East Bay Post-Acute

In the surveyor’s words

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

• Actual harm, isolatedF755Jan 12, 2024

  Based on observation, interview and record review, the facility failed to follow facility medication administration policy, provide pharmacy services and ensure controlled medication (those with high potential for abuse and addiction) were fully accounted for 11 of 57 sampled residents (Residents 1, 400, 69, 329, 42, 20, 70, 30, 41, 57 and 330) when: 1. Licensed Vocational Nurse 8 (LVN 8) gave Resident 400 and Resident 1 medications without verifying residents' identity and did not name the medications given to the residents. 2. Resident 69 did not take her medications for one hour after LVN 3 left medications on Resident 69's overbed table without watching administration. 3. Resident 329 did not receive scheduled medication for 44 hours because the medications had not been delivered. 4. […]

• Actual harm, isolatedF760Jan 12, 2024

  Based on observation, interview and record review, the facility failed to ensure one of two sampled residents (Resident 400) was free from significant medication errors when Licensed Vocational Nurse 8 (LVN 8) administered multiple doses of unprescribed medications, including opioid medications (a group of medications which are federally regulated substances used for pain control with a potential for physical or psychological dependence) to Resident 400. This failure resulted in Resident 400's hospitalization for excessive sedation and respiratory failure (inadequate breathing efforts) requiring mechanical ventilation (machine used to provide artificial breathing), a tracheostomy (a surgically created opening through the neck into the trachea, also known as the windpipe), a gastrostomy (a… […]

• No harm, potential for more than minimal, widespreadF755Jul 2, 2026

  Based on observation, interview and record review, the facility failed to ensure, for Residents 1-10, the scheduled (controlled medication, narcotic) medication record system was complete (all documents available) and accurate (numbers match). The record system included Shipping Manifests (pharmacy delivery receipt), Controlled Substance (drug) Accountability Sheets (CDR, Controlled Drug Record), Medication Administration Records (MAR, record of medication administration), and destruction logs. The facility did not have complete records. The facility did not have accurate records. These failures resulted in the potential for undetected loss and diversion of scheduled medications. In addition, these failures resulted in the potential for avoidable medication errors. […]

• No harm, potential for more than minimal, widespreadF839Jul 2, 2026

  Based on observation, interview and record review, the facility failed to ensure the facility administrator was managed by a state licensed nursing home administrator (NHA) when the facility assigned the Operations Assistant (OA), who was not a state licensed nursing home administrator, as the administrator and posted Administrator 1's (ADM 1) license on the wall without assigning ADM 1 actual administrative duties.This failure resulting in the facility operations being managed by an unlicensed administrative staff for four months.A review of Resident 11's admission record indicated Resident 11 was originally admitted to the facility on [DATE] and discharged on 1/9/26.A review of Resident 12's medical record indicated Resident 12 was admitted for pressure ulcer care, diabetes and… […]

• No harm, potential for more than minimal, widespreadF689Dec 3, 2025

  Based on observation, interview and record review, the facility failed to ensure doors to enter the building were locked for all 84 of 84 sampled residents when the facility failed to ensure two doors (main entrance and rear exit) had functioning locks and failed to ensure staff kept the rear exit closed and supervised according to facility expectations while the doors locks were broken.The failure had the potential for unauthorized people to enter the facility building which had to potential to affect all residents' safety.During an observation on 11/8/25, at 5:02 a.m., in the parking lot at the back of the facility, the rear exit door of the facility was inspected. From 5:02 a.m. to 5:40 a.m., the rear exit door was propped open by a wet floor sign. […]