South Bay Post Acute Care

In the surveyor’s words

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

• Actual harm, isolatedF684Jul 5, 2022

  Based on observation, interview, and record review, the facility failed to ensure care/treatment was provided in accordance with the physician's orders and the resident's written plan of care for two of three residents (Resident 1 and 3) when: 1. Resident 1 was not administered anti-[CONDITION(S)] medications (medications used to prevent seizures; a disorder causing uncontrolled electrical disturbances in the brain) on [DATE], [DATE], [DATE], [DATE], and [DATE]. 2. Resident 3's physician order was not followed related to administering medications when the resident returned from [CONDITION(S)] treatments (process for persons with [CONDITION(S)] that removed wastes and excess fluids from the blood via a machine) on [DATE], [DATE], and [DATE] . […]

• No harm, potential for more than minimal, patternF725Nov 21, 2022

  Based on interview and record review, the facility failed to ensure staff promptly answered resident call lights and met resident's needs in a timely manner for two residents interviewed on the initial tour of the facility and three of seven residents from the confidential group interview. This failure could potentially affect these residents' physical and psychosocial well-being. Findings: 1. Resident 42 had a Brief Interview for Mental Status (BIMS) score of 12 (on a scale of 0-15, with 15 being the most cognitively intact), according to the resident's Minimum Data Set (MDS- a resident assessment tool) assessment, dated 9/28/22. […]

• No harm, potential for more than minimal, patternF949Nov 21, 2022

  Based on interview and record review, the facility failed to ensure all staff were trained regarding behavioral health. Only 17 licensed nurses were in-serviced according to the in-service sign-in sheet. As a result, there was a potential for staff to not have the knowledge to care for residents with behavioral health issues. Findings: An interview was conducted on 11/16/22, 9:52 a.m., with CNA 5. CNA 5 stated she was currently caring for a resident with diagnosis of post- traumatic stress disorder (PTSD - a mental condition that is triggered by a terrifying event). CNA 5 stated she did not receive training regarding how to care for residents who have PTSD. An interview was conducted on 11/21/22 at 9:50 a.m. with the Director of Staff Development (DSD). […]

• No harm, potential for more than minimal, isolatedF686Apr 13, 2026

  Based on interview and record review, the facility failed to ensure physician (MD) ordered wound care treatments for pressure ulcer ((localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) were implemented as directed for one of three sampled residents (Resident 1). As a result, Resident 1's pressure ulcer on the sacrum (the base of the spine or simply the bottom of the back) increased in size and placed Resident 1 at risk for worsening skin integrity, potential infection, delayed healing, and further complications related to pressure ulcer progression.Findings: A review of Resident 1's admission Record indicated Resident 1 was re-admitted to the facility on [DATE] (initial admission 2/8/26-2/24/26) with diagnoses which included history of… […]

• No harm, potential for more than minimal, isolatedF755May 13, 2025

  Based on observation, interview, and record review, the facility failed to provide clear indications (a valid reason to use a certain medication) for two of three sampled residents ' (Resident 1 and Resident 2) controlled pain medications (medications with high abuse potential). As a result of this deficient practice, Resident 1 and Resident 2 were at risk of receiving unnecessary controlled pain medications which may lead to misuse. Findings: 1. Resident 1 was admitted to the facility on [DATE], with the diagnosis which included cellulitis (a skin infection) of the right leg per facility's Admission Record. […]