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 Bancroft Healthcare Center during CMS and state inspections, most recent first.
The facility failed to document discussions about advanced directives for four residents, including those with cognitive impairments. Despite claims by the SSD that discussions occurred, no documentation was found in the residents' medical records, contrary to facility policy. This oversight could lead to treatment against the residents' wishes.
The facility failed to maintain safe and comfortable room temperatures for two residents during severe hot weather. A resident with a stroke and another with asthma reported discomfort due to high room temperatures, with one resident's room reaching 83°F at night. The facility lacked air conditioning, and the Environment Supervisor did not document room temperatures. The Administrator was aware of the issue, and discussions about installing air conditioning had occurred.
The facility failed to use communication binders for three non-English speaking or aphasic residents, hindering their ability to communicate needs. A resident's binder was stored in a drawer, another resident's binder was unknown to staff, and a third resident lacked a binder entirely. This oversight potentially impacted their ability to perform activities of daily living.
The facility failed to ensure accurate MDS assessments for two residents, leading to potential inappropriate care. One resident's MDS did not reflect limitations in range of motion, while another's did not reflect significant weight loss. Staff acknowledged the inaccuracies in coding.
A resident on tube feeding experienced significant unplanned weight loss, dropping from 94 to 82 pounds over three months. The RD did not notice the weight loss or reevaluate the feeding intake, and the facility failed to notify the physician or family. The LVN assumed the DON would follow up, and the care plan did not address the weight loss with appropriate interventions.
A resident with Alzheimer's Dementia was administered Seroquel without adequate clinical indication, despite no observed behaviors warranting its use. The resident's MDS indicated poor cognition but no behavioral symptoms like hitting or kicking. Interviews with staff confirmed the absence of such behaviors, contradicting the medication's prescribed purpose. The facility's policy requires medications to be clinically indicated, which was not adhered to in this case.
The facility failed to ensure safe medication storage and labeling, as expired blood glucose test strips, a bottle of liquid Lorazepam belonging to a deceased resident, and expired Senna tablets were found improperly stored. The DON acknowledged these items should have been disposed of, as per the facility's policy.
A resident with a history of aphasia and stroke was mistakenly served a pureed meal intended for another resident, instead of their prescribed mechanical soft diet. The error was corrected by a CNA who noticed the mistake. Facility protocol requires licensed nurses and CNAs to verify meal trays before serving to prevent such errors.
A deficiency was identified in a resident room that provided less than the required 80 square feet per resident. The room had a floor area of 76.26 square feet per bed, with two nonverbal residents present. A CNA indicated that care could still be provided adequately, including the use of a Hoyer lift, and that residents had sufficient personal space and privacy. No negative consequences were observed, and a room size waiver was recommended.
Failure to Document Advanced Directives Discussions
Penalty
Summary
The facility failed to ensure that the medical records of four residents were updated to reflect discussions about advanced directives. Specifically, the records for Residents 17, 2, 22, and 24 did not contain documentation indicating that advanced directives were discussed with the residents or their responsible parties. Resident 17, who was admitted with severe cognitive impairment and aphasia following a cerebral infarction, had no advanced directive documented in their medical record. Similarly, Resident 2, who had the capacity to make decisions, and Residents 22 and 24, who had varying levels of cognitive impairment, also lacked documentation of advanced directives in their records. Interviews with the Social Services Director (SSD) and the Director of Nursing (DON) revealed that while discussions about advanced directives were claimed to have occurred, there was no documentation to support these claims. The facility's policy requires that information about advanced directives be prominently displayed in the medical record and that assistance be offered to residents who have not established advanced directives. The absence of documentation for these residents indicates a failure to adhere to this policy, potentially leading to the provision of treatment and services against the residents' wishes.
Failure to Maintain Safe and Comfortable Room Temperatures
Penalty
Summary
The facility failed to ensure that the rooms of two residents, Resident 4 and Resident 21, maintained comfortable and safe temperature levels, particularly during severe hot weather. Resident 4, who had a BIMS score indicating intact cognitive status and a diagnosis of stroke, reported that her room was hot and uncomfortable, with temperatures reaching 83°F at night. She used a fan and kept a thermometer by her bedside, which showed a room temperature of 80°F. During a facility tour, the temperature in Resident 4's room was recorded at 80.4°F, and other rooms were similarly hot. The Environment Supervisor confirmed the lack of air conditioning and the presence of a fan in the hallway, but did not document room temperatures. Resident 21, who also had an intact mental status and a diagnosis of asthma, expressed discomfort due to the heat in her room, stating that she wore loose clothing and opened windows at night to cope. The facility's Administrator acknowledged the absence of air conditioning and had provided staff training on handling heat waves. However, the Operations Manager noted that the building was old and lacked air conditioning, and discussions with the owner about installing it had taken place. The National Weather Service had issued a Hazardous Heat Warning, indicating dangerously hot conditions. The facility's policy on maintaining a homelike environment included ensuring comfortable temperatures, which was not adhered to in this case.
Failure to Utilize Communication Binders for Non-English Speaking and Aphasic Residents
Penalty
Summary
The facility failed to utilize communication binders for three non-English speaking or aphasic residents, which are essential tools for helping these residents communicate their needs. Resident 25, who spoke only in her native language, had her communication binder stored inside her bedside table drawer, making it inaccessible for staff use. The Licensed Vocational Nurse (LVN) was unable to communicate effectively with Resident 25, as she did not know the resident's language and relied on gestures. Similarly, Resident 24, who had dementia and spoke Chinese, also had her communication binder stored inside her bedside table drawer. The Certified Nursing Assistant (CNA) was unaware of the existence of the communication binder and communicated with Resident 24 through gestures. Resident 17, who had aphasia following a cerebral infarction, did not have a communication binder at all. The Director of Nursing (DON) confirmed the absence of the binder during an observation and interview. The facility's policy and procedure on dignity and communication indicated that residents who speak a different primary language should have access to resources such as translators and language communication boards. The lack of accessible communication binders for these residents potentially hindered their ability to understand and carry out activities of daily living.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure accurate assessments for two residents, leading to potential inappropriate care and services. For one resident, the Minimum Data Set (MDS) section G did not reflect limitations in the range of motion for the upper and lower extremities, despite the resident's care plan indicating limited physical mobility due to osteoarthritis of the knee. During an observation and interview, the resident confirmed needing assistance to reposition her foot and expressed a need for exercise therapy. The Director of Nursing and the MDS coordinator acknowledged that the MDS section G was not coded accurately. Another resident's MDS section K failed to reflect a significant weight loss, despite the resident's records indicating a 9.3-pound weight loss over 90 days and a 17.4-pound weight loss over 180 days. The Registered Dietician and Dietary Manager confirmed the significant weight loss and acknowledged that the MDS section K was not coded accurately due to a miscalculation of weight variance. The facility's policy on comprehensive assessments emphasizes the importance of accurate representation of a resident's clinical status to develop appropriate care plans.
Failure to Address Unplanned Weight Loss in Resident on Tube Feeding
Penalty
Summary
The facility failed to ensure that a resident on tube feeding maintained an acceptable nutritional status and body weight range. The resident, who had a history of stroke and non-Alzheimer's dementia, experienced significant unplanned weight loss over a three-month period. Despite the resident's weight dropping from 94 pounds to 82 pounds, the Registered Dietician (RD) did not notice the weight loss and did not reevaluate the resident's tube feeding intake. The RD stated she was not informed of the weight changes, and the facility did not notify the physician or the responsible party about the resident's unplanned weight loss. The Licensed Vocational Nurse (LVN) acknowledged the significant weight loss but did not notify the physician or the resident's family, believing that the Director of Nursing (DON) would follow up. The DON confirmed that there was no documentation of notification to the responsible party or physician regarding the weight loss, which was against the facility's protocol. The facility's policy required the RD to review weight records monthly and evaluate negative trends, but this was not done in this case. The resident's care plan also failed to address the significant weight loss with appropriate interventions.
Inappropriate Use of Antipsychotic Medication in Resident with Alzheimer's Dementia
Penalty
Summary
The facility failed to ensure that a resident diagnosed with Alzheimer's Dementia was free from unnecessary drugs. The resident was administered Seroquel, an antipsychotic medication, without adequate clinical indication for its continued use. The resident's Minimum Data Set (MDS) indicated poor cognition with a BIMS score of 01, but no physical or verbal behavioral symptoms such as hitting or kicking were observed. Despite this, the resident was prescribed Seroquel for unspecified dementia with psychotic disturbances manifested by kicking and hitting others, as per the Order Summary Report. However, interviews with the Social Service Director and a Certified Nursing Assistant revealed that the resident did not exhibit such behaviors and attended daily activities with family support. The Director of Nursing acknowledged being informed by CNAs that the resident exhibited kicking and hitting behaviors during the evening, although these behaviors were not consistent. The Preadmission Screening and Resident Review (PASRR) indicated that the resident had no serious mental illness. The facility's policy on antipsychotic medication management stated that residents should not receive medications that are not clinically indicated to treat a specific condition. The use of Seroquel in elderly patients with dementia-related psychosis is associated with an increased risk of death, and it is not approved for use in psychotic conditions related to dementia. This discrepancy between the resident's observed behavior and the prescribed medication regimen highlights the facility's failure to adhere to its own policy and ensure the resident was free from unnecessary drugs.
Improper Medication Storage and Labeling
Penalty
Summary
The facility failed to ensure safe medication storage and labeling, as evidenced by the presence of expired and improperly stored medications. During an observation, a box of expired blood glucose test strips with an expiration date of February 25, 2021, was found in the medication storage room. These strips were intended for a resident who had been discharged. Additionally, a bottle of liquid Lorazepam belonging to a deceased resident was found in the medication room refrigerator. The Director of Nursing (DON) acknowledged that these items should have been disposed of. Furthermore, a bottle of expired Senna tablets with an expiration date of June 2023 was discovered in medication cart 2. The DON confirmed that expired medications should be disposed of to prevent potential adverse side effects for residents. The facility's policy and procedure on medication storage, dated 2007, mandates the immediate removal and proper disposal of outdated, contaminated, or deteriorated medications. These findings indicate a failure to adhere to the facility's medication storage policies, potentially compromising resident safety.
Failure to Serve Correct Diet to Resident
Penalty
Summary
The facility failed to ensure that a resident received and consumed foods in the appropriate form and nutritive content as prescribed by a physician. During an observation, a Certified Nursing Assistant (CNA) served a meal tray intended for another resident to a resident who was on a mechanically altered diet. This resident, who had a history of aphasia and stroke, required partial to moderate assistance with eating. The meal tray served was pureed, which was not consistent with the resident's prescribed mechanical soft texture diet. The error was identified when another CNA noticed the mistake and swapped the meal tray with the correct one. Interviews with the CNAs and the Director of Nursing (DON) revealed that the facility's protocol required licensed nurses to check meal trays before they were served, and CNAs were also expected to verify the names on the trays. The facility's policy emphasized the importance of serving meals accurately to meet individual resident needs and prevent issues such as choking or allergic reactions.
Room Size Deficiency in Resident Room
Penalty
Summary
The facility was found to have a deficiency related to room size requirements. Specifically, one resident room with multiple beds was observed to provide less than the required 80 square feet per resident. During an observation, it was noted that the room had a floor area of 76.26 square feet per bed. Two residents were present in the room, both awake and nonverbal. A Certified Nursing Assistant (CNA) stated that there was enough space to provide care, including the use of a Hoyer lift, and that no heavy equipment was stored in the room that might interfere with care. The CNA also mentioned that each resident had adequate personal space and privacy, and there were no negative consequences observed due to the decreased space. A recommendation for a room size waiver was made.
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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 San Leandro
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| San Leandro Healthcare Center | 0.1 mi | ★★★★★ | 2 | 0 |
| Jones Convalescent Hospital | 0.1 mi | ★★★★★ | 0 | 0 |
| Washington Center | 1.9 mi | ★★★★★ | 0 | 0 |
| Alameda County Medical Center D/p Snf | 2.1 mi | ★★★★★ | 0 | 0 |
| All Saint's Subacute & Transitional Care | 2.2 mi | ★★★★★ | 2 | 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.