Health inspection·October 11, 2024

F 0755 Level of Harm - Minimal harm or potential for actual harm Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on interview, observation, and record review, the facility failed to remove discontinued controlled substances from the Med-Cart for Resident 30. Residents Affected - Some The failure to ensure the proper disposition of discontinued controlled substances had the potential for administration to the resident or drug diversion. Findings: During a concurrent observation and interview on 10/8/24 at 10:55 with LVN1 the Med Cart A had multiple controlled medication in the locked bin that had been discontinued for Resident 30. LVN1 stated they are unaware of how long the medication had been there. The controlled discontinued medications included: 1 bottle of Morphine (Schedule II narcotic under the Controlled Substance Act) 100 mg/ml, with 9.25 ml remaining in bottle, 32 tablets of 1 mg Lorazepam (Schedule IV Controlled Substance), 69 tablets of .5 mg Lorazepam. During an interview on 10/8/24 at 12:00 p.m. with Charge Nurse (CN), the CN stated that the discontinued controlled medications should have been given to Charge Nurse or Director of Nursing (DON) for destruction and the medications should not be left in the med cart. During a review of Resident's 30 Face sheet the information indicated Resident 30 was admitted to facility on 11/29/22 with multifactorial encephalopathy (damage or disease that affects the brain), and Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination). During a review of Resident's 30 medical record and physician's orders, Resident 30 is in Hospice care (a program for terminally ill persons where an array of services is provided for the palliation and management of terminal illness and related conditions). The Physicians orders noted Morphine 100 mg/5 injection was discontinued on 10/4/24; Lorazepam 0.5 mg was discontinued 9/14/24; and Lorazepam 1 mg was discontinued on 10/3/24. During a review of the facility's policy and procedure (P&P) titled, Medication Storage, Controlled Medication Storage dated 9/08, indicated Medications included in the state and federal Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal and record keeping in the nursing care center in accordance with federal state and other applicable laws and regulations. Controlled medications remaining in the nursing care center after the order has been discontinued are retained in the nursing care center in a securely double locked area with restricted access until destroyed as outlined by state regulation. Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 4 Event ID: 555855 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555855 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Baywood Court Health Center 21966 Dolores Street Castro Valley, CA 94546 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)