Health inspection·August 8, 2025

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview and record review, for two of two sampled residents who received dialysis (Resident 1 and Resident 2), the facility failed to ensure routine medications were available for administration. This failure had the potential to result in medical complications not limited to elevated phosphorus, cholesterol, and worsening of symptoms. During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility in January 2024 with diagnoses that included end stage renal disease (ESRD, the final stage of long-term kidney disease when the kidneys are no longer sufficiently able to remove waste products and excess water to support the body's needs), hyperlipidemia (high cholesterol levels in the blood), and gastro-esophageal reflux disease without esophagitis (a digestive disorder where the stomach acid flows back into the esophagus, causing irritation and discomfort). During a review of Resident 1's Order Summary Report (OSR) as of 7/31/25, the OSR indicated the following physician's orders:a. Atorvastatin Calcium 40 milligrams (mg) oral tablet: one tablet by mouth at bedtime for hyperlipidemia.b. Famotidine 10 mg one tablet by mouth as needed (Used to treat heartburn caused by acid indigestion).c. Nephro-Vite Rx oral tablet 1 mg (B complex with C and Folic Acid): one tablet by mouth at bedtime.d. Sevelamer Hydrochloride (HCL) oral tablet 800 mg (used to treat too much phosphate in the blood for patients with chronic kidney disease who are on dialysis): one tablet by mouth three times daily.e. Metoclopramide HCL 10 mg oral tablet (used to treat nausea, vomiting, heartburn, a feeling of fullness after meals, and loss of appetite), one tablet by mouth as needed.During a concurrent observation and interview on 7/16/25 at 2:25 p.m. with Licensed Vocational Nurse (LVN) 1, medication cart did not have the following medications for Resident 1:a. Atorvastatin Calcium 40 milligrams (mg) oral tabletb. Famotidine 10 mg one tabletc. Nephro-Vite Rx oral tablet 1 mg (B complex with C and Folic Acid)d. Sevelamer Hydrochloride (HCL) oral tablet 800 mge. Metoclopramide HCL 10 mg oral tabletLVN 1 stated that for Famotidine 10 mg, LVN 1 administered a Famotidine 40 mg labeled for Resident 3, stored with Resident 1's medications. LVN 1 stated Famotidine 40 mg was used as an alternative for famotidine 10 mg that was ordered. LVN 1 also stated regular multivitamins were used instead of Nephro-Vite Rx as both are over the counter. LVN 1 also stated, LVN1 used Sevelamer HCL 800 mg meant for Resident 4 (already discharged ) and administered metoclopramide 5 mg in place of the prescribed 10 mg for Resident 1. During a review of Resident 2's AR, the AR indicated Resident 2 was admitted to the facility in October 2021 with diagnoses that included end stage renal disease and chronic pain syndrome. During a concurrent observation and joint interview on 7/16/25 at 2:50 p.m. with Assistant Director of Nursing (ADON) and LVN 1, ADON stated that calcium carbonate oyster shell1250 mg and nortriptyline oral capsule 75 mg were not available in the medication cart. LVN 1 stated, LVN1 administered calcium carbonate 500 mg for the 9 a.m. dose instead of the ordered 1250mg. ADON stated that in-service education would be provided to licensed staff to ensure medications are ordered before the last few tablets are given. During a review of the facility's policy and procedure (P&P) titled Page 1 of 2 056280 056280 08/08/2025 Bay Marina Post Acute 2919 Fruitvale Ave Oakland, CA 94602

F 0755 Level of Harm - Minimal harm or potential for actual harm Medication Ordering and Receiving from Pharmacy effective April 2008, the P&P indicated, refills requested by placing the bottom part of the pharmacy label on the order form. Medications should be reordered five days before they are needed to ensure an adequate supply. Residents Affected - Few 056280 Page 2 of 2