Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Bay Area Healthcare Center during CMS and state inspections, most recent first.
A resident with multiple chronic conditions and existing lower extremity edema developed new left knee swelling, bruising, warmth, and tenderness, and later experienced episodes of shortness of breath and gasping for air with a documented RR of 24. Nursing staff documented these changes but did not notify the MD, despite an order to call for RR greater than 20 and a facility COC policy requiring MD notification for altered VS and new significant edema. The DON confirmed these new symptoms and abnormal RR should have been reported, but there was no evidence that the physician was contacted.
A resident with ventilator dependence, intellectual disability, muscular dystrophy, and a myoneural disorder, but intact cognition, alleged that an RN slapped her arm during a vital signs check after equipment malfunctioned. She reported this to the SSD, and progress notes documented her allegation that an RN had smacked her arm and that it would be investigated, but no SOC 341 was filed at that time. Months later, the resident repeated the allegation to an NP, who urged that it be reported; a SOC 341 was then completed, which noted the earlier incident, internal discussions concluding the resident fabricated stories, and that the more recent allegation was not reported to the State Agency. The Administrator acknowledged that the incident was only reported to the Local Ombudsman and not in writing to the State Survey Agency, contrary to facility policy requiring suspected abuse or allegations to be reported to the state health department within 24 hours.
A resident with diabetes, chronic kidney disease, and left hemiplegia had a documented Stage II coccyx pressure ulcer with physician orders for moisture barrier cream every shift and as needed. The care plan required treatment as ordered, but an LVN on night shift reported not doing treatments and only briefly viewing the ulcer without measuring the open area. Another LVN later documented a Stage II coccyx ulcer but did not measure it, stating she believed it was healed and was only noting its prior presence. These actions did not follow the facility’s pressure ulcer policy, which required wound status monitoring and quantitative documentation of wound size and other parameters with each dressing change.
A resident with diabetes, chronic kidney disease, left hemiplegia, and a Stage II coccyx pressure ulcer had incomplete and inaccurate documentation of wound assessments and treatments. The Weekly Pressure Ulcer Injury Record initially documented the ulcer size, and the TAR contained orders for coccyx pressure ulcer and moisture-associated skin damage care every shift. However, an LVN on the NOC shift signed off only a portion of scheduled treatments and reported not performing treatments, only briefly viewing the wound without measuring it. Another LVN later documented a Stage II coccyx ulcer on a weekly assessment but did not measure it, stating the ulcer had already healed and that the entry was only a reminder of the prior wound. These practices did not align with the facility’s policy requiring weekly nursing documentation to accurately reflect the resident’s condition at the time of assessment.
A resident was allowed to self-administer topical medications without a proper assessment or physician's order, contrary to facility policy. The resident, who had intact cognition, was found with multiple medication cups at their bedside, which were left by nursing staff. Interviews with staff, including the DON and Administrator, confirmed the lack of a self-administration assessment or order, resulting in a deficiency in care.
The facility failed to dispose of expired medications on a medication cart. During an observation, an LVN confirmed that two bottles of latanoprost eye drops were expired, as they were opened beyond the 42-day expiration period. The DON stated that expired medications should be removed from the cart and confirmed the expiration.
Failure to Notify Physician of Resident’s Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of a resident’s change in condition related to new left knee symptoms and episodes of respiratory distress. The resident was admitted with multiple diagnoses including hypertension, prediabetes, atherosclerosis of the aorta, a right distal humerus fracture, and a frontal bone fracture from a fall, and had bilateral lower leg 2+ edema with dry, cool skin on admission. A progress note documented that the resident was seen at 11 p.m. with left knee swelling and weakness, and the knee was bruised, warm to touch, and mildly tender. During interview, the DON stated these were new signs and symptoms that should have been reported to the physician, but there was no indication that the physician was notified. The facility also failed to notify the physician when the same resident experienced respiratory distress. A progress note indicated that at 2:30 a.m. the resident had shortness of breath and difficulty breathing, described by the resident as an asthma attack, and at 3:26 a.m. the resident was observed gasping for air with a respiratory rate of 24 breaths per minute, with the episode lasting less than five seconds. The LVN who assessed the resident stated he did not recall notifying the physician, explaining that the resident attributed the symptoms to asthma, refused hospital transfer, and that vital signs remained normal for the rest of the shift, and he was unsure if the resident had an asthma diagnosis. Review of the order summary showed an instruction to call the physician if respiratory rate was greater than 20, and the DON stated the resident’s respiratory symptoms and respiratory rate of 24 should have been reported. The facility’s change of condition policy required assessment, documentation, and appropriate follow-through to the physician for altered vital signs and new significant edema, among other changes, which was not followed in this case.
Failure to Report Resident Abuse Allegation to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to follow its abuse prevention and mandated reporting policies when a resident’s allegation of physical abuse by a nurse was not reported to the State Survey Agency or law enforcement. The resident, who had diagnoses including ventilator dependence, unspecified intellectual disabilities, muscular dystrophy, and a myoneural disorder, was cognitively intact with a BIMS score of 13. The resident reported that in 2025, when a wall-mounted vital signs machine failed during a vital signs check, an RN entered the room and slapped her arm. She stated she reported this incident to the Social Services Director (SSD), who responded that it would be her word against the RN’s. Social services notes from late June documented the resident’s allegation that an RN had smacked her right arm two days earlier and indicated the allegation would be investigated, but no SOC 341 report corresponding to that June allegation was found. Further social services documentation from October showed the resident again reported to a Nurse Practitioner (NP) that the RN had smacked her arm, referring back to the June incident, and that SSD was investigating. A SOC 341 completed in late October described the NP asking the resident about the previously documented abuse allegation and urging the facility to report the incident to the Ombudsman. The SOC 341 also documented that the June incident had been discussed with the physician and Regional Case Manager, who concluded the resident had a history of fabricating stories, and therefore no SOC 341 was filed at that time. The SOC 341 explicitly noted that the abuse allegation reported to the NP in October was not reported to the State Agency, and the section listing agencies to which the incident was reported was left blank. The Administrator later stated that the incident was reported only to the Local Ombudsman and that no written report was sent to the State Survey Agency, despite facility policy requiring the Administrator to report suspected abuse or allegations to the California Department of Health within 24 hours.
Failure to Provide Ordered Treatment and Complete Assessment for Coccyx Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered treatment and adequate assessment for a coccyx pressure ulcer in one resident. The resident was admitted with multiple diagnoses, including type 2 diabetes mellitus, chronic kidney disease, and left hemiplegia. A Weekly Pressure Ulcer Injury Record dated 11/3/25 documented a Stage II coccyx pressure ulcer measuring 1 x 0.3 cm, and the resident’s care plan dated the same day included interventions such as providing treatment as ordered to promote comfort and prevent infection. The physician’s order summary directed staff to apply moisture barrier cream to the buttocks and coccyx pressure ulcer every shift and as needed. During interviews and record review, it was determined that nursing staff did not consistently follow these orders or perform complete wound assessments. One LVN stated he did not perform treatments on the night shift and, when he assessed the coccyx ulcer on 11/12/25, he observed a small open area but did not measure it, only taking a quick look. Another LVN, who completed the weekly assessment dated 11/19/25, documented a Stage II coccyx pressure ulcer but did not measure it, explaining that she believed it had already healed and that she only noted the ulcer as a reminder of its prior existence. The facility’s pressure ulcer policy required monitoring wound status with each dressing change and documenting wound assessment parameters, including wound size and depth, using a quantitative tool such as the Bates-Jensen Wound Assessment Tool, which was not followed in these instances.
Inaccurate Documentation of Pressure Ulcer Assessment and Treatment
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate and complete medical record documentation for a resident with multiple comorbidities, including type 2 diabetes mellitus, chronic kidney disease, and left hemiplegia, who was admitted with a Stage II pressure ulcer on the coccyx. The Weekly Pressure Ulcer Injury Record dated 11/3/25 documented a Stage II coccyx pressure ulcer measuring 1 x 0.3 cm. The Treatment Administration Record for November 2025 showed physician orders for coccyx pressure ulcer care and moisture-associated skin damage care every shift and as needed. However, the TAR indicated that one LVN signed off only seven of 20 scheduled night-shift treatments for this resident. During a telephone interview and concurrent record review, the LVN who completed the weekly assessment dated 11/12/25 stated he did not perform treatments on the night shift and acknowledged that when he assessed the coccyx pressure ulcer, he only took a quick, superficial look and did not measure the wound. In another interview and review of the weekly assessment dated 11/19/25, a second LVN stated she documented the presence of a Stage II coccyx pressure ulcer but did not measure it because she believed it had already healed, and she left the notation as a reminder that a pressure ulcer had previously been present. The facility’s policy on Weekly Nurses Progress Notes states that these notes are part of the medical record and must summarize the resident’s condition based on the nurse’s assessment and reflect the assessment at the time of documentation, which was not followed in these instances.
Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident #6, was assessed for the clinical appropriateness and safety of self-administering topical medications. The facility's policy requires an interdisciplinary team assessment to determine a resident's ability to self-administer medications safely, which was not conducted for Resident #6. Despite the resident's intact cognition, as indicated by a BIMS score of 15, there was no documented assessment or physician's order allowing the resident to self-administer their topical medications. Observations revealed that Resident #6 had multiple medication cups containing topical medications at their bedside, which were left by the nursing staff. The resident confirmed that they requested to keep the medications to apply as needed. However, the nursing staff, including LVN #3, admitted to leaving the medications at the bedside without an order for self-administration. The facility's policy was not followed, as there was no assessment or order documented in the resident's medical record. Interviews with the facility staff, including the DON and the Administrator, confirmed that the facility did not have a self-administration assessment or an order for Resident #6 to manage their topical medications. The staff acknowledged the oversight and indicated that an assessment should have been completed to ensure the resident's safety in self-administering the medications. The failure to adhere to the facility's policy resulted in a deficiency in the care provided to Resident #6.
Expired Medications Not Disposed of Properly
Penalty
Summary
The facility failed to dispose of expired medications stored on one of the five medication carts. During an observation and interview with an LVN, it was revealed that two bottles of latanoprost eye drops were expired. One bottle was labeled for a resident with an open date of January 1, 2025, and the other for another resident with an open date of January 8, 2025. The LVN confirmed that both bottles were expired, as latanoprost eye drops expire 42 days after opening. The Director of Nursing stated that expired medications should be removed from the medication cart and confirmed that the two bottles were indeed expired.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Oakland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lake Park Healthcare Center | 0.9 mi | ★★★★★ | 3 | 0 |
| Oakland Heights Nursing And Rehabilitation | 1.1 mi | ★★★★★ | 0 | 0 |
| St Paul's Towers | 1.3 mi | ★★★★★ | 0 | 0 |
| Lake Merritt Healthcare Center Llc | 1.3 mi | ★★★★★ | 8 | 0 |
| Garfield Neurobehavioral Center | 1.5 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.