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 June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Alameda Hospital D/p Snf during CMS and state inspections, most recent first.
A resident with a history of anxiety and dementia was physically assaulted by another resident with prior aggressive incidents, resulting in a facial contusion and emotional distress. Staff observed the assault, and records indicated the aggressor had a pattern of unpredictable, aggressive behavior despite being assessed as cognitively intact.
A resident with severe intellectual disability, unable to provide consent, was sexually abused by another resident who did not have significant cognitive impairment. Staff discovered the incident in progress, separated the individuals, and documented the resident's pain and distress. The event was confirmed by staff interviews, medical records, and a police investigation.
The facility failed to discard discontinued insulin medications, which were found stored with ready-to-use medications in the medication refrigerator. A nurse acknowledged that the residents had not received insulin for some time, and the facility's policy requires discontinued medications to be returned or destroyed. Interviews revealed a misunderstanding of the policy, highlighting the risk of accidental use.
The facility had 11 rooms with multiple beds that did not meet the required 80 square feet per resident. Despite this, observations showed adequate space for care, no heavy equipment interference, and no resident complaints or safety concerns.
A resident with Non-Alzheimer's Dementia was found to have a visibly soiled bedside commode, with brown, crusty material and food crumbs observed over several days. Despite facility policy requiring regular cleaning, the commode remained unclean, posing a risk of infection. Staff interviews confirmed the oversight in maintaining cleanliness.
Failure to Prevent Resident-on-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical and emotional abuse when another resident physically assaulted him. The incident involved one resident punching another in the face twice and placing him in a choke hold, resulting in a facial contusion and pain that required transfer to an acute care hospital. The assaulted resident, who had a history of anxiety and dementia, reported feeling fearful and unsafe following the event. Observations and interviews confirmed the details of the assault, with staff witnessing the aggressive behavior and providing immediate assessment and care. The resident who committed the assault had a diagnosis of cognitive communication deficit and dementia with psychotic disturbance, but was assessed as having intact cognitive status according to a recent MDS assessment. This resident had a documented history of four prior aggressive incidents toward other residents, as noted in his care plan. On the day of the incident, a CNA assigned as a sitter to the aggressive resident observed a sudden change in behavior from calm to aggressive, leading to the assault. Staff interviews and record reviews indicated that the aggressive resident's behavior could escalate without warning. The facility's policy and procedure on resident rights, which guarantees freedom from abuse and neglect, was not upheld in this instance. The failure to prevent the assault resulted in physical injury and emotional distress for the victimized resident.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident with severe intellectual disability from sexual abuse by another resident. The resident who was abused was admitted with severe intellectual disability, weakness, schizophrenia, and developmental delay, and was under conservatorship, indicating a lack of capacity to provide consent for sexual activity. The resident required supervision for mobility and had a very low Brief Interview for Mental Status (BIMS) score, confirming severely impaired cognitive status. Staff and family confirmed the resident was unable to make healthcare or personal decisions, including consent for sexual activity. On the night of the incident, a certified nursing assistant (CNA) heard the resident crying and entered the room to find another resident at the bedside with his pants down, thrusting his hips against the resident, who was lying on the bed with her pants pulled down and her diaper exposed. The CNA immediately called for a registered nurse (RN), who separated the two residents and removed the perpetrator from the room. The abused resident complained of elbow pain from being held down and made statements about "making babies" and being pregnant, which were new behaviors for her. Multiple staff interviews and nursing notes corroborated the sequence of events and the resident's inability to consent. The incident was reported to the police, and a subsequent investigation confirmed that the abused resident's cognitive state rendered her incapable of giving legal consent. The perpetrator did not have documented cognitive impairment that would have prevented him from understanding his actions. The police report and hospital records further documented the physical and psychosocial impact on the abused resident, including pain and distress following the assault.
Failure to Discard Discontinued Medications
Penalty
Summary
The facility failed to ensure that discontinued medications were properly discarded, as observed during a survey. In the medication refrigerator at the nursing station, several discontinued insulin medications were found stored alongside ready-to-use medications. These included Admelog for one resident, Lantus for two residents, and Basaglar Kwikpen for another resident. The registered nurse acknowledged that these residents had not received insulin for some time, as they had either transitioned to oral medications or the insulin had been discontinued. The facility's policy and procedure documents, dated 2007 and 2001, respectively, clearly state that discontinued medications should be returned to the dispensing pharmacy or destroyed. However, during interviews, the registered nurse and the nurse manager indicated a misunderstanding or misapplication of this policy, with the nurse manager emphasizing the risk of mistakenly using discontinued medications if not properly separated. The pharmacist also confirmed that discontinued medications should be separated from regular medications to prevent accidental use.
Deficiency in Resident Room Space Requirements
Penalty
Summary
The facility was found to have 11 resident rooms with multiple beds that did not meet the required minimum space of 80 square feet per resident. Specifically, these rooms provided less than the mandated space, with some rooms offering as little as 70.88 square feet per bed. This deficiency was identified through observations, interviews, and record reviews conducted over a period of several days. Despite the space deficiency, observations indicated that there was sufficient space for the provision of care, and no heavy equipment was present in the rooms that could interfere with resident care. Residents had adequate personal space and privacy, and there were no complaints from them regarding insufficient space for their belongings. Additionally, there were no negative consequences or safety concerns reported as a result of the decreased space in these rooms.
Inadequate Cleaning of Bedside Commode
Penalty
Summary
The facility failed to implement proper infection control practices, as evidenced by the condition of a bedside commode in a resident's room. The commode was observed to be visibly soiled with brown, crusty material, suspected to be fecal matter, and food crumbs on multiple occasions over several days. Despite the facility's policy requiring daily cleaning or cleaning when visibly contaminated, the commode remained unclean, posing a risk of healthcare-associated infections to residents. Resident 21, who has an active diagnosis of Non-Alzheimer's Dementia and requires supervision for mobility and toilet hygiene, was directly affected by this deficiency. Observations revealed that the resident's bedside commode, positioned next to her bed and eating area, was not adequately cleaned by the assigned CNAs, despite their acknowledgment of the need for regular sanitation. Interviews with facility staff, including CNAs and the Nurse Manager, confirmed the oversight in maintaining cleanliness, which is crucial given the resident's tendency to touch surfaces in her environment.
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What surveyors actually found near you
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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 Alameda
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bay View Rehabilitation Hospital, Llc | 0.3 mi | ★★★★★ | 3 | 0 |
| Alameda Healthcare & Wellness Center | 0.6 mi | ★★★★★ | 2 | 0 |
| Marina Garden Nursing Center | 1.1 mi | ★★★★★ | 0 | 0 |
| West Shore Post Acute | 1.1 mi | ★★★★★ | 0 | 0 |
| Fruitvale Healthcare Center | 1.5 mi | ★★★★★ | 1 | 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 June 2026) and official state health department websites.