Baywood Post Acute

In the surveyor’s words

From the most serious findings on record at Baywood Post Acute, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF908Jan 12, 2024

  Based on observation, interview, and record review, the facility failed to maintain the reach-in freezer in good and safe operating condition when the reach-in freezer had ice-build up and freezer temperature was negative forty degrees Fahrenheit. This failure had the potential to cause the freezer to be ineffective for keeping food frozen and may lead to food spoilage and food-borne illness (illness resulting from contaminated food) for 23 residents who received food from the kitchen out of 24 residents. Findings: During the kitchen initial tour with the cook on 1/8/24, at 8:30 a.m., she confirmed the temperature logs for refrigerator 1, 2 and freezer were blank. She stated that checking of the temperature for refrigerator 1, 2 and freezer was done at 6:00 a.m., and p.m. […]

• No harm, potential for more than minimal, patternF700Apr 4, 2025

  Based on observation, interview, and record review, the facility failed to ensure the proper use of bed or side rails (adjustable rigid bars attached to the side of a bed) for 10 of 36 residents (9. 21. 24, 29, 30, 34, 41, 42, 145, and 146) when: 1. Alternatives were not attempted prior to the use of bed or side rails for Residents 9, 34, 41, 42, 145, and 146; and 2. Bed or Side Rail Assessment was not done quarterly for Residents 21, 24, 29, and 30. These failures had the potential to place the residents at risk of entrapment and serious injury. Findings: 1. […]

• No harm, potential for more than minimal, patternF758Apr 4, 2025

  2. Review of Resident 20's admission Record indicated he was admitted to the facility on [DATE] with dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) diagnosis. Review of Resident 20's physician order indicated he had orders for Cymbalta 30 milligram (mg, a metric unit of mass) every day for depression (persistent feeling of sadness and loss of interest), dated 11/21/24; and for Seroquel 25 mg in the morning and Seroquel 37.5 mg in the afternoon for dementia with behavioral disturbance, dated 12/9/24. Review of Resident 20's clinical record indicated he did not have quarterly review on the use of Cymbalta 30 mg, Seroquel 25 mg, and Seroquel 37.5 mg. […]

• No harm, potential for more than minimal, patternF759Apr 4, 2025

  Based on observation, interview and record review, the facility had a medication error rate of 25.93% when 7 medication errors occurred out of 27 opportunities during medication administrations for four out of six residents (5, 6, 14, and 146). This failure resulted in medications not given in accordance with the prescriber's orders which resulted in residents not receiving the full therapeutic effects of the medications. Findings: 1. During a medication pass observation on 4/1/25, at 10:29 a.m. with Licensed Vocational Nurse C (LVN C), LVN C stated he did not have gabapentin (pain reliever) 100 milligrams (mg, a metric unit of mass) and tamsulosin (helps increase the flow of urine) 0.4 mg on hand to give to Resident 146. […]

• No harm, potential for more than minimal, patternF761Apr 4, 2025

  Based on observation, interview, and record review, the facility failed to ensure medications were stored appropriately when expired medications and the medication opened over the period found in Medication Cart 1. This failure had the potential for residents to be given expired or over open period medication. Findings: On 4/1/25, at 11:24 a.m., during an observation on Medication Cart 1 with licensed vocational nurse C (LVN C), the following were observed: a. One bottle of Calcium Citrate Magnesium and Zinc with vitamin D3 (supplements) and one bottle of Centrum Silver Women 50+ (multivitamin) had an expiration date of 3/2025. b. […]