West Shore Post Acute

In the surveyor’s words

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

• Actual harm, isolatedF580Aug 18, 2026

  Based on interview and record review, for one of two sampled residents (Resident 1) reviewed for pressure ulcer (also called a bedsore, or pressure injury, is localized damage to the skin and/or underlying tissue caused by constant or prolonged pressure, often combined with shear [mechanical force that causes deep tissue damage when layers of skin and underlying tissues slide in opposite directions] or friction), the facility failed to notify the physician and Resident Representative (RR 1) when Resident 1 developed a Stage 3 pressure ulcer (a full thickness skin loss injury in which the damage extends through the epidermis, outermost layer of the skin, and dermis, below the epidermis, into the fat layer, but does not expose muscle, tendon, ligament, cartilage, or bone. […]

• Actual harm, isolatedF686Aug 18, 2026

  Based on interview and record review, the facility failed to ensure appropriate preventative measures were implemented for one of two sampled residents (Resident 1) who had a known history of sacral (tail bone) pressure ulcer (a pressure injury characterized by localized damage to the skin and/or underlying tissue caused by prolonged pressure, often combined with shear or friction) when the facility failed to do the following:Complete Braden Scale for Predicting Pressure Ulcer (BSPP, a standardized, evidence based nursing assessment tool used to determine a patient's risk for developing pressure ulcers) assessment as scheduled to evaluate Resident 1's risk for pressure ulcer development for a period over more than four months from 2/13/26 to 7/20/26.Implement Resident 1's potential for… […]

• Actual harm, isolatedF689Feb 13, 2025

  Based on observation, interview and record review the facility failed to ensure one of three sampled residents (Resident 1) had at least two staff members to assist Resident 1 when Certified Nursing Assistant 1 (CNA 1) performed incontinence care by themselves which resulted in Resident 1 falling from their bed. This failure resulted in Resident 1 falling from their bed sustaining a left arm and left leg fracture. Resident 1 was not suitable for surgery to repair the fractures and had to enter hospice care due to the injuries sustained in the fall. […]

• No harm, potential for more than minimal, widespreadF801May 2, 2025

  Based on interviews and record reviews, the facility failed to ensure the Registered Dietitian (RD) and Dietary Services Manager (DSM) carried out the functions of the dietetic services in the food & nutrition services department when multiple issues in food safety, sanitation, and clinical nutrition care for residents with weight loss or weight gain were identified, according to facility policy and standards of practice. This failure had the potential to expose residents to unsafe contaminated food and unsanitary equipment and utensils, leading to foodborne illness and altered nutrition status among 114 residents who consume food from the kitchen. Cross reference F802, F803, F804, and F812 Findings: According to the 2019 California Retail Food Code, CHAPTER 3. […]

• No harm, potential for more than minimal, widespreadF802May 2, 2025

  Based on observation, interview, and record review, the facility failed to ensure the kitchen staff competently carried out the functions of the food and nutrition services department according to facility policy and standards of practice when: 1. Two Cooks (CK 1 and CK 2) did not properly verbalize or demonstrate the correct two-step cool down process used to prevent contamination in a cooked beef pot roast. 2. A Diet Aide (DA 1) did not know how to correctly calibrate a food thermometer. 3. A Diet Aide (DA 3) did not know how to test the sanitizer concentration in a red bucket. These failures had the potential to expose residents to bacterial contamination, that could result in food borne illnesses for all residents who consume food from the kitchen. […]