg, unit of measurement) tablet. On 1/27/25 at 4:32 p.m., in a concurrent interview with LVN E, and review of Resident 3's metformin medication, LVN E confirmed the prescription label indicated to give with meals. LVN E stated, We give the medication between 4 to 6 p.m., usually give it with snacks. She said the administration time varies each day. A review of Resident 3's clinical record indicated a physician order, dated 8/3/2024, for metformin 1,000 mg, give 1 tablet by mouth two times a day for diabetes administer with meal. On 1/27/25 at 5:01 p.m., a cart of meal trays was observed about 20 feet from Resident 3's room. The staff stated the cart was for downstairs residents as downstairs always get their meal trays first. This indicated, by 5:01 p.m. on that day (or 33 minutes after metformin administration), Resident 3 did not get his dinner yet. An interview and record review regarding the administration of Resident 3's metformin was conducted with the DON on 1/28/25 at 11:35 a.m. She explained medication ordered with meals means it should be given with a meal. She stated metformin is an irritant and can cause nausea so it should be given with a meal. A review of the Package Insert (provides detailed information of the drugs uses, contraindications, dosage ranges, side effects and how to administer the drug) for metformin indicated: Metformin should be given in divided doses with meals to reduce gastrointestinal side effects. A review of the facility's P&P titled Administering Medications, revised April 2019, indicated, Medications are administered within 1 hour of their prescribed time, unless otherwise specified (for example before and after meal orders). 4. On 1/28/2025 at 8:28 a.m., while preparing medications for Resident 10, registered nurse (RN) C stated she will hold the resident's amlodipine and lisinopril (medications used to treat high blood pressure or hypertension). She stated resident's blood pressure was 108/80 (the upper number is the systolic blood pressure, also known as SBP; the lower number is the diastolic blood pressure, also known as DBP). A review of Resident 10's clinical record indicated a physician's order, dated 11/6/2024, for amlodipine 10 mg, 1 tablet one time a day related to ESSENTIAL (PRIMARY) HYPERTENSION HOLD FOR SBP <100. It was scheduled to be administered daily at 9 a.m. A review of the resident's January 2025 MAR indicated a 4 (4= vitals outside of parameters for administration) in the 1/28/2025 9 a.m. entry for amlodipine administration. On 1/28/25 at 11:25 a.m., during a follow up interview and concurrent record review with RN C, she confirmed holding both amlodipine and lisinopril for Resident 10. RN C confirmed the physician's order indicated to hold the amlodipine for SBP <100 while the resident's SBP was 108. She stated, .in general the hold for blood pressure is 110. An interview was conducted 1/28/2025 at 2:09 p.m. with the DON regarding the amlodipine hold parameters for Resident 10. The DON confirmed the hold parameter for amlodipine is to hold if blood pressure is less than 100. A review of the facility's P&P titled Administering Medications, revised April 2019, indicated, Medications are administered in accordance with prescriber orders, including any required time frame, vitals parameters .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

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Based on observation, interview, and record review, the facility failed to ensure food was stored and prepared in a clean environment, within standards for safety when: 1. Floor drains were not maintained clean; 2. Kitchen tile floors were not clean and were not maintained in good repair; 3. Kitchen wall had an opening in the wall around the drain; 4. Kitchen backsplash, where dishes were cleaned, had food and black substance buildup; 5. A kitchen cleaning schedule was not maintained according to facility policy; 6. Frozen meat did not have date received, date placed in freezer, use by date, and expiration date; 7. Produce and food were not labeled with use by date and were not rotated with FIFO, First in-First out per facility policy; 8. Food in refrigerator had expired. These failures had the potential to result in contamination of food leading to food borne illness, for 69 residents who resided in the facility. Findings: During an observation on 1/27/2025, at 9:30 a.m., in the kitchen, a drain cover over the floor drain in the middle of the dish room was not secured with tile, and there was black build up around the drain. The wall was exposed to wooden structure, the wall around the perimeter of the drain was open with a large gap, the backsplash behind the sink had buildup of black sludgy material, and the tile and flooring to the wall of the sink had missing grout with noted buildup of black substance and food particles. Tiles around the floor drain were loose and not attached. There were additional tiles around the floor that were broken off, had missing grout, and were collecting pools of water. There was separation from the wall and the floor tile with no grout, with a length of approximately 2 feet. The gap with no grouting had dark residue particles resembling food crumbs, and small pieces of debris collected in the area. There were loose wall tiles along the right and behind the area of the manual dish washing sink, which created a gap between the wall and the tiles. During a concurrent observation and interview on 01/27/25, at 9:30 a.m., with Certified Dietary Manager (CDM 1), there was exposed wood on the wall as the protective plastic molding against the lower part of the wall was missing. This area had a collection of dirt and debris with openings on the wall. CDM 1 stated a request had been put in to the Maintenance Director (MD) around one month ago to have this repaired, along with the other areas of missing grout and exposed walls. CDM 1 stated loose tiles and pooled water on the floor could harbor bacteria and was a safety hazard. During a concurrent interview and record review on 1/29/25, at 9:30 a.m., with MD, MD stated there was a maintenance log where staff put in maintenance requests. A review of the log indicated there was no request to repair the kitchen tile, flooring, and walls. During an interview on 1/30/25, at 10:04 a.m., with MD, MD stated there was no record of when a deep cleaning was last done in the kitchen. During an interview on 1/30/25, at 11:01 a.m., with the Janitor, CDM 1 and MD, Janitor stated it was difficult to do a deep cleaning when the surfaces were not maintained. The Janitor stated the area with missing grout and tile could collect food and dirt and develop mold if the sealant was not maintained. During an observation on 1/27/25, at 9:45 a.m., in the kitchen, Refrigerator #1 contained a bag of turkey slices covered in plastic with expiration date 1/25/25 and a jar of jelly with expiration date of 1/26/25. During an observation on 1/27/2025, at 10:15 a.m., in the kitchen, Freezer 1 had five bags of five pounds of ground beef and seven bags of 12 chicken breasts per bag, with no date when the ground beef and chicken breasts were received, no use by dates, and no expiration dates. During an observation on 1/28/25, at 11 a.m., the facility received a large order of onions. During an observation on 1/29/25, at 10:15 a.m., in the storage room, onions received on 1/28/25 were in a box labeled 1/21/25. During an interview on 1/29/25, at 10:31 a.m., with the Dietary Manager (DM 1) and Cook, [NAME] stated that onions were received on 1/28/25 and were put in the box with the older onions. The box had a date of 1/21/2025. DM 1 stated the onions should have been placed in a box with the date they were received, and the onions from the previous shipment should have been placed in a box on top of the box of new onions. The [NAME] stated the new onions should have been put in a separate container with the date of delivery posted on the container. During a concurrent observation and interview on 1/27/2025, at 10:30 a.m., in the storage pantry, with CDM 1, clear containers containing large loose black items were on a cupboard shelf with no open, use by or expiration dates on the containers. CDM 1 stated they were unwrapped raisins. DM 1 stated the raisins needed to be disposed of as they may be contaminated. During an interview on 1/30/25, at 9:46 a.m., with CDM 1, CDM 1 stated not having received and use by dates on food put residents at risk for acquiring a food borne illness. CDM 1 stated exposed openings in the area where dishes were cleaned made the area susceptible to food and mold build up and made it difficult to sanitize and clean the area. During a review of the policy and procedure (P&P) titled, Sanitation and Infection Control subject cleaning schedules, dated 2023, best practice would include a deep cleaning in the kitchen by an outside cleaning agency quarterly. Cleaning schedules should include drains and walls weekly. During a review of the facility's P&P titled, For food purchasing receiving and production, subject receiving food, dated 2023, expiration dates will be checked on predated packages to ensure food and beverages are not expired. Items not predated will be labeled with the date received to ensure FIFO first in and first out. During a review of the facility's P&P titled, Sanitation and infection control, subject, canned and dry food storage, dated 2023, new stock must be placed behind the old stock so that the oldest items will be used first. Product should be dated to assure FIFO - first in and first out. During a review of the P&P titled, Sanitation, and Infection Control, subject for your freezer storage, dated 2023, frozen foods should be labeled with a date it was placed in the freezer. According to the 2022 Federal Food Code, floors and floor coverings are to be constructed so they are smooth and easily cleanable. In addition, when cleaning methods other than water flushing are used for cleaning floors, the floor and wall junctures are to be coved and closed to no larger than 1 mm (millimeter). If water flush cleaning methods are used, wall junctures are to be coved and sealed. According to the 2022 Federal Food Code Annex, pooling liquid wastes could attract pests such as insects and rodents or contribute to problems with certain pathogens.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

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Based on observation, interview, and record review, the facility failed to observe proper infection control practices when: 1. A nursing staff failed to perform hand hygiene after touching potentially contaminated surfaces during the medication administration; 2. A nursing staff touched and opened two medication capsules with bare hands; 3. A nursing staff failed to observe the enhanced barrier precautions (EBP) as per facility policy and procedures (P&P) for two residents (Residents 37 and 61) during the medication administration; These failures had the potential for Residents 37, 54 and 61 to be placed at risk for infections. Findings: 1. During a medication administration observation with Registered Nurse (RN) A on 1/27/25, at 9:29 a.m., RN A was observed preparing two medications, which was put in a small medication cup, for Resident 54. On 1/27/25, at 9:40 a.m., RN A placed the medication cup along with a cup of juice in a medication tray, brought it to Resident 54's bedside, and placed it on the resident's table. Then, with her gloved hands, she moved the resident's wheel chair out of the way. Next, she looked to the bed's remote control cable that was found disconnected and lying on the floor. She connected it to the resident's bed and pressed on the remote to raise the head of the bed while the resident was lying in it. Then, without changing gloves and performing hand hygiene, she picked up the medication cup and handed to the resident to take. She did the same with the juice cup. During an interview on 1/27/25, at 9:48 a.m., RN A confirmed she touched the resident's wheel chair, the bed remote control cable, and the remote control itself with gloved hands, and stated she should have changed her gloves and performed hand hygiene before proceeding with the medication administration. She acknowledged those were potentially contaminated surfaces and had potential for the spreading of infections. 2. During a medication administration observation on 1/27/25, at 10:35 a.m., Licensed Vocational Nurse (LVN) B was observed preparing five medications for Resident 61, who received medications via the gastrostomy tube (also called a G-tube; a tube inserted through the abdomen that delivers nutrition and medications directly to the stomach). The medications included two capsules of gabapentin (medication to treat nerve pain) 100 milligrams (mg, unit of measurement). Without donning gloves, LVN B was observed picking up each capsule with her bare hands and opening them to pour the powder contents into a medication cup. During an interview on 1/27/25, at 10:55 a.m., when asked about opening the gabapentin capsules with bare hands, LVN B stated, I should have worn gloves. During an interview with the Director of Nursing (DON) on 1/28/25, at 11:35 a.m., she stated nurses should avoid touching medications with their hands; and they are supposed to wear gloves when opening capsules. A review of the facility's P&P titled, Administering Medications, revised 4/2019, indicated, Staff follows established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable. 3. On 1/27/25, at 10:11 a.m., LVN B was observed administering a medication to Resident 37 via the G-tube. On 1/27/25, at 10:35 a.m., LVN B was observed administering five medications to Resident 61 via the G-tube. Resident 37 and Resident 61 were roommates. During the medication administration for both residents, LVN B was observed wearing a facial mask and gloves while administering the medications, but she did not wear a protective gown. A large orange/reddish poster was observed outside the residents' room, which read: STOP. ENHANCED BARRIER PRECAUTIONS EVERYONE MUST: Clean their hands, including before entering and when leaving the room. PROVIDERS and STAFF MUST ALSO: Wear gloves and a gown for the following High-Contact Resident Care Activities . Device care or use: central line, urinary catheter, feeding tube . During an interview with LVN B on 1/27/25, at 10:55 a.m., when asked about wearing personal protective equipment (PPE) while administering medications to Residents 37 and 61, LVN B stated she was supposed to gown up during care such as a wound treatment, but for med pass, I am not quite sure on that. During an interview with the DON on 1/28/25, at 11:35 a.m., she stated the nursing staff need to protect the residents from external infections by donning full PPE including a mask, gown, and gloves while providing care such as wound treatment and G-tube administration. During a review of facility's P&P titled, Enhanced Barrier Precaution, dated 6/18/24, the P&P indicated, EBP involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with chronic wounds or indwelling medical devices) .'High-Contact Resident Care Activities' include . Device care or use .feeding tube . Incorporate periodic monitoring and assessment of adherence to determine the need for additional training and education.

Dec 2024 1 deficiency

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0676 (Tag F0676)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide meal assistance for one of five sampled residents ' (Resident 1) when staff did not reposition Resident 1 higher in bed and did not assist in setup of meal tray for 30 minutes during dinner. This failure prevented Resident 1 from finishing dinner because Resident 1 was in an uncomfortable position and could not reach or open food items on the meal tray, which had the potential for weight loss and low blood sugar. Findings: A review of Resident 1 ' s admission record indicated Resident 1 was admitted to the facility on [DATE] with a diagnosis of fall, fracture of lumbar vertebra (lower back bone), rib fractures, muscle weakness, and diabetes (long-term disease in which the body cannot regulate the amount of sugar in the blood). During a record review of Resident 1 ' s physician order set titled, Order Summary Report, dated 10/29/24, the order set indicated Resident 1 had an order for [Carbohydrate control] diet .assist with meal, dated 9/7/24. A review of Resident 1 ' s minimum data set (MDS, an assessment tool to guide resident care), dated 9/13/24, indicated Resident 1 had a Brief interview for mental status score of 14 (BIMS, is a scoring system used to determine the resident ' s cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status), was able to make themself understood and was able to feed themself but required setup assistance for meals. During a phone interview on 10/17/24, at 3:40 p.m., with Resident Family (RF), RF stated Resident 1 had been calling RF complaining about lack of staff assistance during meals. RF stated Resident 1 said staff often left Resident 1 flat on the bed with the bed controls and/or bedside table out of reach. During an observation on 10/18/24, at 5:15 p.m., Resident 1 was in his room in bed, lying down with the head of the bed flat. A bedside table with the dinner meal tray was set up parallel to the bed. Resident 1 ' s feet were at the very end of the bed. The food items on the meal tray were covered and were not opened. During a concurrent observation, interview and record review on 10/18/24, at 5:45 p.m., with Resident 1, Resident 1 was in their room, in bed lying flat and Resident 1 ' s meal ticket for dinner, dated 10/18/24, was on the bedside table. The head of the bed was flat, and the bedside table was parallel to the bed. Resident 1 had finished a cup of fruit and dropped the cup while attempting to place it back on the bedside table. Resident 1 then attempted to reach another food item but was unable to reach anything else. Resident 1 was unable to reposition the bedside table and stated staff brought in the meal tray and left the table like this. The surveyor pushed a cup of soup to Resident 1 ' s reach, but Resident 1 was unable to remove the lid. The meal ticket indicated Resident 1 needed ASSIST W MEALS. Resident 1 stated staff always left food unopened and didn ' t assist with repositioning during meals because staff don ' t follow instructions. Resident 1 exclaimed: look at where my feet are and explained they were too low in the bed to be comfortable even if the head of the bed was raised. Resident 1 was not able to pull themself up higher in bed to reach the bed controls. Resident 1 stated they were uncomfortable and couldn ' t eat the rest of dinner. During a concurrent interview and record review on 10/29/24, at 2:10 p.m., with Dietary Manager (DM), Resident 1 ' s food preferences listed on a facility diet management program were reviewed. DM stated she recalled Resident 1 required assistance in opening food items and removing covers on food. DM stated the ASSIST w MEAL instructions printed on the meal ticket indicated staff were expected to assist Resident 1 with meals according to Resident 1 ' s needs. During a concurrent interview and record review on 10/29/24, at 2:22 p.m., with Certified Nursing Assistant 1 (CNA 1), Resident 1 ' s dinner meal ticket, dated 10/18/24, was reviewed. CNA 1 stated Resident 1 ' s meal ticket indicated Resident 1 needed assistance with meals and would need to ask the nurse or resident what assistance was needed when the meal was served. During an interview on 10/29/24, at 2:48 p.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated Resident 1 was admitted for rehabilitative therapy after a fall. LVN 1 stated Resident 1 needed to be positioned into a comfortable position due to back pain. LVN 1 recalled Resident 1 wanted the head of the bed elevated for comfort while eating. LVN 1 stated Resident 1 could use the bed controls but needed staff assistance for large position changes in bed such as sliding up in bed. During an interview on 10/29/24, at 3:50 p.m., with Director of Staff Development (DSD), DSD recalled the care needs for Resident 1. DSD stated Resident 1 required staff assistance with positioning and to have the bedside table comfortably within reach. DSD stated as long as the lids were open, Resident 1 was able to independently feed themself. During a record review of Resident 1 ' s care plan titled, ADL FUNCTIONING WITH SELF-CARE DEFICIT REQUIRES ASSISTANCE WITH ADL ' S, undated, the care plan indicated Resident 1 needs extensive assistance for . setup help for oral hygiene/eating.

Sept 2023 11 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to protect the right of privacy for one of 23 sampled residents (Residents 52) when personal care instructions were posted on the walls of the resident's shared room. This failure had the potential to affect Resident 52's sense of self-worth and self-respect due to the public display of personal care information. Findings: During an observation on 9/11/23, at 8:06 a.m., inside Resident 52's shared room, three signs without privacy covers (two signs stated, Please use wipes when cleaning him. Thank you. and one sign stated, Please use the wipes to wipe the Resident instead of the towel. Thank you!), were posted on the walls (by Resident 52's headboard, to the left side of Resident 52's bed, and across the room, taped to the closet of Resident 52). The signs listed were specific personal care instructions for Resident 52. During an interview on 9/12/23, at 11:45 a.m., with the Director of Nursing (DON), the DON stated because it was the family of Resident 52 who posted the signs in the shared room, DON thought it was acceptable to leave openly posted clinical care instructions on the walls. The DON stated for confidentiality purposes, the signs should have privacy covers. Review of the facility's policy and procedure (P&P) titled, Dignity, revised date February 2021, the P&P indicated, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem .Residents are treated with dignity and respect at all times .Demeaning practices and standards of care that compromise dignity are prohibited .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0584)

Could have caused harm · This affected 1 resident

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.Based on observation, interview, and record review, the facility failed to provide an orderly and homelike environment for two of 23 sampled residents (Resident 52 and resident 119), when an old, uncovered sign that showed the name of the previous resident (Resident 42) was not removed from the shared room currently occupied by Resident 52 and Resident 119. This failure had the potential to affect Resident 52 and Resident 119's well-being and cause mental confusion in a setting meant to be their home. Findings: During a concurrent observation and interview on 9/11/23, at 8:06 a.m., with Certified Nursing Assistant 2 (CNA 2), an uncovered typewritten sign (stating, Family will do laundry. followed by a handwritten name of Resident 42) was posted on the closet door visible from both Resident 52 and Resident 119's beds. CNA 2 stated Resident 42's family posted the uncovered sign which was not removed when Resident 42 was sent out to the hospital then later discharged from the facility. CNA 2 stated the old sign should have been removed because it didn't belong to the current residents occupying the shared room. CNA 2 stated housekeeping should have removed the old sign. During an interview on 9/11/23, at 8:50 a.m., with the Housekeeping Aide 1 (Hskg. Aide 1), Hskg. Aide 1 stated housekeeping should remove the personal signs on the wall when a resident is discharged from the facility. Hskg. Aide 1 further stated CNAs or any staff who noticed the old sign was still posted, should have removed it. During an interview on 9/12/23, at 11:45 a.m., with the Director of Nursing (DON), the DON stated old signs posted on the wall showing name of previous resident or anything that pertained or belonged to the old occupant should have been removed by either the housekeeping, CNAs, or Licensed Nurses (LNs) at the time the old resident was discharged or when the bed hold was up for the old occupant. Review of the facility's policy and procedure (P&P) titled, Homelike Environment, revised date February 2021, the P&P indicated, Residents are provided with a safe, clean, comfortable, and homelike environment .Staff provides person-centered care that emphasizes the resident's comfort, independence, and personal needs and preferences .The facility staff and management minimizes, to the extent possible, the characteristics of the facility and reflect a depersonalized, institutional setting.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to verify the physician's wound care treatment order for one of 23 sampled residents (Resident 29) prior to rendering wound treatment. This failure had the potential to not promote the healing of Resident 29's wounds. Findings: A review of the face sheet for Resident 29, indicated Resident 29 was admitted to the facility on [DATE]. During a review of Resident 29's Surgical Consult, dated 9/6/23, the Surgical Consult indicated, Resident 29 had left foot wounds caused by venous stasis disease (veins cannot send the blood from the legs back to the heart). During a concurrent observation and interview on 9/12/23, at 1:29 p.m., with Infection Preventionist (IP), in Resident 29's room, IP administered Resident 29's left foot wound care without checking the physician's wound care order. IP stated the risk of doing the wound treatment without checking the physician's order was giving the wrong wound care to Resident 29. During an interview on 9/14/23, at 11:07 a.m., with Director of Nursing (DON), DON stated, IP should have checked the wound treatment order before administering the wound care for Resident 29 to prevent mistakes in giving wound care. During a review of the facility's policy and procedure (P&P) titled, Wound Care, dated 2010, the P&P indicated, The purpose of this procedure is to provide guidelines for the care of wounds to promote healing .Wound treatment administered per order of attending physician and/or wound physician .License nurse to verify that there is physician's order for wound care prior to rendering treatment.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0687 (Tag F0687)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one of 23 sampled residents (14) was referred and was provided podiatry services. This deficient practice resulted in Resident 14 to have pain and at risk of injury because of her long toenails. Findings: A review of Resident 14's face sheet, dated 8/14/23, indicated Resident 14 was admitted to the facility on [DATE] with a diagnosis of peripheral vascular disease (narrowing of the tubes that carry blood to the different parts of the body which can cause poor blood flow to the legs). A review of Resident 14's Minimum Data Set (MDS, a comprehensive assessment tool to guide care), dated 7/5/23, indicated Brief Interview for Mental Status (BIMS, a screening tool to identify resident's cognitive status) score of 13, indicating Resident 14 had intact cognitive function. During a concurrent observation and interview on 9/11/23, at 9:50 a.m., with Resident 14, in Resident 14's room, Resident 14 had long toenails. Resident 14 stated all her toenails were long, painful and were rubbing against each other. During a concurrent observation and interview on 9/11/23, at 9:52 a.m., with Licensed Vocational Nurse (LVN) 1, in Resident 14's room, Resident 14 had long toenails. LVN 1 described each of Resident 14's toenails as approximately ½ inch long. LVN 1 stated long toenails could cause Resident 14 pain. During a concurrent interview and record review on 9/12/23, at 10:51 a.m., with the Social Service Director (SSD), the Podiatry Worksheet, dated 6/21/23, was reviewed. The Podiatry Worksheet indicated, the last time Resident 14 had her toenails trimmed was on 6/21/23. SSD stated she was responsible for making the podiatrist referrals in the facility. SSD stated, Resident 14 requested podiatry services, and SSD made the podiatrist referral, on 8/14/23. SSD further stated Resident 14 had not been seen by the podiatrist yet, and SSD did not follow up with the resident's podiatrist referral since 8/14/23 because the podiatrist only went to the facility every 3 months. During an interview on 8/14/23, at 11:05 a.m., with Director of Nursing (DON), DON stated that facility could refer the residents to podiatrist as needed. DON stated the risks for Resident 14 who had long toenails were pain, discomfort and a wound could be created by the long toenails which could get infected. During a review of the facility's policy and procedure (P&P) titled, Foot Care, dated 2018, the P&P indicated, Residents will receive appropriate care and treatment in order to maintain mobility and foot health .Residents will be provided with foot care and treatment in accordance with professional standards of practice. Overall footcare will include the care and treatment of medical conditions associated with foot complications (e.g., . peripheral vascular disease, etc.). Residents will be assisted in making transportation appointments to and from specialists (podiatrist .) as needed .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to provide a safe environment for one of 23 sampled residents (Resident 27) when Certified Nursing Assistant 1 (CNA 1) transferred Resident 27 from bed to shower chair using a mechanical lift (a mechanical device used to assist with transfer and movement of residents who required support for mobility beyond the manual support provided by caregivers alone) by himself and without assistance. This failure had the potential to result in serious avoidable resident injury. Findings: A review of Resident 27's admission Record, dated 9/12/23, indicated Resident 27 was admitted to the facility in 2021 with diagnoses of Parkinson's disease (a chronic disorder that affects movement causing tremors, stiffness, and loss of balance) and other abnormalities of gait and mobility. A review of Resident 27's Minimum Data Set (MDS, a resident assessment tool used to guide care) dated 6/13/23, indicated resident required extensive assist with 2 or more person-transfer from bed to chair. A review of Resident 27's Care Plan, dated 8/28/23, indicated, Resident requires [mechanical] lift for safe transfer .Interventions/Tasks - 2 person assist at all times when operating mechanical lift . During a concurrent observation and interview on 9/11/23, at 9 a.m., with Registered Nurse 1 (RN 1), outside by Resident 27's room, Certified Nursing Assistant 1 (CNA 1) transferred Resident 27 from bed to shower chair using the mechanical lift by himself and without assistance from another staff. RN 1 stated mechanical lift transfers were usually 2-person assist. RN 1 also stated sometimes CNAs called licensed nurses to assist with transfers when other CNAs were unavailable. During an interview on 9/12/23, at 8:30 a.m., with CNA 1, CNA 1 stated Resident 27 required a mechanical lift during transfer from bed to chair or chair to bed. CNA 1 stated he transferred Resident 27 using the mechanical lift by himself even though he knew the resident was a 2-person assist. CNA 1 stated transfers with mechanical lift required 2-persons for safe resident transfer. During an interview on 9/14/23, at 10:03 a.m., with the Director of Nursing (DON), the DON stated when a resident required extensive assist, it could be because a resident is not able to follow directions and/or he/she needed more assistance during care. DON also stated some residents can be on extensive assist or total assist (when a resident is totally dependent and not able to help at all). DON stated that either way, use of a mechanical lift always required a 2 or more person-assist for safe transfer. A review of the facility's Patient Lift Owner's Manual titled Battery Operated Patient Lift, revised date 8/10/16, indicated, .TRANSFER FROM BED .Roll the patient onto one side with the assistance of another caregiver .The second caregiver can now pull the remainder of the sling (a cloth harness placed under and around patients with mobility issues to assist during safe transfers from a bed to chair and to help in reducing possible injury for both the patient and the caregiver) from the other side of the patient so that the sling lays flat .Lift the patient above the bed using the hand control .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0697 (Tag F0697)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pain-relieving medication to one of 23 sampled residents (Resident 120) before a Stage 4 pressure ulcer (severe tissue damage that extends to muscles, bones and/or tendons) wound dressing change was rendered. This failure resulted in Resident 120's avoidable, unnecessary pain and discomfort during Resident 120's wound treatment which affected Resident 120's ability to maintain his highest practicable physical, mental, and psychosocial well-being. Findings: A review of Resident 120's admission Record, dated 9/14/23, indicated resident was admitted to the facility on [DATE] with diagnosis of Stage 4 pressure ulcer of sacral region. A review of Resident 120's clinical record titled, Admit/Readmit Assessment, dated 9/12/23, indicated Resident 120 had moderately impaired cognition. Resident 120's Pain Assessment indicated resident verbalized and/or exhibited non-verbal symptoms of pain and had a numeric pain scale (pain rate where 0 is no pain, and 10 is worst pain possible) of 3-4 (mild pain). A review of Resident 120's Physician Order, dated 9/8/23, indicated, Acetaminophen tablet 325 milligrams (mgs) give two (2) tablets via PEG tube (Percutaneous Endoscopic Gastrostomy, a feeding tube) every 4 hours as needed for general discomfort . A review of Resident 120's Care Plan, dated 9/11/23, indicated, Resident 120 had a Stage 4 pressure ulcer on sacrum (present on admission). The Care Plan also indicated, Administer medications as ordered . Further review of the Care Plan, dated 9/11/23, indicated, The resident is at risk for pain related to medical diagnoses .Anticipate the resident's need for pain relief and respond immediately to any complaint of pain .Monitor/record/report to Nurse any signs/symptoms (s/sx) of non-verbal pain: Changes in breathing (noisy, deep/shallow, labored, fast/slow); Vocalizations (grunting, moans, yelling out, silence); Mood/behavior (changes more irritable, restless, aggressive, squirmy, constant motion); Eyes (wide open/narrow slits/shut, glazed, tearing, no focus); Face (sad, crying, worried, scared, clenched teeth, grimacing) Body (tense, rigid, rocking, curled up, thrashing) . During a concurrent observation and interview on 9/13/23, at 11:10 a.m., with the Infection Preventionist (IP) and Licensed Vocational Nurse 2 (LVN 2), Resident 120's wound dressing change was observed. Resident 120 was noted to be stiff and grimacing during the entire time of wound treatment. Resident 120 was also heard saying, Stop, once before the treatment ended. After Resident 120's wound treatment was completed, IP stated she did not assess resident's pain level nor offered the resident pain medication 30 minutes prior to start of the wound dressing change. IP also stated she did not know if the resident took any pain medication from RN 1 in the morning. During an interview on 9/13/23, at 11:50 a.m., with Registered Nurse 1 (RN 1), RN 1 stated she assessed Resident 120 for his pain level during the start of the morning shift but since the resident denied any pain, RN 1 did not offer resident any pain-relieving medication. RN 1 stated IP did not request any pain-relieving medication for Resident 120 prior to rendering wound treatment. A review of the facility's policy and procedure (P&P) titled Wound Treatment, undated, indicated, .Assess resident for pain prior to treatment, if pain indicated, offer pain medication as ordered, administer pain medication as ordered, and wait 30 minutes - 1 hour for medication to be effective prior to rendering treatment. If pain medication is denied, ask resident if agreeable to render treatment. If not agreeable, cease treatment and contact physician .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to ensure accurate accountability of controlled medications (those with high potential for abuse and addiction) and safe use of emergency medications when: 1. Random controlled medication use audit for three of three sampled residents (Residents 53, 59, and 62) did not reconcile. The medications were signed out of the Controlled Drug Record (CDR, an inventory sheet that keeps record of the usage of controlled medications) but not documented on the Medication Administration Records (MAR) to indicate they were administered to the residents. The failure resulted in inaccurate accountability and had the potential for misuse or diversion of controlled medications; and 2. Three of nine emergency kits (e-kit; a kit/box containing medications and supplies for immediate use during a medical emergency) were not replaced timely after being opened or expired. The failure had the potential for not having emergency medications/supply on hand when needed or expired medications given to the residents. Findings: 1. During the survey, CDRs for three random residents (Residents 53, 59, and 62) receiving PRN (as needed for) controlled medications were requested for review. During an interview with the Director of Nursing (DON) on 9/12/23 at 1:57 p.m., she stated any time a resident requested a PRN controlled medication, the nurse removes the medication from the locked compartment in the medication cart, signs it out of the CDR, administers it to the resident, and then documents the administration on the resident's MAR. a. A review of Resident 62's clinical record indicated he had a physician's order, dated 2/27/23, for Norco (hydrocodone-acetaminophen, a controlled medication for pain) 5/325 milligrams (mg, unit of measurement) 1 tablet by mouth every 8 hours as needed for severe chronic pain. A review of her CDR for Norco indicated she infrequently requested for the PRN Norco. During a concurrent interview and record review with the DON on 9/12/23 at 2 p.m., a review of Resident 62's CDR for Norco 5/325 mg and the April and September 2023 MARs indicated the nursing staff removed and signed out 1 tablet on 4/20/23 at 1700 (5 p.m.) and on 9/1/23 at 9 a.m. but did not document the respective administration on the MARs. The DON confirmed two Norco tablets were not documented as given to the residents and unaccounted for. b. A review of Resident 53's clinical record indicated a physician's order for Norco 5/325 mg, give 1 tablet every 4 hours as needed for moderate pain, dated 6/7/23. During a concurrent interview and record review with the DON on 9/12/23 at 2:09 p.m., a review of Resident 53's CDR for Norco 5/325 mg and the July and August 2023 MARs indicated the nursing staff removed and signed out 1 tablet on 7/17/23 at 1800 (6 p.m.) and on 8/10/23 at 7:15 a.m. without documenting the respective administration on the MARs. The DON confirmed this finding. c. A review of Resident 59's clinical record indicated a physician's order for oxycodone (a potent narcotic for pain) 10 mg, 1 tablet every 4 hours PRN moderate pain, and 2 tablets every 4 hours PRN severe pain, dated 8/10/23. During a concurrent interview and record review with the DON on 9/12/23 at 2:13 p.m., a review of Resident 59's CDR for oxycodone 10 mg and the September 2023 MAR indicated the nursing removed and signed out 2 tablets on 9/9/23 at 6:15 p.m. but did not document the administration on the MAR. The DON verified two oxycodone tablets for Resident 59 were unaccounted for. A review of the facility's policy and procedures (P&P) titled Controlled Substances, dated 4/2019, indicated: The facility complies with all laws, regulations, and other requirements related to handling . and documentation of controlled medications . The nurse administering the medication is responsible documenting record of administration of dose. A review of the facility's P&P titled Medication Administration, dated 4/2019, indicated, The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication . the individual administering the medication records in the resident's medical record . the date and time the medication was administered . 2. On 9/11/23 at 9:44 a.m., a visit to Station 2 Medication Room was conducted with Registered Nurse 1 (RN 1). Three expired e-kits were identified. The CIII-CV E-kit (kit containing Scheduled 3 to Schedule 5 controlled medications) had the expiration date of 4/2023. Two medications, the lorazepam and temazepam (medications to treat agitation and anxiety) tablets, inside the kit had the expiration date of 4/2023. Two large IV Supply e-kits (kit containing solutions and supplies for intravenous injection) were identified with the expiration date of 7/2023. A review of the Emergency Drug Kit Usage Report (log) inside each e-kit indicated one was opened with a content removed on 6/9/23 (3 months ago), and the other was opened on 6/19/23. RN 1 confirmed the findings and acknowledged they should have been replaced. During an interview with the DON on 9/11/23 at 10:04 a.m., she stated, Usually when we use it, we fax to the pharmacy [for replacement] right away. She stated the facility staff requested the replacement shortly after they were opened, but she was not sure what happened and why they were not replaced since June 2023. During a telephone interview with the Consultant Pharmacist (CP) on 9/12/23 at 11:29 a.m., he stated the e-kits should be replaced right away after opening. A review of the facility's P&P titled Emergency Medications, dated 4/2007, indicated: Any time medications and supplies used from the emergency medication kit are used, pharmacy should be contacted immediately for replacement.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Drug Regimen Review (Tag F0756)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the Consultant Pharmacist (CP) inspect the emergency medication kits (e-kits) on a monthly basis in accordance with the facility policy and procedures (P&P). Also, the CP failed to identify and report to the facility medication irregularities during the monthly medication regimen review (MRR) for two of 23 sampled residents (14 and 27). The failures resulted in opened and expired e-kits not being replaced timely for resident use; and undetected medication irregularities had the potential for residents not achieving highest therapeutic outcomes. Findings: 1. During a visit to Station 2 Medication Room with Registered Nurse 1 (RN 1) on [DATE] at 9:44 a.m., three expired e-kits were identified in a locked cabinet. The CIII-CV E-kit (kit containing Scheduled 3 to Schedule 5 controlled medications) had the expiration date of 4/2023. Two medications, the lorazepam and temazepam (medications to treat agitation and anxiety) tablets, inside the kit had the expiration date of 4/2023. Two large IV Supply e-kits (kit containing solutions and supplies for intravenous injection) were identified with the expiration date of 7/2023. RN 1 confirmed the findings and acknowledged they should have been replaced. During a telephone interview with the CP on [DATE] at 11:30 a.m., he stated he saw those expired e-kits during one of the previous visits and asked a nurse to request for replacement, but did not document that on the report to the facility. During another interview with the CP on [DATE] at 10:30 a.m., when asked whether he inspected the e-kits during the monthly visits to the facility, the CP stated, When I can. He explained that he did so whenever the nurse was available to open the locked cabinet for him to inspect. He added, I try to. The CP was asked to show written reports indicating he inspected the e-kits on a monthly basis, he showed an example of a report indicating random medication room/med cart audit completed. He stated he did not make any written reports specific to the inspection of the e-kits. A review of the facility's P&P titled Emergency Medications, dated 4/2007, indicated: The Consultant Pharmacist shall inspect the emergency medication kits monthly and record the findings on the record maintained with each kit. 2a. A review of Resident 27's clinical record indicated he had physician's orders for and had been receiving Oyster Shell (calcium carbonate) 500 milligrams twice daily at 9 a.m. and 5 p.m.; and ferrous sulfate (to prevent or treat low blood iron level) 325 mg twice daily at 9 a.m. and 5 p.m., both dated [DATE]. A review of Lexicomp (www.[NAME].com), a nationally recognized drug information resource, indicated the concurrent use of calcium carbonate and ferrous sulfate would lead to Risk Rating D (meaning significant) drug-drug interaction. Specifically, Lexicomp indicated calcium carbonate may decrease the absorption of Iron Preparations . The absorption of ferrous sulfate has been shown to be reduced by 15% to 24% with calcium carbonate. It further indicated to consider separating the doses of the two medications as much time as possible in patients who require chronic use of both agents and monitor for decreased therapeutic effects of oral iron preparations. During a concurrent interview and record review with the DON on [DATE] at 9:58 a.m., she confirmed Resident 27 had been receiving both medications at the same time each day since [DATE]. She reviewed the drug information online and stated the calcium would decrease the iron absorption if given together at the same time. She also reviewed Resident 27's clinical record and stated the resident has had low hemoglobin (amount of protein in the red cells able to transport oxygen to all cells in the body ) and hematocrit (represents the percent of red cells in the blood) in February 2023, indicating he was anemic (problem of not having enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissues). She also stated the resident had a chronic wound which bled often. When asked whether the CP identified as an irregularity and made a recommendation to separate the two medications, the DON reviewed the resident's clinical record and the MRR binder (which contained the CP's recommendations), and stated she could not find any. During an interview with the CP on [DATE] at 10:40 a.m., he stated he typically would make a suggestion to the nurse based on the resident's reference, but did not make a written recommendation for separating the iron and calcium administration for Resident 27. He confirmed that co-administration of the two medications would lead to decreased absorption of iron. He agreed that he should have made the recommendation in order to minimize the effect of the drug interaction so the resident could receive the full therapeutic effect of the iron. 2b. A review of Resident 14's clinical record indicated she had been receiving Risperdal (an antipsychotic medication) 2 mg once daily since [DATE]. However, there was no documented evidence the facility staff monitored for its adverse effects (or side effects). During a concurrent interview and record review with the CP on [DATE] at 10:45 a.m., he stated, for residents receiving psychotropic medications (drugs that affects brain activities associated with mental processes and behavior), he would make sure the the facility staff monitor for their effectiveness and side effects. He reviewed Resident 14's clinical record and confirmed there had been no monitoring of Risperdal's side effects since [DATE] (10 months ago). He stated it was discontinued when the medication was reduced on that day. When asked whether he identified this as an irregularity and made a recommendation to the facility during the monthly MRR for Resident 14, he stated, It's something that I missed. A review of the facility's P&P titled Psychotropic Medication Use, dated 7/2022, indicated, Residents receiving psychotropic medications are monitored for adverse consequences. A review of the facility's P&P titled, Medication Regimen Reviews, dated 5/2019, indicated, The Consultant Pharmacist performs a medication regimen review (MRR) for every resident in the facility . The MRR involves a thorough review of the resident's medical record to prevent, identify, report, and resolve medication related problems .other irregularities, for example . inadequate monitoring for adverse consequences; potentially significant drug-drug .interactions. A review of the facility's P&P titled, Pharmacy Services- Role of the Consultant Pharmacist, dated 4/2019, indicated, The Consultant Pharmacist will provide specific activities related to medication regimen review including . Providing the facility with written and electronic reports and recommendations related to all aspects of medication and pharmaceutical services review.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0760 (Tag F0760)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to ensure two of 23 sampled residents (Residents 10 and 27) and a non-sampled resident (Resident 39) were free from a significant medication error when they received insulin (medication to lower blood sugar) past the discard (expiration) date. This deficient practice had the potential for ineffective use of the insulin, which would result in uncontrolled high blood sugar for the residents. Findings: 1. On 9/11/23 at 10:18 a.m., an inspection of Medication Cart #2 with Registered Nurse 1 (RN 1) revealed the following: - A Basaglar Kwikpen (a pre-filled insulin pen containing a long-acting insulin called insulin glargine) for Resident 27, which had a written open date of 8/3/23. - A Lantus SoloStar (a pre-filled insulin pen containing insulin glargine) for Resident 39, which had a written open date of 8/10/23. On 9/11/23 at 10:45 a.m., a review of the pharmacy label on both insulin pens with RN 1 indicated to discard 28 days after opening. RN 1 confirmed the insulin pen for Resident 27 would have expired on 9/1/23 (28 days after opening); and Resident 39's Lantus SoloStar would have expired on 9/8/23. She reviewed Resident 27's current medication administration record (MAR) and stated he had a physician's order to receive 6 units of insulin glargine at each bedtime; and had received 9 doses since 9/1/23. A review of Resident 27's physician's order, dated 7/25/23, indicated to give insulin glargine 100 units/milliliter, inject 6 units subcutaneously (under the skin) at each bedtime for type 2 diabetes (disease that impairs the body's ability to regulate blood sugar). During a concurrent interview and record review with the Director of Nursing (DON) on 9/12/23 at 1:52 p.m., she stated Resident 39's Lantus SoloStar, which was opened on 8/10/23, would have expired on 9/8/23 (28 days after opening). A review of the physician's order with the DON indicated to give Lantus SoloStar, 6 units in the morning and 3 units at bedtime, dated 9/6/23. The DON reviewed the current MAR and stated the resident received a total of 7 doses since the medication expired on 9/8/23. She stated it is important to discard the insulin after 28 days because it may not be as effective anymore. A review of Lexicomp, a nationally recognized drug information resource, indicated to store opened (or in-use) insulin glargine prefilled pens at room temperature and use within 28 days. 2. On 9/12/23 at 11:19 a.m., an inspection of Medication Cart #3 with Licensed Vocational Nurse 1 (LVN 1) identified a Lantus SoloStar pen for Resident 10 with a written open date of 8/12/23. LVN 1 verified the pen would have expired on 9/10/23 (28 days after opening). She reviewed Resident 10's current MAR and stated the resident received a dose of 12 units each day on 9/10 and on 9/11/23. Review of Resident 10's physician order, dated 1/6/23, indicated to give Lantus 12 units subcutaneously at bedtime related to type 2 diabetes. A review of Resident 10's September 2023 MAR indicated he received 12 units at 9 p.m. on 9/10 and 9/11/23. During an interview with the Consultant Pharmacist (CP) on 9/13/23 at 10:45 a.m., he stated giving insulin past its 28-day discard date would not be as effective. A review of an online publication by the Consumermedsafety.org (a nationally recognized medication safety organization), titled Storage of Insulin, it indicated, Never use insulin if expired. The expiration date will be stamped on the vial or pen. Remember if not in the fridge, the date on the vial or pen does not apply. You must throw away after 28 days since outside the fridge. (https://consumermedsafety.org; accessed 9/18/23) During a review of the facility's policy and procedure (P&P) titled, Administering Medications, dated 1/1/2020, the P&P indicated, The expiration/beyond use date on the medication label is checked prior to administering.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to ensure three of nine emergency kits (e-kit; a kit/box containing medications and supplies for immediate use during a medical emergency) did not expire; expired insulin (medication to lower blood sugar) prefilled pens were removed from the medication carts for two of two medication carts inspected; and an opened multi-dose vial had an open date in one of two medication refrigerators inspected. The failure resulted in insulin pens given past the expiration date; and the potential for residents to receive expired medications which would result in unsafe and ineffective use. Findings: 1. During a visit to Station 2 Medication Room with Registered Nurse 1 (RN 1) on 9/11/23 at 9:44 a.m., three expired e-kits were identified. The CIII-CV E-kit (kit containing Scheduled 3 to Schedule 5 controlled medications) had the expiration date of 4/2023. Two medications, the lorazepam and temazepam (medications to treat agitation and anxiety) tablets, inside the kit had the expiration date of 4/2023. Two IV Supply e-kits (kit containing solutions and supplies for intravenous injection) had the expiration date of 7/2023. RN 1 confirmed the findings. 2. On 9/11/23 at 10:18 a.m., an inspection of Medication Cart #2 with RN 1 revealed the following: - A Basaglar Kwikpen (a pre-filled insulin pen containing a long-acting insulin glargine) for Resident 27, which had a open date of 8/3/23. - A Lantus SoloStar (a pre-filled insulin pen containing insulin glargine) for Resident 39, which had a written open date of 8/10/23. On 9/11/23 at 10:45 a.m., a review of the pharmacy label on both insulin pens with RN 1 indicated to discard 28 days after opening. RN 1 confirmed the insulin pen for Resident 27 would have expired on 9/1/23 (28 days after opening); and Resident 39's Lantus SoloStar would have expired on 9/8/23. She reviewed Resident 27's current medication administration record (MAR) and stated he had a physician's order to receive 6 units of insulin glargine at each bedtime; and had received 9 doses since 9/1/23. A review of Lexicomp, a nationally recognized drug information, indicated to store opened (or in-use) insulin glargine prefilled pens at room temperature and use within 28 days. 3. On 9/11/23 at 11:15 a.m., during a visit to the Station 1 Medication Room with the Director of Nursing (DON) identified an open aplisol (an agent to aid diagnosis of tuberculosis infection) solution vial without a written open date. A review of the manufacturer's label with the DON indicated to discard 30 days after opening. The DON confirmed it should have been written with an open date. 4. On 9/12/23 at 11:19 a.m., an inspection of Medication Cart #3 with Licensed Vocational Nurse 1 (LVN 1) identified a Lantus SoloStar pen for Resident 10 with a written open date of 8/12/23. LVN 1 verified the pen would have expired on 9/10/23 (28 days after opening). She reviewed Resident 10's current MAR and stated the resident received a dose of 12 units each day on 9/10 and on 9/11/23. During an interview with the Consultant Pharmacist (CP) on 9/13/23 at 10:45 a.m., he stated giving insulin past its 28-day discard date would not be as effective. During a review of the facility's policy and procedure (P&P) titled, Administering Medications, dated 1/1/2020, the P&P indicated, The expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container. A review of the facility's P&P titled, Medication Storage, dated 11/2020, indicated: The nursing staff is responsible for maintaining medication storage . in a .safe . manner . outdated, or deteriorated drugs . are returned to the dispensing pharmacy or destroyed.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Unnecessary Medications (Tag F0759)

Could have caused harm · This affected multiple residents

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Based on observation, interview, and record review, the facility had a medication error rate of 15.63% when five medication errors occurred out of 32 opportunities during the medication administration observation for three of five residents (Residents 11, 20, and 36). Resident 20 received a corticosteroid (aka steroid) oral inhaler without rinsing her mouth with water afterwards; Resident 11 did not receive two medications as scheduled; and Resident 36 did not receive two medications as prescribed. The failures had the potential for the residents not receiving the full therapeutic effect of medications, or adverse affects, compromising their health. Findings: 1. During a medication administration observation on 9/11/23 at 8:05 a.m., Registered Nurse (RN ) 2 was observed preparing 8 medications for Resident 20 including an oral inhaler containing a combination of budesonide and formoterol (budesonide belongs to a class of drugs known as corticosteroids. It works by reducing the irritation and swelling of the airways. Formoterol belongs to the class of drugs known as long-acting beta agonists. It works by relaxing the muscles around the airways so that they open up and you can breathe more easily) 160 micrograms (mcg)/4.5 mcg. On 9/11/23 at 8:16 a.m., at the resident's bedside, RN 2 was observed administering two puffs of the oral inhaler and asking the resident to drink some water after she finished all her medications. RN 2 did not ask the resident to rinse her mouth with water after the inhaler administration. During an interview on 9/11/23 at 8:33 a.m., RN 2 stated she did not ask the resident to rinse her mouth after the oral inhalation because she did not think it was a steroid medication. A review of the pharmacy label on the budesonide-formoterol inhaler with RN 2 indicated, Rinse mouth after use. A review of Resident 20's physician's order indicated to give budesonide-formoterol 160/4.5 mcg/actuation, inhale 2 puffs orally two times a day related to asthma with acute exacerbation, dated 8/8/23. A review of Lexicomp, a nationally recognized drug information resource, indicated the following for the administration of budesonide-formoterol oral inhalation: Rinse mouth with water (spit out without swallowing) after each use to reduce risk of oral candidiasis (oral thrush infection). A review of the facility's policy and procedures (P&P) titled Medication Administration, dated 4/2019, indicated: Oral inhalers are administered per physician orders and manufactures guidelines. 2. On 9/11/23 at 9:06 a.m., Licensed Vocational Nurse 1 (LVN 1) was observed going into Resident 11's room and informing Resident 11 she did not have his eye drops this morning and was waiting for the pharmacy to deliver. In an interview on 9/11/23 at 9:08 a.m., LVN 1 stated the resident had an eye drop medication, brimonidine (medication to treat glaucoma), which was due this morning but they ran out of it since yesterday evening. During a medication administration observation on 9/11/23 at 9:19 a.m., LVN 1 was observed administering 10 medications to Resident 11. The medications did not include brimonidine eye drops. A review of Resident 11's clinical record indicated a physician's order, dated 2/7/23, for brimonidine ophthalmic solution 0.2%, instill 1 drop into left eye two times a day for glaucoma. The facility scheduled it to be administered at 9 a.m. and 6 p.m. daily. A review of Resident 11's clinical record also indicated a physician's order for Miralax powder (a medication to prevent constipation) 17 grams by mouth one time a day for bowel regularity, dated 10/29/22. A review of Resident 11's September 2023 Medication Administration Record (MAR) indicated the facility scheduled Miralax to be administered daily at 9 a.m.; and that LVN 1 documented she administered the Miralax at 9 a.m. on 9/11/23. This was not observed earlier during the administration of 10 medications at 9:19 a.m. During another interview with LVN 1 on 9/11/23 at 1:48 p.m., she stated she did not have the brimonidine eye drop for Resident 11 yet, and confirmed it was not given last night and this morning. Regarding the Miralax, LVN 1 stated she charted the Miralax administration this morning by mistake, and she had not given it yet. She stated, I missed that one. She went to the medication room and momentarily came back with a Miralax bottle, and stated she will give it now. A review of the facility's 4/2019 P&P titled Pharmacy Services Overview indicated, Residents have sufficient supply of their prescribed medications and receive medications (routine, emergency or as needed) in a timely manner. 3. On 9/11/23 at 9:28 a.m., RN 1 was observed using the blood pressure (BP) monitor to obtain Resident 36's BP and pulse (heart rate) at his bedside. After finished, she stated the resident's pulse was 54 beats per minute (regular pulse for adults ranges from 60 to 100 beats per minute). During a medication administration observation on 9/11/23 at 9:35 a.m., RN 1 was observed administering 7 medications to Resident 36 including one tablet of Vitamin B Complex (a medication containing a combination of various B vitamins such as B1, B2, B3, B5, B6, B9, and B12) and a tablet carvedilol (medication for high blood pressure) 6.25 mg. A review of Resident 36's clinical records indicated the following physician's orders: - Vitamin B and C Complex (B complex with C), give one tablet by mouth one time a day for supplements, dated 7/22/23; and - Carvedilol 6.25 mg, give 1 tablet by mouth two times a day for hypertension (high BP). Hold for . HR<60, dated 7/20/23. During an interview with RN 1 on 9/11/23 at 1:53 p.m., she showed the Vitamin B Complex bottle and stated that was what she had been administering to the resident. She stated, It's just B-Complex, not B-Complex with C [as ordered]. She acknowledged they were not the same. Regarding the carvedilol administration, RN 1 confirmed twice that she should have held it, as ordered, because the resident's HR was 54. A review of the facility's P&P titled Medication Administration, dated 4/2019, indicated, Medications are administered in accordance with prescriber orders, including any required time frame . Medications are administered within one (1) hour of their prescribed time, unless otherwise specified .

Jun 2023 3 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

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Based on observation and interview, the facility failed to properly store a medication when Protonix (a medication which works by decreasing the amount of acid the stomach makes) was on top of the medication cart unattended. This failure placed demented residents in the area at risk of ingestion and subjected medication to theft or loss. Findings: During an observation on 3/21/23, at 10:40 a.m., medication Protonix was in a box sitting on top of the unsupervised medication cart. During an interview on 3/21/23, at 10:42 a.m., with Charge Nurse 1 (CN 1), CN 1 stated the medication should have been stored inside the locked medication cart. During an interview on 3/21/23, at 10:50 a.m., with the Director of Nurses (DON), the DON stated the medication should not have been sitting on top of the medication cart unsupervised and should have been securely locked inside the medication cart. During an interview on 3/21/23 at 1 p.m., the Administrator (Admin) stated the expectation is that all medications are locked up inside the medication cart. The facility ' s Medication Storage Policy & Procedure was requested but was not given to this writer.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Menu Adequacy (Tag F0803)

Could have caused harm · This affected 1 resident

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Based on interview and record review the facility failed to ensure the facility menu was followed. This failure had the potential to result in residents having unmet nutritional need due to substitution of nonequivalent foods. Findings: During an interview on 3/15/23 at 2:15 p.m. with the Dietary Supervisor (DS), DS was asked about food supplies and menu substitutions. DS stated the facility was having issues with the facility food delivery vendor. DS stated when the vendor did not have the ordered food item, the vendor would substitute another item such as cauliflower when broccoli was ordered, but not available. During an interview on 3/15/23 at 3:06 p.m. with the facility [NAME] 1, and [NAME] 2, (translation by Certified Nursing Assistant), [NAME] 1 stated sometimes the cooks did not have the food items they needed to cook the foods planned on the menu, and would have to substitute items and change the menu. [NAME] 2 stated the cooks would change the menu when they did not have the necessary ingredients. [NAME] 2 stated she checked the menu in advance and would tell DS what items were missing, and DS would change the menu using substitute items. During an interview and concurrent record review on 3/21/23 at 11:30 a.m., with DS, the Menu Substitution Log was reviewed. DS stated the Menu Substitution Log indicated the following dated entries: 2/4/23 (dinner): No tater tots, used mashed potatoes. No coleslaw, used Italian vegetables. 2/9/23 (breakfast): No cream of wheat to make hot farina, used oatmeal. 2/10/23 (lunch): Cranberry gelatin salad peach fluff wasn ' t prepared. No peaches. Used apricots, fresh strawberries. 2/11/23 (lunch): No pumpkin cheesecake, used pumpkin pie. 2/14/23 (lunch): No turkey meat to make meat balls for renal, gave ground beef. 2/16/23 (lunch): no berry cheesecake bar, used vanilla pudding. 2/16/23 (dinner): No diced ham, used diced chicken. 2/23/23 ( dinner): No bow tie pasta, used macaroni pasta. No mandarin oranges, used peaches. 2/28/23 (dinner): No soy sauce, used sweet and sour sauce. 3/1/23 (lunch): No cherry and cream squares, used banana pie. Didn ' t have all ingredients needed to make. 3/4/23 (lunch): No Dijon mustard for chicken and no chicken thighs, used chicken breasts with turkey gravy. No chicken gravy. No brussel sprouts, used carrots. 3/5/23 (breakfast): No muffin mix to make apple raisin muffins, used wheat toast and rest of English muffins. 3/6/23 (dinner): No split peas to make soup, used vegetable soup. 3/7/23 (lunch): No peanut butter cookie. Made chocolate chip cookies. 3/7/23 (dinner): No beef broth, used chicken broth. No cornbread, used biscuit mix. Not enough fresh fruit for fruit salad. During an interview on 3/21/23 at 1:00 p.m., with the Administrator (Admin), Admin stated she was aware that food substitutions were an issue.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0921)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain a safe environment when: 1. The porch window was broken, and residents were exposed to sharp glass edges for over two weeks. 2. Twenty containers labeled, Caution Corrosive, were not stored in accordance with manufacturer's safety recommendations. These failures placed residents, staff, and visitors at risk for accident and injury. Findings: During an observation on 3/15/23, at 1:30 p.m., on the smoking porch, the porch window was broken with sharp edges exposed to residents. Resident 2 was observed on the porch, unsupervised. During a concurrent observation and interview on 3/21/23, at 10:40 a.m., with Licensed Vocational Nurse (LVN) 1, on the smoking porch, the porch window was broken with sharp edges, and Resident 2 and Resident 4 were on the smoking porch. LVN 1 confirmed the window was broken with sharp edges. A review of the facility's smoking list indicated six residents smoked, and designated times were 9:30 a.m., 2:30 p.m., and 7:30 p.m. The designated smoking location was the back patio smoking porch where the window was sheared and broken with sharp areas. In an interview on 3/21/23, at 12:00 p.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated she took residents to the back porch to smoke. CNA 1 stated she saw the broken window over the past few weeks, and the area was not walled or roped off. During a concurrent interview and record review on 3/21/23, at 10:45 a.m., with the Maintenance Director (Main-D), the facility maintenance log was reviewed. The Main-D stated the window was broken for two weeks, but there was no documentation on the maintenance log that indicated there was a broken window on the smoking porch or a plan to repair the window. During an observation on 3/15/23, at 1:30 p.m., at the facility entrance, 20 containers labeled Caution Corrosive were stored. During an observation on 3/21/23, at 10:40 a.m., at the facility entrance, 20 containers labeled Caution Corrosive were stored. During a concurrent interview and record review, on 3/21/23, at 10:45 a.m., with Main-D, the Material Safety Data Sheet (MSDS) for the 20 corrosive containers was reviewed. The Main-D stated he was waiting for the company to pick up the containers. Review of the MSDS separated the chemicals into kitchen and laundry room categories and indicated: Kitchen Chemicals: 1. [NAME]- Skin corrosion, causes severe skin burns and eye damage. May be harmful if swallowed. Do not inhale or ingest. Store locked up. 2. Pot-n-Pan Pink Suds- Eye and Skin irritation. Do not inhale or ingest. Handle in accordance with good industrial hygiene and safety practice. Use personal protection as recommended. Store containers in cool, dry and well-ventilated place. Keep out of reach of children. 3. Aqua Clean Diamond- Skin burns and eye damage. Do not breathe vapors or ingest. Store locked up. 4. Aqua Dry- Avoid contact with eyes, skin, inhalation, and ingestion. Causes severe eye damage and skin burns. Store locked up. 5. Aqua Pure- Severe skin burns and eye damage. Do not breathe vapors or ingest. Store locked up. Laundry Room: 6. Premium Power Surge- Harmful if swallowed, harmful in contact with skin, harmful if inhaled, causes skin irritation, may cause damage to organs through prolonged or repeated exposure. Dispose of contents/container to an approved waste disposal. Handle in accordance with good industrial hygiene and safety practice. Use personal protection as recommended. Store containers in cool, dry and well-ventilated place. Keep out of reach of children. 7. Aqua Bright Bleach- Causes severe skin burns. Do not breathe vapors or ingest. Store locked up. 8. Soil Buster Break- Causes severe skin burns and eye damage. Store locked up. May be harmful if swallowed and harmful when contacted with skin.

Apr 2021 10 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure two of five sampled resident rooms had accurate wall clocks. This failure resulted in emotional distress from not knowing what time it was for two (Resident 306 and Resident 307) of four residents in the rooms with inaccurate wall clocks. Findings: During a review of Resident 306's admission Record, the Record showed Resident 306 was his own responsible party. During a review of Resident 306's Minimum Data Set (MDS, a resident assessment tool used to guide care) dated 4/28/21, the MDS indicated Resident 306 had a Brief Interview for Mental Status score of 13. (BIMS, a scoring system used to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.) the MDS also indicated Resident 306 had adequate vision. During a review of Resident 307's Order Summary Report dated 4/27/21, the Report indicated Resident 307 had been admitted to the facility on [DATE], with the mental capacity to make healthcare decisions. During a review of Resident 307's MDS dated [DATE], the MDS indicated Resident 307 had a BIMS score of 12, an indication of moderate cognitive impairment. A review of the facility census dated 4/25/21 indicated Resident 306 and 307 shared a room. During an interview on 4/26/21, at 11:21 a.m., with Resident 306, in the shared room of Resident 306 and 307, Resident 306 stated he was hungry, but he didn't know if it was lunchtime because there was no clock in his room. During an observation on 4/26/21, at 11:25 a.m., the shared room of Resident 306 and 307 had a clock on the wall, the clock was not keeping time, and had stopped with the hands at 12:01. During an interview with Resident 307, in the shared room of Resident 306 and 307, Resident 307 stated the clock had not worked since he had been admitted into this room, although he had told the nurses multiple times it was broken. Resident 307 stated the lack of a working clock made him feel hopeless. During an interview on 4/26/21, at 12:10 p.m., with Certified Nursing Assistant 1 (CNA) 1, in the shared room of Resident 306 and 307, CNA 1 confirmed the wall clock had stopped at 12:01. CNA 1 stated it was the first time he had been in this room, so he had not known the clock was not working. During a concurrent observation and interview on 4/26/21, at 12:25 p.m., with Certified Nursing Assistant 2 (CNA 2) in Resident 309's room, the room had a clock on the wall which indicated the current time was 11:24. CNA 2 confirmed the clock was not showing the correct time. During an interview on 4/27/21, at 9:45 a.m., with Social Services Director (SSD), in SSD office, SSD stated it was important for the clocks in resident rooms to be accurate so that residents would know what time of day it was. During an interview on 4/27/21, at 9:50 a.m., with the Activity Director (AD), in the hallway near nursing station 1, AD stated he checked resident rooms on Tuesdays and Thursdays but had not seen any nonfunctioning clocks. AD stated resident room clocks were important to helping prevent confusion and increasing awareness of routines for residents. During a concurrent interview and record review on 04/27/21, at 12:10 p.m., with the Administrator (ADM), the facility Maintenance Log was reviewed. ADM confirmed the Log showed no documentation of clock maintenance for the clock in the shared room of Resident 306 and 307. ADM stated any employee could enter a work order request in the maintenance log whenever equipment required repairs. During a review of the facility's policy and procedure (P&P) titled, Quality of Life - Dignity, dated February 2020, the P&P indicated, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, feeling of self-worth and self-esteem.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0584)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to provide a homelike environment for two (Resident 39 and Resident 11) of 23 sampled residents when; 1. the facility did not address Resident 39's complaints of noise. 2. the facility did not replace Resident 11's broken television for over three weeks. For Resident 39 this failure resulted in decreased sleep and rest from excessive noise which caused mental and physical stress. For Resident 11, this failure resulted in less enjoyment of life from not being able to watch his favorite television shows on a screen large enough for him to see the shows. Findings: 1. A review of Resident 39's admission Record dated 4/27/21, indicated Resident 39 was admitted to the facility in 2015 with diagnoses which included muscle weakness, and cerebral infarction (stroke). The admission Record indicated Resident 39 had a family member, Responsible Party 1 (RP 1) for healthcare decisions. A review of Resident 5's admission Record dated 4/27/21, indicated Resident 5 was admitted to the facility in 2015 with diagnoses which included dementia with behavioral disturbance (a brain disorder that affects the ability to remember, think clearly, communicate, and perform daily activities and that may cause changes in mood and personality) and delirium (an acute mental disturbance characterized by confused thinking and disrupted attention usually accompanied by disordered speech). A review of the facility census dated 4/25/21, indicated Resident 39 and Resident 5 shared a room. During an observation and concurrent interview with Resident 39 on 4/26/21 at 11:55 a.m., Resident 39 was awake and seated on a geriatric chair (a geri-chair is a padded, reclining chair with casters) next to her bed. Resident 5 sat in a wheelchair in the room, talking or yelling continuously. Resident 39 complained she had not been able to get a good night's rest because her roommate yelled and screamed. During an interview with RP 1 on 4/26/21 at 2:30 p.m., RP 1 complained that she had called the facility to speak to Resident 39 on multiple occasions, and she always heard Resident 5 yelling and screaming in the background. RP 1 stated she had asked the facility to change Resident 39 to a different room. During an interview with the Restorative Nursing Assistant (RNA 1) on 4/26/21 at 9:00 a.m., RNA 1 stated Resident 5 yelled constantly. RNA 1 stated she had informed the licensed nurse that Resident 39 had complained she was unable to rest because Resident 5's yelling bothered her so much. During an interview with the Certified Nursing Assistant (CNA 3) on 4/27/21 at 10:00 a.m., CNA 3 stated Resident 5 constantly yelled and screamed, and Resident 39 had complained about it to the licensed nursing staff. During a telephone interview with Licensed Vocational Nurse 5 (LVN 5) on 4/27/21 at 6:00 a.m., LVN 5 stated Resident 5 talked loudly enough to be heard at the nursing station. During an interview with the Social Services Director (SSD) on 4/28/21 at 10:00 a.m., SSD stated she had not received reports from the staff about Resident 39's complaint of Resident 5's noisy behaviors. During a review of the facility policy titled, Quality of Life - Environment, dated May 2017, indicated Residents are provided with a safe, clean, comfortable and homelike environment .Staff shall provide person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: .Comfortable noise levels. 2. During a review of Resident 11's admission Record dated 4/28/21, the admission Record indicated Resident 11 was admitted to the facility in 2014 with diagnoses that included glaucoma (an eye disease that causes vision loss). During a review of Resident 11's Minimum Data Set (MDS, an assessment tool used to direct care) dated 4/27/21, the MDS indicated Resident 11 was understood and could understand others. The MDS also indicated Resident 11 had moderately impaired vision. During an interview on 4/27/21 at 10:02 a.m., in a resident group meeting, Resident 11 stated his 40-inch television (TV) had been broken for almost a year and had not yet been replaced by the facility. Resident 11 stated he had impaired vision to his right eye which made it difficult for him to watch his favorite basketball games on the 20-inch television provided as a temporary replacement by the facility. Resident 11 stated the Administrator (ADM) had promised to replace his TV but had not yet done so. During a concurrent interview and record review on 4/27/21 at 12:28 p.m., with the Social Services Director (SSD), a Theft and Loss Report was reviewed. The Theft and Loss form was dated 3/31/21, and indicated Resident 11's personal 40-inch TV was broken. SSD stated she had completed the Theft and Loss form, but the TV had not yet been replaced. During an interview on 4/28/21 at 8:47 a.m., with the ADM, the ADM stated Resident 11's TV had broken when room changes were being made but could not remember the exact date Resident 11 had reported the broken TV. ADM stated he had promised to replace the TV but had not yet done so. During a review of the facility's policy and procedure (P&P) titled, Personal Property, revised September 2012, the P&P indicated, Residents are permitted to retain and use personal possessions and appropriate clothing, as space permits. The resident is encouraged to maintain his/her room in a home-like environment by bringing personal items (i.e., photographs, knickknacks, etc.) to place on nightstands, televisions, etc. The facility will promptly investigate any complaints of misappropriation or mistreatment of resident property.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to provide needed assistance with nail care for one of 22 sampled residents (Resident 1) when Resident 1's fingernails were untrimmed with sharp, chipped edges and black substance beneath the nail tips. This failure resulted in Resident 1 appearing poorly groomed with the potential to cause emotional distress and physical discomfort from injuries resulting from scratched skin from chipped nails. Findings: During a review of Resident 1's Minimum Data Set (MDS, an assessment tool used to direct care) dated 3/27/21, the MDS indicated Resident 1 had a diagnosis of cerebrovascular accident (CVA, impaired blood flow to the brain, commonly called a stroke) and was totally dependent on one person for assistance with personal hygiene. During a concurrent observation and interview on 4/27/21, at 9:50 a.m., with Certified Nursing Assistant 4 (CNA 4), Resident 1's right hand maintained a passive position of his fingers curled inward towards his palm (contracted). CNA 4 opened Resident 1's left hand and uncurled the contracted right hand to show Resident 1's fingernails were untrimmed with sharp, chipped edges, and black substance beneath the tips of the nails. CNA 4 stated Resident 1's fingernails needed to be clipped to prevent the nails from poking into the skin or palm of Resident 1's hand. CNA 4 stated two people were needed to clip Resident 1's fingernails, or to apply the right-hand splint (an aid used to maintain correct position or alignment of a body part). CNA 4 opened Resident 1's nightstand drawer and showed the drawer contained his right hand splint. During an interview on 4/29/21, at 9:17 a.m., with the Director of Staff Development (DSD), DSD stated resident hand hygiene was important to help prevent infection and injury. During a review of the facility's policy and procedure (P&P) titled, Fingernails/Toenails, Care of, revised February 2018, the P&P indicated, The purposes of this procedure are to clean the nail bed, keep nails trimmed, and to prevent infections Nail care includes cleaning and regular trimming Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0679 (Tag F0679)

Could have caused harm · This affected 1 resident

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Based on observation, interview and record review, for two residents (Resident 56 and Resident 39) the facility failed to inform residents and their responsible parties regarding the current facility visitation policy when: 1. The facility did not notify Resident 56 and her family that in-person visitation was allowed. 2. The facility did not notify Resident 39's Responsible Party 2 (RP 2, an individual responsible for health care decisions for a resident without capacity to make decisions) that in-person visitation was allowed. These failures resulted in feelings of depression and social isolation for Residents 56 and 39. Findings: 1. A review of Resident 56's admission Record on 4/26/21 at 11:00 a.m., indicated Resident 56 was admitted In February 2020 included diagnoses of anxiety, muscle weakness, and a broken right foot. During an observation and concurrent interview with Resident 56 on 4/26/21 at 11:46 a.m. Resident 56 complained the facility was not allowing her spouse to visit her in-person. Resident 56 stated she had seen other residents with visitors inside the facility last Sunday but had never been told in-person visitation was allowed. Resident 56 stated she was depressed and felt lonely as she has not seen her spouse for months. During an interview with the Administrator (ADM) on 4/28/21 at 11:45 a.m., ADM stated the facility followed current State and Federal guidelines for visitation during COVID-19 pandemic (a globally wide-spread infectious respiratory disease that can result in serious illness or death), which meant in-person visitation was allowed. ADM stated the Social Services Director (SSD) was responsible for notifying families that in-person visitation was now allowed. During an interview with SSD on 4/28/21 at 11:45 a.m., SSD stated the facility was now open for in-door visitation, and that the Activity Director was responsible for notifying the residents and their responsible parties. During an interview with the Activity Director (AD) on 4/28/21 at 11:57 a.m., AD confirmed the facility opened for in-door visitation on March 26, 2021. AD stated she had only told Resident 56 the facility was opened for in-person visitation. A review of the AD Room Visit Log, dated week of March 29-April 2, 2021, for Resident 56 indicated, Resident was also let known abt [about] visitation, letting her know she can schedule a visit. A review of the facility policy and procedure titled, Visitation - COVID Policy and Procedure, undated, indicated, Family members will be updated with changes visitation policy and operating status. A review of the facility policy titled, Communication: COVID Activity, revised August 2018, indicated, Facility staff will provide updates to residents and family on status of facility and updates to operations in regards to COVID-19 . 2. A review of Resident 39's admission Record on 4/26/21 at 11:00 a.m., indicated Resident 39 was admitted in 2015 with included diagnoses of muscle weakness, and cerebral infarction (stroke). The admission Record indicated Resident 39 had a family member, Responsible Party (RP 1) for healthcare decisions. During an observation and concurrent interview with Resident 39 on 4/26/21 at 11:55 a.m., Resident 39 sat in a geri-chair (a geri-chair is a padded, reclining chair with casters) next to her bed. Resident 39 stated she was sad because she had not seen her family for month and she missed her family. During an interview with the Responsible Party 1 (RP 1) on 4/26/21 at 2:30 p m., RP 1 stated she has been calling the facility to speak Resident 39 and to the staff. RP 1 stated she had not been notified she could visit Resident 39 in-person. During an interview with the Activity Director (AD) on 4/28/21 at 11:57 a.m., AD was not able to provide documentation that Resident 39 and RP1 were informed the facility now allowed in-person visits. A review of the facility policy and procedure titled, Visitation - COVID Policy and Procedure, undated, indicated, Family members will be updated with changes visitation policy and operating status. A review of the facility policy titled, Communication: COVID Activity, revised August 2018, indicated, Facility staff will provide updates to residents and family on status of facility and updates to operations in regards to COVID-19 .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to ensure that one (Resident 11) of 22 sampled residents, received sevelamer (a medication that helps control blood phosphorus levels) according to physician orders. The failure to ensure Resident 11 received the correct dose of sevelamer had the potential to result in increased levels of phosphorus in the blood which can lead to decreased bone strength and broken bones. Findings: During a review of Resident 11's admission Record, dated 4/28/21, the admission Record indicated Resident 11 was admitted to the facility in 2014 with included diagnoses of end-stage renal disease (ESRD) requiring dialysis three times a week. (Dialysis, a process by which dissolved substances are removed from a patient's body by diffusion from one fluid compartment to another across a semipermeable membrane. Dialysis is used for the treatment of end stage renal disease, the stage of kidney impairment that appears irreversible and permanent and requires a regular course of dialysis or kidney transplantation to maintain life.) During a review of Resident 11's Minimum Data Set (MDS, an assessment tool used to direct care) dated 1/25/21, the MDS indicated Resident 11's was understood and could understand others. During a review of Resident 11's Physician Order Summary Report dated 4/28/21, the Report indicated an order to administer sevelamer 800 milligrams (mg), three times a day at 6 a.m., 12 p.m., and 6 p.m., with a start date of 4/25/21. During a concurrent interview and record review on 4/29/21, at 9:51 a.m., with the Licensed Vocational Nurse 4 (LVN 4), Resident 11's Medication Administration Record (MAR) dated April 2021, was reviewed. The MAR showed no checkmarks in the administered box for Resident 11's sevelamer 800 mgs on 4/26/21 at 12 p.m., or 4/28/21 at 12 p.m. LVN 4 stated Resident 11 had not received sevelamer during lunch or prior to leaving for dialysis on 4/26/21 and 4/28/21. During an interview on 4/29/21 at 9:55 a.m., with Resident 11, Resident 11 confirmed Licensed Nurses had not administered sevelamer or any other medications whenever he takes an early lunch and/or prior to dialysis treatment. During an interview on 4/29/21, at 9:58 a.m., with the Director of Nursing (DON), the DON stated sevelamer was a phosphorus-binding medication. DON stated phosphorus levels could increase if not administered as ordered for residents with ESRD. During a review of the facility's policy and procedure (P&P) titled Administering Medications, revised April 2019, the P&P indicated, Medications are administered in accordance with the prescriber orders, including any required time frame. Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include: a. Enhancing optimal therapeutic effect of the medication; b. preventing potential medication or food interactions .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0804 (Tag F0804)

Could have caused harm · This affected 1 resident

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Based on observation, interview and record review, the facility failed to ensure one of 22 sampled residents (Resident 16) received a meal at a nourishing and palatable temperature. The failure of dietary staff (Cook 2) to check the temperature of hot food items before plating and serving the meal to Resident 16 had the potential to result in scalds or burns from excessively hot food, or decreased intake and/or food borne illness from a meal cooked and/or served at an inadequate temperature. Findings: A review of Resident 16's admission Record showed an admission in June 2020 with included diagnoses of end stage renal disease and dependency on dialysis. (Dialysis is a process by which dissolved substances are removed from a patient's body by diffusion from one fluid compartment to another across a semipermeable membrane. Dialysis is used for the treatment of end stage renal disease, the stage of kidney impairment that appears irreversible and permanent and requires a regular course of dialysis or kidney transplantation to maintain life.) During an observation on 4/27/21 at 11:38 a.m., in the kitchen with Dietary Manager (DM), [NAME] 2 prepared an early lunch tray for Resident 16, who was scheduled to leave the facility for dialysis. [NAME] 2 plated and served Resident 16's meal without checking the temperature of hot food items. During an interview on 4/27/21 at 11:45 a.m., with DM, DM confirmed [NAME] 2 had not checked the temperature of the hot food items of Resident 16's lunch meal. During a review of the facility's policy and procedure (PNP) titled, Meal Service, dated 2018, the PNP indicated, Meals that meet the nutritional needs of the resident will be served in an accurate and efficient manner, and served at the appropriate temperatures The Food and Nutrition services staff member will take the food temperatures prior to service of the meal with a thermometer that has been cleaned and sanitized.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Accident Prevention (Tag F0689)

Could have caused harm · This affected multiple residents

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Based on observation, interview, and record review, the facility failed to keep two of three treatment carts (a portable cart containing supplies needed for wound care) locked when not in the view of a licensed nurse. This failure had the potential to result in injury to residents, staff, or visitors from unauthorized use of injection needles, scissors, and suture supplies (needles and surgical thread used to sew wounds closed). Findings: During an observation on 4/26/21 at 11 a.m., at nursing station 3, on the ground floor of the facility, was an unlocked, unsupervised treatment cart. The second drawer of the cart was unlocked and contained surgical scissors, injection needles, and suture materials. There was no licensed nurse present at nursing station 3, or on the ground floor. Certified Nursing Assistant 2 (CNA 2) was the only nursing staff present on the ground floor and was not in view from the nursing station. During a continual observation on 4/26/21 from 11 a.m. to 12:25 p.m., the treatment cart was unlocked and unsupervised. During an interview on 4/26/21 at 11:17 a.m., with CNA 2, CNA 2 stated she had no knowledge about the treatment cart; she did not even know if it was used for resident care. During an interview on 4/26/21 at 12:20 a.m., Director of Staff Development (DSD), DSD stated she had not yet checked or used the treatment cart at nursing station 3. DSD stated the treatment carts were always to be kept locked, when not actually in use by licensed staff. DSD stated the treatment carts contained sharp equipment that could cause result injury. During an interview on 4/26/21 at 12:17 a.m. with Licensed Nurse 1 (LVN 1), LVN 1 stated she was the charge nurse for the ground floor nursing station, but she had not checked the treatment cart at nursing station 3 and had not known it was unlocked. LVN 1 stated the cart should be kept locked to prevent unauthorized access. During an observation, with Director of Nursing (DON) and Licensed Vocational Nurse 3 (LVN 3), on 4/26/21, at 1:00 p.m., the Station 2 wound care treatment cart was parked in the nursing station 2 hallway. The Station 2 treatment cart was unlocked, unsupervised and unattended. LVN 3 stated the treatment cart should not be left unlocked for safety reasons and to avoid unauthorized access. A review of the facility policy and procedure (P & P) titled, Treatment Cart, dated 4/2007, the P & P indicated, any treatment carts with medication or sharps items, must be securely locked at all times when out of the nurse's view.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected multiple residents

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Based on observation, interview and record review the facility failed to ensure to drugs used to control pain and anxiety were labeled with the correct physician orders for 8 of 11 sampled residents (Residents 51, 106, 52A, 52B, 10, 308, 16, 24, and 7). These failures had the potential to result in Residents 51, 106, 52A, 52B, 10, 308, 16, 24, or 7 receiving incorrect medication doses with resultant overdosage or underdosage causing oversedation or ineffective treatment of pain and/or anxiety. Findings: During an observation on 04/27/21 at 12:16 p.m., Licensed Vocational Nurse 1 (LVN 1) picked up Resident 51's multidose medication package labeled Hydrocodone-Acetaminophen 5-325 milligrams (a combination pain reducing medication subject to government regulations due to five milligrams of an opium-based ingredient with 325 milligrams of acetaminophen). The label indicated, 1 tablet every 6 hours as needed for pain. LVN 1 removed one tablet from the package and administered the tablet to Resident 51. During a review of Resident 51's Physician Order Summary Report dated 4/3/21, the Report reflected an order for, hydrocodone-acetaminophen tablet 5-325 mg (milligrams) give one tablet by mouth every 6 hours for severe pain (Routine) . During an interview with LVN 1 on 04/27/21 at 12:16 p.m. LVN 1 stated there was a discrepancy between the pharmacy order on the package and the physician's order and stated she had not noticed that discrepancy before. A review of physician orders and medication package labels for eleven residents receiving controlled medications (substances that have an accepted medical use, but also have a potential for abuse, ranging from low to high, and may also lead to physical or psychological dependence) reflected the following discrepancies: Resident 106: Order dated 3/17/21, indicated, hydrocodone-acetaminophen 10-325 mg 1 tablet every 4 hours as needed for moderate pain. Medication package label dated 3/4/21, indicated, hydrocodone-acetaminophen 10-325 mg . 1 tablet every 8 hours as needed for moderate to severe pain . Resident 52B: Order dated 4/18/21, indicated, Oxycodone 10 mg 1 tablet every 6 hours for severe pain (routine). Medication package label dated 4/6/21, indicated, Oxycodone 10 mg .1 tablet every 4 hours as needed for pain . Resident 10: Order dated 5/20/2019, indicated, Tramadol 50 mg 1 tablet every 6 hours for severe pain (routine) Medication package label dated 12/8/20, indicated, Tramadol 50 mg .1 tablet every 4-6 hours as needed for pain. Resident 308: Two orders: Order 1 dated 11/4/18, indicated, Oxycodone 5 mg 1 tablet by mouth every 6 hours as needed for moderate pain. Order 2 dated 11/6/18, indicated, Oxycodone 5 mg 2 tablets by mouth every 6 hours as needed for severe pain. Medication package label dated 9/29/20, indicated, Oxycodone 5 mg .2 tablets (10mgs) by mouth daily at bedtime . Resident 16: Order dated 4/21/21, indicated, .5 mg Escitalopram (medication for depression and anxiety) 1 tablet by mouth one time a day . Medication package label dated 4/12/21, indicated, Escitalopram 5 mg 2 tablets by mouth every day . Resident 24: Two orders: Order 1 dated 4/19/21, indicated, Hydrocodone-Acetaminophen 5-325 mg 1 tablet every 8 hours as needed for pain. Order 2 dated 4/19/21, indicated, Hydrocodone-Acetaminophen 5-325 mg give 1 tablet by mouth in the morning for pain prior to ADLs (activities of daily living such as hygiene and bathing). Medication package label dated 3/24/21, indicated, Hydrocodone-Acetaminophen 5-325 mg .1 tablet by mouth every day prior to ADLs (Activity of Daily Living) and 1 tablet every 6 hours as needed for pain. Resident 7: Order dated 3/2/21, indicated, Hydrocodone-Acetaminophen 10-325 mg 1 tablet by mouth two times a day for severe pain. Medication package label dated 4/19/21, indicated, Hydrocodone-Acetaminophen 10-325 mg .1 tablet every 12 hours as needed for pain . Resident 52A: Two orders: Order 1 dated 4/19/21, indicated .Lorazepam (Ativan) 0.5 mg 1 tablet by mouth twice a day . Order 2 dated 4/27/21, indicated, Lorazepam 0.5 mg every 2 hours as needed for anxiety . Medication package label dated 4/19/21, indicated, 0.5 mg Ativan, 1 tablet twice a day . The label did not reflect the order for as needed medication. During an interview with LVN 1 on 04/28/21 at 08:29 a.m., LVN 1 stated when nurses found when a discrepancy between the physician order and the medication package label, the nurses were expected to call the pharmacist for clarification. LVN 1 stated it was important to provide pain medication according to physician orders so that residents did not suffer from unmanaged pain or have ill effects from too much medication. During an interview on 04/28/2 at 10:00 a.m., with Licensed Vocational Nurse 4 (LVN 4), LVN 4 stated nurses had a responsibility to inform the pharmacy when the physician changed a medication order so that the pharmacy could send new labels with the correct instructions for medication administration. LVN 4 stated it could be confusing if the label instructions did not agree with the physician order. During an interview with Pharmacist 1 (PH 1) on 04/27/21 at 01:14 p.m., PH 1 stated pharmacy staff were expected to call the facility to clarify discrepancies in resident medication orders. During an interview and record review with Director of Nursing (DON) on 04/28/21 at 12:04 p.m., the medication orders for the residents with controlled medication discrepancies were reviewed (Residents 51, 106, 52A, 52B, 10, 308, 16, 24, and 7). DON stated the process for receipt of new orders was for nursing staff to enter the new order in the computer. The pharmacy would receive a copy of the new order and would compare it to the medication currently in stock for the resident at the facility. The pharmacy and nursing staff were expected to communicate if any discrepancies were noted to resolve any issues. After resolution, the pharmacy would send new labels for nursing staff to apply to the medication packages or provide new medication packages. DON stated there was a possibility of nurses administrating the wrong dose of medications if they didn't have the right instructions on the medication packet, which could result in a resident receiving insufficient medication or too much medication. During a review of the facility's policy and procedure, Administering Medications revised April 2019, indicated, . Medications are administered in accordance with prescriber orders, including any required time frame . During a review of the facility's policy and procedure (PNP), labeling of Medication Containers, revised April 2019, the PNP indicated, All medication maintained in the facility are properly labeled in accordance with current state and federal guidelines and regulations Any medication packaging or containers that are inadequately or improperly labeled are returned to the issuing pharmacy. Labels for individual resident medications include all necessary information, such as: .appropriate accessory and cautionary statements .directions for use.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

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Based on observation, interview, and record review, the facility failed to store, prepare, and serve food under sanitary conditions when: 1. Several food items in the kitchen refrigerator were unlabeled and undated. 2. Expired nutritional supplements were stored on the same shelf as nutritional products designated for current consumption. These failures had the potential to cause food contamination or food borne illness. Findings: 1. During an observation in the kitchen on 4/26/21 at 9:45 a.m., the refrigerator had the following unlabeled and undated items: two cups of apple sauce, an opened plastic bag of vegetables, and a tray containing twelve assorted drinks in glasses. During an interview with the Dietary Manager (DM) on 4/26/21 at 11:00 a.m., DM confirmed that the items were not dated and did not have a use by date. 2. During an observation in the hallway storage room on 4/28/21 at 11:03 a.m., a shelf contained the following expired items: one 8 Fluid ounce carton of Jevity (nutritional formula), expiration date of 2/19/2021; seven cans of Two-Cal HN (nutritional formula), expiration date of 2/19/2020. The shelf also contained nutritional supplements designated for current consumption. During an interview with the DON on 4/28/21 at 11:45 a.m., the DON stated the expired nutritional supplements should not be stored with nutritional supplements designated for current consumption. During a review of the facility policy titled, Food Receiving and Storage, dated October 2017 indicated, Foods shall be received and stored in a manner that complies with safe and food handling practices All foods in the refrigerator or freezer will be covered, labeled, and dated (use-by date).

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A review of Resident 306's admission Record indicated Resident 306 was admitted to the facility on [DATE]. A review of Resident 306's Order Summary Report showed an order, start date 4/22/21, for nursing staff to monitor Resident 306 for symptoms of COVID-19 (a an infectious respiratory disease that can result in serious illness and death), on every shift, for 14 days. A review of Resident 306's care plan titled, Droplet Isolation, dated 4/27/21, indicated Resident 306 was on droplet isolation precautions for COVID-19. (Droplet isolation precautions are actions designed to reduce/prevent the transmission of organisms spread through close respiratory or mucous membrane contact with secretions,) A review of Resident 307's admission Record showed Resident 307 was admitted to the facility on [DATE]. A review of Resident 307's Order Summary Report indicated a physician order dated 4/21/21, for Resident 307 to be in quarantine (isolation) for possible COVID-19 infection for 14 days. The Order Summary showed an order, start date 4/22/21, for nursing staff to monitor Resident 307 for symptoms of COVID-19, on every shift. A review of Resident 307's droplet isolation care plan, dated 4/27/21, indicated Resident 307 was on droplet isolation for possible COVID-19 exposure related to recent hospitalization. The care plan also indicated to inform staff/caregivers of the isolation protocol. A review of the facility census dated 4/25/21 showed Resident 306 and 307 shared a room. During an observation on 4/26/21 at 10 a.m., posted on the wall adjacent to the door of the shared room of Residents 306 and 307 was signage which indicated, You must wear the following PPE prior to entry to this room: gown, N95 respirator, eye protection [goggles or face shield], and gloves. During an observation on 04/26/21 at 12:15 p.m., Certified Nursing Assistant 1 (CNA 1) entered the shared room of Resident 306 and 307 wearing only a surgical mask for facial/eye protection. During an observation on 4/26/21 at 9:45 a.m., the isolation supply cart located outside the door of the shared room of Resident 306 and 307 had no face shields or face masks. An observation of the same cart later that day, at 12:17 p.m., still showed no face shields or face masks. During an interview on 4/26/21 at 12:20 p.m., with CNA 1, CNA 1 stated the shared room of Resident 306 and 307 required use of a face shield and N95 respirator, but the isolation supply cart outside the room had not contained any face shields or N95's, so he had not worn either a face shield or N95 before he entered the room. During an interview on 4/27/21 at 11:00 a.m., with the Infection Preventionist (IP), the IP stated isolation signs informed staff of the PPE requirements needed for care provision for the room residents in order to provide protection against infection and the spreading of infection. The IP also stated isolation carts with isolation supplies were located outside the rooms of residents in isolation. A review of the facility policy and procedure (P & P) titled, Personal Protective Equipment (PPE)-COVID Observation, revised 10/2018, the P & P indicated, PPE required for COVID observation is maintained outside and inside the resident's room, as needed. Based on observation, interview and review of records the facility failed to ensure infection control policies and procedures were followed for three of six sampled residents (Resident 52, 306, and 307) when: 1. Licensed Vocational Nurse 1 (LVN 1) failed to perform necessary hand hygiene during wound care for Resident 52, and did not disinfect scissors used for the wound treatment before storing the scissors. 2. The facility failed to provide required Personal Protective Equipment (PPE, protective items or garments worn to protect the body or clothing from hazards that can cause injury) readily available outside the residents room per policy and procedure, and that staff wore the necessary PPE for two of two residents (Resident 306 and 307). These failures had the potential to result in infection or spread of infection for Resident 52, 306, and 307 and increased exposure for all facility residents and staff. Findings: 1. During a review of Resident 52's admission Record, the Record indicated Resident 52 was admitted to the facility with diagnoses which included a fracture (broken bone) of the right lower leg. During a review of Resident 52's Physician Order Summary dated 4/26/21, the Summary indicated, .rinse with normal saline, apply triple antibiotic ointment then wrap with rolled gauze every evening shift for surgical pin sites . During an observation in Resident 52's room, on 4/27/21 at 12:00 p.m., LVN 1 provided wound care for Resident 52's right lower leg. LVN 1 donned gloves, used nonsterile scissors to remove the old dressing, then directly placed the scissors in the pocket of her pants. LVN 1 cleaned the wound, applied ointment, then applied a new sterile dressing without changing gloves and intervening hand hygiene. During an interview with LVN 1 on 4/27/21 at 12:20 p.m., LVN 1 stated the scissors in her pocket needed to be cleaned to prevent the potential spread of contaminated material to other locations. During an interview with the Director of Nursing (DON) on 04/29/21 at 11:59 a.m. DON stated it was standard nursing practice to change the gloves and do hand hygiene after removal of an old dressing, and before applying a new dressing during the wound care. During a review of the facility's policy and procedure Hand washing/Hand hygiene, revised August 2019 indicated .use an alcohol-based hand rub .After handling used dressing, contaminated equipment . During a review of the facility's policy and procedure Wound care, revised October 2010 indicated .Wipe reusable supplies with alcohol as indicated (i.e., outside of containers that were touched by unclean hands, scissor blades, etc.) .

Understanding Severity Codes (click to expand)

Life-Threatening (Immediate Jeopardy)

J - Isolated K - Pattern L - Widespread

Actual Harm

G - Isolated H - Pattern I - Widespread

Potential for Harm

D - Isolated E - Pattern F - Widespread

No Harm (Minor)

A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

"Can I speak with families of current residents?"
"What's your RN coverage like on weekends and overnight?"

Our Honest Assessment

Strengths

• No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
• No fines on record. Clean compliance history, better than most California facilities.
• 35% turnover. Below California's 48% average. Good staff retention means consistent care.

Concerns

• 31 deficiencies on record. Higher than average. Multiple issues found across inspections.

Bottom line: Mixed indicators with Trust Score of 70/100. Visit in person and ask pointed questions.

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About This Facility

What is Vista Post Acute's CMS Rating?

CMS assigns VISTA POST ACUTE an overall rating of 4 out of 5 stars, which is considered above average nationally. Within California, this rating places the facility higher than 99% of the state's 100 nursing homes. This rating reflects solid performance across the metrics CMS uses to evaluate nursing home quality.

How is Vista Post Acute Staffed?

CMS rates VISTA POST ACUTE's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 35%, compared to the California average of 46%. This relatively stable workforce can support continuity of care.

What Have Inspectors Found at Vista Post Acute?

State health inspectors documented 31 deficiencies at VISTA POST ACUTE during 2021 to 2025. These included: 31 with potential for harm.

Who Owns and Operates Vista Post Acute?

VISTA POST ACUTE is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by BVHC, LLC, a chain that manages multiple nursing homes. With 71 certified beds and approximately 66 residents (about 93% occupancy), it is a smaller facility located in HAYWARD, California.

How Does Vista Post Acute Compare to Other California Nursing Homes?

Compared to the 100 nursing homes in California, VISTA POST ACUTE's overall rating (4 stars) is above the state average of 3.2, staff turnover (35%) is significantly lower than the state average of 46%, and health inspection rating (4 stars) is above the national benchmark.

What Should Families Ask When Visiting Vista Post Acute?

Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"

Is Vista Post Acute Safe?

Based on CMS inspection data, VISTA POST ACUTE has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 4-star overall rating and ranks #1 of 100 nursing homes in California. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.

Do Nurses at Vista Post Acute Stick Around?

VISTA POST ACUTE has a staff turnover rate of 35%, which is about average for California nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.

Was Vista Post Acute Ever Fined?

VISTA POST ACUTE has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.

Is Vista Post Acute on Any Federal Watch List?

VISTA POST ACUTE is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.

Facility Details

Beds: 71
Avg. Residents: 66
Occupancy: 93.5%
Ownership: For profit - Limited Liability company
Chain: BVHC, LLC
Medicare: Yes
Medicaid: Yes
Sprinklers: Yes

Trust Score Breakdown

Base Score: 50
4-Star Rating: +30
31 Deficiencies: -10
Final Score: 70/100

Nearby Alternatives

ST PAUL'S TOWERS 5-star THE VINEYARDS HEALTHCARE CENTE... 5-star OAKLAND HEALTHCARE & WELLNESS ... 5-star

View all in HAYWARD →

Check Bed Availability

Data: CMS Medicare Care Compare

Updated: November 2025

Facility ID: 056475