Berkley Post-Acute

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF925Apr 12, 2023

  Based on observation, interview, and record review, the facility failed to maintain the kitchen pest free (free of cockroaches) and prevent pest harborage areas. This deficient practice had the potential to place all 114 residents residing in the facility and receiving food or utensils from the kitchen at risk of vector-borne diseases (Illness that results from infections transmitted to humans by insects, such as cockroaches) if cockroaches spread in the facility. Findings: On 4/3/2023, the California Department of Public Health (CDPH, the Department) made an unannounced visit to the facility to investigate a complaint about physical environment. […]

• No harm, potential for more than minimal, patternF684Jul 30, 2026

  Based on interview and record review, the facility failed to follow physician's orders for taking orthostatic blood pressure (blood pressure taken when one is laying in the bed and in a sitting position to see if there is a large discrepancy between blood pressures) when Licensed Vocational Nurse 1 (LVN 1) took orthostatic blood pressure incorrectly for seven times in the months of 6/2026 and 7/2026 for one (Resident 6) of five residents reviewed for unnecessary medication. This deficient practice had the potential for Resident 6 to experience dizziness, lightheadedness, or even fainting when standing up, which can lead to falls and injury.Findings: During a review of Resident 6's admission Record (Facesheet, the front page of the chart that contains a summary of basic information about… […]

• No harm, potential for more than minimal, patternF689Jul 30, 2026

  Based on observation, interview, and record review, the facility failed to ensure the resident environment was free of accident hazards and adequate supervision to prevent accidents for three of four sampled residents (Resident 2, Resident 125, and Resident 92) by failing to: 1. Ensure medications were not left at bedside readily available for resident self- administration for Resident 2 and Resident 125. These failures had the potential to result in resident harm from omission of medications, overdose of medications, and residents ingesting medications not intended for their use. (Cross Reference F554). 2. […]

• No harm, potential for more than minimal, patternF697Jul 30, 2026

  Based on observation, interview and record review, the facility failed to provide pain management consistent with professional standards of practice and the residents' goals and preferences for three of 25 sampled residents (Resident 21, 23, 132, and 124) reviewed for pain by failing to: 1. Ensure the licensed nurse (LN) administered as needed (PRN) tramadol (an opioid [also called a narcotic - powerful pain-reducing medication) per the physician's order and based on the assessed numeric pain rating scale (a standard pain scale with zero being no pain and ten [10] as the worst pain one can imagine) for Resident 21. 2. […]

• No harm, potential for more than minimal, patternF755Jul 30, 2026

  Based on observation, interview, and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, and administering of all drugs and biologicals to meet the needs of each resident for five of 25 sampled residents (Resident 21, 23, 132, 51, and 3) by failing to: 1.Ensure the Controlled Drug Record (CDR, accountability record of medications that are considered to have a strong potential for abuse) coincided with the Medication Administration Records (MAR, a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for: 1a. Resident 21 who was prescribed tramadol (an opioid pain medicine used to treat moderate to severe pain). 1b. […]