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Deficiency Records for East Bay Post-Acute
A list of the most recent deficiencies for East Bay Post-Acute. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for East Bay Post-Acute. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Provide and implement an infection prevention and control program. | Health | 2024-08-29 | 2024-09-24 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-08-29 | 2024-09-20 | Y |
| Dispose of garbage and refuse properly. | Health | 2024-05-16 | 2024-05-30 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2024-01-16 | 2024-02-14 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2024-01-16 | 2024-02-14 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2024-01-16 | 2024-02-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-01-16 | 2024-02-14 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-01-16 | 2024-02-14 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-01-16 | 2024-02-14 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-01-16 | 2024-02-14 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-01-16 | 2024-02-14 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2024-01-16 | 2024-02-14 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-01-12 | 2024-02-12 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2024-01-12 | 2024-02-12 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-01-12 | 2024-02-12 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2024-01-12 | 2024-02-12 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2024-01-12 | 2024-02-12 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2024-01-12 | 2024-02-12 | N |
| Provide care by qualified persons according to each resident's written plan of care. | Health | 2024-01-12 | 2024-02-12 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-01-12 | 2024-02-12 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-01-12 | 2024-02-12 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-01-12 | 2024-02-12 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2024-01-12 | 2024-02-12 | N |
| Post nurse staffing information every day. | Health | 2024-01-12 | 2024-02-12 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2024-01-12 | 2024-02-12 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-01-12 | 2024-02-12 | N |
| 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. | Health | 2024-01-12 | 2024-02-12 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2024-01-12 | 2024-02-12 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2024-01-12 | 2024-02-12 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2024-01-12 | 2024-02-12 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2024-01-12 | 2024-02-12 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2024-01-12 | 2024-02-12 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-01-12 | 2024-02-12 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2024-01-12 | 2024-02-12 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-01-12 | 2024-02-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-01-12 | 2024-02-12 | N |
| Keep all essential equipment working safely. | Health | 2024-01-12 | 2024-02-12 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2024-01-12 | 2024-02-12 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-01-12 | 2024-02-12 | Y |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2023-09-20 | 2023-10-13 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-06-22 | 2022-07-19 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2022-06-22 | 2022-07-19 | N |
| Provide emergency officials' contact information. | Fire Safety | 2022-06-22 | 2022-07-19 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-06-22 | 2022-07-19 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-06-22 | 2022-07-19 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-06-22 | 2022-07-19 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-06-22 | 2022-07-19 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2022-06-17 | 2022-07-18 | N |
| Provide appropriate foot care. | Health | 2022-06-17 | 2022-07-18 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2022-06-17 | 2022-07-18 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-06-17 | 2022-07-18 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2022-06-17 | 2022-07-18 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2022-06-17 | 2022-07-18 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-06-17 | 2022-07-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-06-17 | 2022-07-18 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2019-09-12 | 2019-10-09 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-09-12 | 2019-10-09 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2019-09-12 | 2019-10-09 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2019-09-12 | 2019-10-09 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2019-09-12 | 2019-10-09 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2019-09-12 | 2019-10-09 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2019-09-12 | 2019-10-09 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2019-09-12 | 2019-10-09 | N |
| Establish staff and initial training requirements. | Fire Safety | 2019-09-12 | 2019-10-09 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-09-12 | 2019-10-09 | N |
| Implement emergency and standby power systems. | Fire Safety | 2019-09-12 | 2019-10-09 | N |
| Use approved construction type or materials. | Fire Safety | 2019-09-12 | 2019-10-09 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2019-09-12 | 2019-10-09 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-09-12 | 2019-10-09 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2019-09-12 | 2019-10-09 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-09-12 | 2019-10-09 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-09-12 | 2019-10-09 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-09-12 | 2019-10-09 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-09-12 | 2019-10-09 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-09-12 | 2019-10-09 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-09-12 | 2019-10-09 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-09-12 | 2019-10-09 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2019-08-02 | 2019-09-02 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-08-02 | 2019-09-02 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-08-02 | 2019-09-02 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-08-02 | 2019-09-02 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-08-02 | 2019-09-02 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2019-08-02 | 2019-09-02 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-08-02 | 2019-09-02 | N |
| 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. | Health | 2019-08-02 | 2019-09-02 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-08-02 | 2019-09-02 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-08-02 | 2019-09-02 | N |
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