The same Long Beach nursing home stored residents' food in malfunctioning freezers that reached dangerous temperatures of 18 degrees Fahrenheit while ice buildup leaked onto kitchen floors.
Federal inspectors found Bay Vista Healthcare & Wellness Centre repeatedly violated basic safety protocols during a June inspection, documenting the same types of violations that had been cited three years earlier. The facility's quality improvement committee failed to prevent the problems from recurring.
The freezer failures put 180 residents at risk for foodborne illness. One freezer storing frozen meat, ice cream and butter reached 18.5 degrees — nearly 20 degrees above the safe storage temperature. Ice had built up on its upper section, and clear liquid pooled on the floor outside another freezer.
"The equipment was not functioning properly and need to be replaced," the maintenance supervisor told inspectors, acknowledging that water leakage and ice buildup inside freezers indicated malfunction.
The dietary supervisor explained that kitchen equipment must maintain proper temperatures — freezers at zero degrees or below, refrigerators at 40 degrees or below — to prevent bacterial growth that causes food poisoning. One refrigerator storing milk and eggs was found operating at 60 degrees.
Inspectors observed the same freezer multiple times over two days. At 12 p.m. on June 29, it registered 18.5 degrees using the facility's thermometer gun, with the internal thermometer reading 16 degrees. Less than an hour later, the temperature had dropped to 5 degrees externally and 4 degrees internally.
The facility's maintenance director confirmed that a "D" notation on one freezer's external monitor meant defrosting was taking place — "a normal mechanism of the freezer to give the condenser coils to work." But the equipment manual stated that defrost cycles should not affect interior temperatures or the food stored inside.
One freezer storing tortilla bags had no thermometer at all. Staff found an opened bag without a date tag and another unopened bag with ice crystals inside.
Administrator acknowledged she was unaware of the kitchen equipment problems when inspectors brought them to her attention.
The infection control violations were equally concerning.
A certified nursing assistant told inspectors she cared for Resident 41, who had pressure ulcers on her buttocks and lower back. The resident could only sit in a wheelchair for two hours before returning to bed to relieve pressure.
The assistant explained she had to walk from wherever the protective equipment cart was located to get gloves and gowns, then carry them to the resident's room. "There was no PPE cart close by to get the gloves or gowns needed," she said.
Inspectors observed her walking the hallway already wearing gloves, then entering a room marked with enhanced barrier precaution signage. The facility's own policy stated that protective equipment should be available "immediately outside of the resident room" and that "gowns and gloves are to be donned before each high contact task not prior to entering the room."
A licensed vocational nurse told inspectors that nursing assistants "should not be walking around with gloves on because of infection control." The infection preventionist agreed, stating staff should not walk around the facility wearing any protective equipment.
The violations represented a broader failure of oversight.
Bay Vista had been cited for the same types of problems during its 2021 recertification survey: quality of care, pharmaceutical services, medication errors, infection control and physical environment issues. The facility's quality improvement committee was supposed to ensure these problems were corrected and prevented from recurring.
Instead, inspectors found repeat deficiencies in all the same areas.
The administrator told inspectors that current quality improvement projects included fall management, behavior management and addressing a previous abuse violation. But the facility had no focused improvement plan for the freezer problems that were identified again during the inspection, "nor a system in place to ensure the freezers were functioning correctly."
The director of nursing promised that medication administration errors and infection control practices would be addressed immediately.
The water management failures added another layer of risk.
The administrator admitted the facility had not tested water quality and could not provide documentation of any testing. The facility's water management plan required quarterly testing throughout the system to prevent legionella growth — bacteria that can cause serious lung infections.
Federal guidance states that water quality should be measured throughout building systems and that facilities must document verification steps showing the program is being followed and validation showing it works effectively.
Bay Vista operates under a quality improvement policy that promises to "monitor and evaluate the quality of resident care, pursue methods to improve quality of care, and resolve identified issues." The policy aims for "optimal achievement in clinical and operational outcomes."
The inspection findings suggest that promise remains unfulfilled three years after the same problems were first identified.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Bay Vista Healthcare & Wellness Centre, Lp from 2024-06-30 including all violations, facility responses, and corrective action plans.
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