Inspection visit

Health inspectionMay 4, 2023

BAY AREA HEALTHCARE CENTERCMS #5558515 citations on this visit

5 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 5 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure controlled medications (medications with high potential for abuse or addiction) were available and given according to the Physician's Order and fully accounted for, when: A random controlled medication use audit for three out of three residents (Residents 20, Resident 1 and Resident 19) indicated that Morphine (a potent medication for pain) was not administered as prescribed for Resident 20, and medications were documented as given to the Resident 1 and Resident 19 on the Medication Administration Records (MAR), but were not signed out of the Control Drug Record (CDR, an inventory sheet that keeps record of the usage of controlled medications). These failures resulted in Resident 20 enduring unnecessary pain, and had the potential to result in loss, misuse, and/or diversion of controlled prescription medications. Findings: During a random controlled drug audit, the CDRs of three residents (20, 1 and 19) were reviewed during the survey. 1. During a concurrent interview and record review on 5/02/23 at 11:10 a.m., with Registered Nurse (RN) 2, a review of Resident 20's CDR sheet for Morphine reflected the following Morphine Sulfate ER (extended release) 15 mg (milligram, a unit of measurement) 1 tablet by mouth every 12 hours for chronic post-traumatic headache. The CDR documentation indicated that the medication was only being administered QD (once a day) at 9:00 a.m. RN2 stated the current Morphine Sulfate order in the MAR dated 6/30/2020, indicated Morphine Sulfate Contin ER 15 mg 1 tablet by mouth every morning around the clock for pain management. RN2 stated s/he goes by the MAR while administering controlled medication and do not pay close attention to the label on the CDR sheet. RN 2 stated, s/he was not aware of the discrepancy in the order until today .It looks like Resident 20 has not been receiving her pain medications as ordered. RN2 stated QD is every day and Q12 is every 12 hours. RN2 stated, Resident 20 is able tell the staff when she is in pain, by pointing to the pain area of her body. During a Record Review of the Clinical Progress Notes dated 5/05/2023, printed on 5/2/2022, indicated, Morphine (MS Contin/Oramorph SR) 15 mg Oral tablet, take 1 tablet by mouth every 12 hours prescribed by a physician with a start date of 4/15/2022. During a phone interview on 5/02/23 at 12:41 p.m., with Pharmacy Tech (PT). PT sated, the electronic script (a digital alternative to a paper prescription) submitted on 04/15/22, indicated Morphine (continued on next page) 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 11 Event ID: 555851 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 555851 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bay Area Healthcare Center 1833 10th Avenue Oakland, CA 94606 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)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Sulfate Contin Sustained release 15 mg oral tablet, take 1 tablet by mouth every 12 hours, a change in frequency from 1 tablet a day. 2. During a concurrent interview and record review on 5/01/23 at 11:13 a.m., with the RN2, a review of the Resident 1's MAR indicated, oxycodone HCL (a potent controlled medication for moderate to severe pain) was administered for 5/02/23 at 8:00 a.m., but not signed out as removed on the CDR. RN2 stated s/he administered the medication at 8:00 a.m. but forgot to sign out the CDR after administering the medication. 3. During a concurrent interview and record review on 5/02/23 at 11:29 a.m., with the RN 2, a review of Resident 19's MAR for pregabalin (a potent controlled medication used to treat nerve pain) indicated the following medication's 3 capsules were administered on 5/02/23 at 9 a.m., but not documented removed on the CDR. The medication bubble-pack contained 30 capsules. RN2 verified the findings and acknowledged the medication bubble pack contained 30 capsules, and the CDR reflected the number of capsules remaining was 33. RN2 stated, s/he forgot to document on CDR after administering the morning dose at 9:00 a.m. During an interview on 5/02/23 at 1:40 p.m., with the Director of Nursing (DON). DON stated, when the nurse is pulling a controlled medication from the medication cart, the nurse is to confirm the order, sign out on the CDR, and then prep the medication in the MAR. As soon as the controlled medication is administered, the nurse is to sign the MAR 'as given. S/he stated, All medications must be documented both in the MAR and CDR, if it is not documented, it is not given. DON stated, it was her expectation for nurses to check the CDR label, narcotic bubble pack label and the MAR order prior to a medication administration, If it's not matching, they have to inform the charge nurse and notify the physician. DON stated, s/he was not sure why the morphine order was missed for more than one year, it's very concerning. DON stated, the risk of under medicating a resident means they are in constant unmanaged and uncontrollable pain. During a review of the Resident 20's Face Sheet dated 5/02/23, the record indicated, Resident 20 was admitted to the facility on [DATE] with multiple diagnoses which included Motor Vehicle Accident, and Right Femur (thigh bone) fracture. During an interview with Resident 20 on 5/02/23at 2:29 p.m., Resident 20 pointed to her right thigh and stated she was in a lot of pain and rated her pain level at 10 out of 10. (a numerical scale from 0 to 10. Here, 0 means no pain and 10 means severe pain). During a review of the facility's policy titled, Medication Administration, dated 2007, indicated, Prior to administration, the medication and dosage schedule on the resident's MAR is compared with the medication label. If the label and MAR are different .the prescriber's orders are checked for the correct dosage schedule .9. Read medication label three (3) times before preparing/pouring medication. a. when pulling medication package from med cart, b. When dose is prepared, c. before dose is administered . Medications are administered in accordance with written orders of the prescriber . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555851 If continuation sheet Page 2 of 11 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 555851 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bay Area Healthcare Center 1833 10th Avenue Oakland, CA 94606 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)

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure the medication error rate did not exceed 5% for 2 of 4 sampled residents (Resident 29 and Resident156) when: Residents Affected - Few 1. Resident 29 was not administered Chlorhexidine solution (a prescription oral rinse that prevents the growth of bacteria in your mouth and reduces inflammation in gums) 15 ml (milliliter, unit of measurement) per manufacturer's guidelines. 2. Resident 156 was not administered oxycodone (a pain medication) 5 mg (milligram, unit of measurement) as prescribed by the physician. This failure resulted in 2 medication errors being identified out of 28 opportunities during an observation of medication administration which then resulted in the facility having a medication error rate of 7.14%. Findings: 1.During a review of Resident 29's admission Record, dated 5/2/23), the admission record indicated, Resident 36 was admitted to the facility in March of 2023 with multiple diagnoses including broken internal left hip prosthesis (an artificial body part) and left hip pain. During a medication pass observation on 5/2/23 at 8:47 a.m., with Licensed Vocational Nurse (LVN) 2, LVN2 administered Resident 29's Chlorhexidine solution. Resident 29 swished the medication for two seconds and spit out the medication in a cup. Based on a review of medication label on 5/2/23 at 8:50 a.m., with LVN2, s/he verified the manufacturer's guidelines printed on the Chlorhexidine solution bottle indicated Swish the medication in your mouth for 30 seconds. During a review of Resident 29's Physician's Order, dated 4/15/23, indicated, Chlorhexidine 15cc (cubic centimeter, unit of measurement), to be given every 12 hours, and to swish and spit. During an interview with LVN2 on 5/2/23 at 8:54 a.m., LVN2 stated, s/he was not aware of the manufacturer's guidelines on having the resident swish the medication for 30 seconds. LVN2 stated, swishing for 30 seconds is important to mouth to be clean, the resident did it for only 2 seconds. 2.During a review of Resident 156's admission Record dated 5/4/23, the review indicated, Resident 156 was admitted to the facility in April of 2023 with multiple diagnosis including right femur (thigh bone) fracture, and chronic gout (painful swelling of the big toe joint). During a medication pass observation on 5/2/23 at 9:10 a.m., with LVN2, LVN2 did not administer Resident 156'sr oxycodone as ordered by the physician. LVN2 stated to Resident 156 You have therapy this morning. Resident 156 pointed at her right thigh stated, I have so much pain, will that hurt? (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555851 If continuation sheet Page 3 of 11 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 555851 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bay Area Healthcare Center 1833 10th Avenue Oakland, CA 94606 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)

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of Resident 156's Physician Orders, dated 5/1/23, indicated Premedicate with Oxycodone, 5 mg (give 0.5 tablet = 2.5 mg (milligram, a unit of measurement) tablet, need to be given every morning 30-60 minutes prior to Rehab (care that can help Resident 156 get back, keep, or improve abilities needed for daily life) for pain management. During an interview on 5/2/23, at 9:21 a.m., with LVN 2, LVN 2 stated,the pain medication was not available in the medication cart, and no other pain medication was available. LVN 2 stated, she would inform the charge nurse to get the pain medication. During an interview on 5/2/23, at 12:00 p.m., with LVN 2, LVN 2 stated, the pain medication had not been administered to Resident 156 and the Director of Nursing (DON) was calling the pharmacy. LVN 2 stated, Resident 156's rehab therapy was not conducted as the resident did not get the pain medication. During an interview on 5/2/23, at 12:04 p.m., with Resident 156, Resident 156 rated her pain level at 10 out 10 (a numerical scale from 0 to 10. Here, 0 means no pain and 10 means severe pain). Resident 156 stated I scream when I have to move, my right leg hurts a lot. During an interview on 5/02/23, at 1:44 p.m., with DON, DON stated We did not make sure the pain medication was delivered today .the physician should have been called to get a one-time dose to eliminate severe pain and to ensure the resident had morning rehab therapy This resident is here for rehab therapy, they should have to not lay in pain for 5 hours. During a review of the facility's policy titled, Medication Administration, dated 2007, indicated, Medications are administered as prescribed in accordance with manufacturer's specifications .Medications are administered in accordance with written orders of the prescriber .Medications are administered within 60 minutes of scheduled time . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555851 If continuation sheet Page 4 of 11 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 555851 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bay Area Healthcare Center 1833 10th Avenue Oakland, CA 94606 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)

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure 1 resident in a census of 58 (Resident 156) was free from significant medication error when: Residents Affected - Few For Resident 156, Oxycodone (a potent pain medication) was not administered as prescribed by the physician. This failure resulted in Resident 156 suffering from moderate to severe pain. Findings: During a review of Resident 156's admission Record dated 5/4/23, the admission Record indicated, Resident 156 was admitted to the facility in April of 2023 with multiple diagnosis including right femur (thigh bone) fracture, and chronic gout (painful swelling of the big toe joint). During an observation and interview on 5/02/23, at 9:04 a.m., with Licensed Vocational Nurse (LVN) 2 and Resident 156, Resident 156 stated, she wanted to do Rehab therapy (a care that can help you get back, keep, or improve abilities that you need for daily life) for pain management) time and that she was in severe pain every time she moved in bed. LVN 2 stated that she was unable to find her prescription pain medication in the medication cart and informed the resident We are going to order the pill. During a review of Resident 156's clinical record, the clinical record indicated, a physician order dated 5/1/23, Premedicate with Oxycodone, 5 mg (give 0.5 tablet = 2.5 mg [milligram, a unit of measurement] tablet, need to be given every morning 30-60 minutes prior to Rehab. During a subsequent interview on 5/02/23, at 12:03 p.m., with LVN 2, LVN 2 stated, she had informed the Director of Nursing (DON) who is calling the pharmacy now. LVN 2 stated that Resident 156 has not had Rehab Therapy today. During an interview on 5/02/23, at 12:04 p.m., with Resident 156, stated, she had not yet received the medication to relieve the pain in her right knee and that her leg hurt every time she moved. Resident 156 stated, she lay still and do not move to help with the pain and her pain was 10 out of 10. (a numerical scale from 0 to 10. Here, 0 means no pain and 10 means severe pain). During an interview on 5/02/23 at 12:54 p.m., with the DON, she stated, the medication was not delivered by the pharmacy, and the nurses were not able to pull out a one-time dose from the emergency kit (e-kit, a small quantity of medications that can be dispensed when pharmacy services are not available) as the Physician was not notified. DON stated, the physician should have been called to get a one-time dose to eliminate severe pain and to ensure [Resident 156] had morning rehab therapy . [Resident 156] is here for rehab therapy, they should have to not lay in pain for 5 hours .it took me 20-30 minutes on the phone with pharmacy, and the pain medication will be available soon. During an interview on 5/02/23 at 1:46 p.m., with LVN2, she stated, she was finally able to access the e-kit and get the pain pill. LVN2 sated, I am going to administer it now. A review of facility policy titled, Medication Administration, dated 2007, indicated Medications must be administered in accordance with written orders of the prescriber .medications are administered withing 60 minutes of scheduled time. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555851 If continuation sheet Page 5 of 11 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 555851 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bay Area Healthcare Center 1833 10th Avenue Oakland, CA 94606 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)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure pharmaceutical products were stored and labeled correctly, when: 1a. One open and expired medication for Resident 356 was in the medication cart, which put residents 356 at risk of receiving expired medication, 1b. One expired can of test strip was in the medication cart, which put all residents at risk of receiving testing with expired test strips. 2a. One opened bottle of medication in the medication cart was not labeled, which put all residents at risk of receiving expired or outdated medication, 2b. Two expired medications were for Resident 28 and 44 were in the medication cart, which put residents 28 and 44 at risk for receiving expired medications. 2c. One expired medication was in the treatment cart, which put all residents at risk for receiving expired medications. 3a. One expired medication was in the medication cart, which put all residents at risk for receiving expired medications. 3b. One expired medication for Resident 6 was in the medication cart, which put Resident 6 at risk for receiving expired medications. 3c. One expired medication for Resident 20 was in the medication cart, which put Resident 6 at risk for receiving expired medications. 3d. One expired medication for use for Resident 19 was in the medication cart, which put Resident 6 at risk for receiving expired medications. 3e. One opened bottle of medication in the medication cart was not labeled and dated, which put all residents at risk of receiving expired or outdated medication, 3f. One opened bottle of medication in the medication cart was not labeled, which put all residents at risk of receiving expired or outdated medication, 3g. Loose pills were found in the medication carts, which could result in diversion of the loose medication, 4. One expired can of test strip was in the medication cart, which put all residents at risk of receiving testing with expired test strips. These deficient practices had the potential for residents to receive medications with reduced potency, had the potential to result in medication errors, or drug diversion. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555851 If continuation sheet Page 6 of 11 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 555851 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bay Area Healthcare Center 1833 10th Avenue Oakland, CA 94606 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)

F 0761 Findings: Level of Harm - Minimal harm or potential for actual harm 1. During an inspection of the Medication Cart number 1 on 5/1/23, at 11:03 a.m., with Registered Nurse (RN) 3, two expired and unlabeled with open date medications were identified in the locked compartment of the medication cart, as follows: Residents Affected - Few a. An opened multi-dose bottle containing heparin (medication is used to prevent and treat blood clots)50,000 units ([NAME] unit, a unit of measurement) /10 ml (milliliter, a unit of measurement)for Resident 356 without an open date. b. An opened multiuse bottle containing glucose test strips without an open date. During an interview on 5/1/23, at 11:10 a.m., with RN 3, s/he stated s/he could not verify when the heparin bottle was opened, and it has a life span for 28 days after opening. RN3 stated, s/he considered the Heparin expired. RN3 stated, the manufacturer's label on glucose test strip bottle indicated, good for 6 months after first opening. RN3 stated, s/he was unable to confirm the open date as it does not have an open date and that s/he would consider it to be expired. 2. During an inspection of the Medication Cart number 2 and the sub-acute treatment cart on 5/1/23, at 11:31 a.m., with Registered Nurse (RN) 4 two expired, one expired and unlabeled with resident information were identified in the locked compartment of the medication cart, and one expired medications were identified in the locked compartment of the treatment cart, as follows: a. An opened unlabeled multi-dose bottle containing insulin (a hormone that lowers the level of glucose (a type of sugar) in the blood by helping glucose enter the body's cells)100 units/ml (the number of units of insulin in one milliliter (mL)) with an open date of 3/25/23. b. 1. A Systane eye drop for Resident 44 with an opened date of 2/17/23. 2. A Systane eye drop for Resident 28 with an open date of 2/21/23. c. An unlabeled hemorrhoidal ointment with an expiration date of 11/2022 During an interview on 3/01/23, at 11:50 a.m., with RN 4, s/he verified the findings above and stated, s/he could not verify which Resident the Insulin belonged to. RN4 stated, Insulin expires 28 days after opening and this insulin is expired. RN 4 stated, both eye drops are expired, we are to discard them 42 days after opening, they both have been open for more than 42 days. RN4 stated the hemorrhoid ointment expired on 11/2022, and s/he did not know who was responsible for the rotating and removing of the expired medication from the carts. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555851 If continuation sheet Page 7 of 11 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 555851 B. Wing (X3) DATE SURVEY COMPLETED A. Building 05/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bay Area Healthcare Center 1833 10th Avenue Oakland, CA 94606 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)

F 0761 Level of Harm - Minimal harm or potential for actual harm 3. During an inspection of the Medication Cart number in Station 2 with RN2 on 5/02/23, at 11:06 a.m., four expired, one unlabeled and undated, one unlabeled, and three loose pills were identified in the locked compartment of the medication cart, as follows: a. Residents Affected - Few An opened multi-dose bottle of Melatonin with a printed expiration date of 04/30/23. b. An unopened bottle of Naloxone (a medicine that rapidly reverses a narcotic overdose) for Resident 6 with a printed expiration date of 03/2023. c. An Lumigan eye drop bottle for Resident 20 with an open date of 03/29/23 d. A multi-dose inhaler Combivent Respimat for Resident 19 with an open date of 1 10/19/22. e. An unlabeled opened Artificial Tears eye drops without an open date. f. An unlabeled opened Artificial Tears eye drops with an open date of 3/30/23. g. Three loose pills at the bottom of the cart drawer During an interview on 5/02/23 at 11:15 a.m., with RN2, s/he verified the findings above and stated, Both the Melatonin and the Naloxone are expired, The Lumigan eye drops expires 28 days after opening. RN2 stated the Combivent inhaler expired 90 days after opening as printed on the medication box. RN2 could not verify which Resident/s the Artificial eye drop bottles belonged to. RN2 stated eye drops should have been labeled and dated, and expire 30 days after opening, and that both eye drop bottles were now expired. RN2 stated s/he was not able to correctly identify the three loose pills and it could cause an issue with medication count. RN2 stated she did not know who was responsible for removing of the expired medication from the carts. 4. During an inspection of the Medication Cart number 4 with Licensed Vocational Nurse (LVN) 2 on 5/02/23, at 11:18 a.m., one opened glucose test strip without an open date, was identified in the locked compartment of the medication cart. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555851 If continuation sheet Page 8 of 11 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 555851 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bay Area Healthcare Center 1833 10th Avenue Oakland, CA 94606 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)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 5/02/23 at 11:20 a.m. with LVN2, she stated, she could not verify the open date and that per the manufacturer's instructions Use within 6 months after first opening, I would consider these expired. During an interview with the DON on 5/2/23 at 12:52 p.m., she verified all the above findings, and stated the staff nurse was supposed to give expired and discontinued medications to the Charge Nurse right away. The DON verified the above expired medications should have been removed from the medication carts to prevent medication errors. The DON stated the Charge Nurse, and the Pharmacist are responsible for removing expired and discontinued drugs from the medication carts. A review of the facility's policy and procedure(P&P) titled Disposal of Medications, dated 2007, the P&P indicated, .8. Outdated medications, contaminated, or deteriorated medications and the contents of containers with no label shall be destroyed . A review of the facility's policy and procedure titled Storage of Medication, dated 2007, the P&P indicated, Outdated, contaminated, discontinued or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stocks, disposed of according to procedures for medication disposal . A review of the facility's policy and procedure titled medication Administration, dated 2007, the P&P indicated, 8. No expired medication will be administered to a resident .b. The nurse shall place a 'date opened' sticker on the medication .and enter the date opened. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555851 If continuation sheet Page 9 of 11 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 555851 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bay Area Healthcare Center 1833 10th Avenue Oakland, CA 94606 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)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interviews and record review, the facility failed to ensure storage of food under sanitary conditions when the following food items were not labeled and dated with use-by date in refrigerator: -Three gallons of milk opened not dated; - Bottle of pickle relish opened not dated; - One container of garlic spread opened not dated; - Bowl of cooked minestrone dated 4/23/23; - One container of low fat cottage cheese opened dated 4/21/23; - One bottle of horse Radish opened not dated ; - Bowl of crushed garlic not labeled or dated; - One container of low fat cottage cheese opened not dated; - One Med Pass 2.0 nutritional shake vanilla opened dated 2/3/23; - One bottle of yellow mustard opened dated 4/6/23; - One bottle of mayonnaise opened an dated 4/6/23; - One tray of dispensed cups with juice and milk beverage dated 4/25/23; - Two trays of dispensed cups of beverage not label or dated; - One bottle of caramel sauce opened and dated 12/2/22; - One can of peanut butter opened and dated 3/24/23; - Bowl of cooked yam dated 4/25/23; These failures had the potential to result in food borne illnesses. Findings: During the initial tour of the kitchen on 5/1/23 at 9:17 a.m., accompanied by [NAME] and Dietary Supervisor/Dietician (RD) the followings were observed in the refrigerator; three gallons of milk opened not dated, gallon of pickle relish opened not dated, one container of garlic spread opened not dated, bowl of cooked minestrone dated 4/23/23, one container of low fat cottage cheese opened dated 4/21/23, one bottle of horse Radish opened not dated, bowl of crushed garlic not labeled or dated, two carton of low fat cottage cheese opened not dated, one Med Pass 2.0 nutritional shake vanilla (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555851 If continuation sheet Page 10 of 11 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 555851 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bay Area Healthcare Center 1833 10th Avenue Oakland, CA 94606 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)

F 0812 Level of Harm - Minimal harm or potential for actual harm opened dated 2/3/23, one bottle of yellow mustard opened dated 4/6/23, one bottle of mayonnaise opened an dated 4/6/23, one tray of dispensed cups with juice and milk beverage dated 4/25/23, two trays of dispensed cups of milk and juice beverage not label or dated and bowl of cooked yam dated 4/25/23; and in kitchen cabinet observed one bottle of caramel sauce opened and dated 12/2/22 and one can of peanut butter opened and dated 3/24/23. Residents Affected - Some During an interview on 5/1/23 at 9:33 a.m., [NAME] stated, all food items must be labeled and dated when opened and placed in refrigerator with expiration date. During an interview on 5/1/23 at 9:54 a.m., RD stated, the expectation was that all food items are covered, labeled and dated including milk products must be labeled and dated in refrigerator. During an observation on 5/1/23 at 12:14 p.m., Certified Nursing Assistant (CNA1) picked up a paper napkin from the floor and proceeded to distribute meal tray without performing hand hygiene. During an interview on 5/1/23 at 12:17 p.m., CNA1 stated, she was trained to perform hand hygiene before passing meal trays. CNA1 said she felt she was only picking up clean paper from the floor. During an interview on 5/3/23 at 10:08 a.m., Infection Preventionist/Registered Nurse (IP) stated, CNAs are trained to wash hands or perform hand hygiene before distributing meal trays. IP said the floor is dirty. The facility's policy, titled Procedure for refrigerated storage, dated 2018, indicated ; Individual packages of refrigerated or frozen food taken from the original packing box need to be labeled and dated. Leftovers will be covered, labeled and dated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555851 If continuation sheet Page 11 of 11

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Citations

5 citations recorded^*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

0755GeneralS&S Dpotential for harm
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
0760GeneralS&S Dpotential for harm
F760 - Residents are free of any significant medication errors
Ensure that residents are free from significant medication errors.
0761GeneralS&S Dpotential for harm
F761 - Labeling of Drugs and Biologicals
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
0812GeneralS&S Epotential for harm
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
0759GeneralS&S Dpotential for harm
F759 - Medication Errors
Ensure medication error rates are not 5 percent or greater.

FAQ · About this visit

Common questions about this visit

What happened during the May 4, 2023 survey of BAY AREA HEALTHCARE CENTER?

This was a inspection survey of BAY AREA HEALTHCARE CENTER on May 4, 2023. The surveyor cited 5 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at BAY AREA HEALTHCARE CENTER on May 4, 2023?

Yes, 5 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharm..."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

Next steps

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Data from CMS Care Compare public records. Dataset last refreshed June 22, 2026. If you believe any information is inaccurate, report it here.

Health inspection·May 4, 2023