Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
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 Oakland Healthcare & Wellness Center during CMS and state inspections, most recent first.
Failure to maintain ROM and restorative services for three residents with significant mobility limitations. One resident with hemiplegia and contractures was bed bound with stiff lower extremities and a contracted left arm/hand, another resident with CKD on dialysis and lower-extremity ROM limits said therapy had stopped and she needed more exercises, and a third resident with cognitive impairment, hand osteoarthritis, and upper/lower-extremity ROM limits reported a right-hand splint had been discontinued. RNA staff said the residents were not on the RNA program because there was no order, and records showed missing or outdated therapy follow-up and restorative recommendations.
Food Storage and Labeling Deficiencies: A Dietary Supervisor was observed in the kitchen with uncovered facial hair, and both the kitchen refrigerator and a resident refrigerator contained expired, beyond-use-date, and unlabeled food items. The RD stated facial hair should be covered in the kitchen and food in resident refrigerators should be labeled with the resident name, date, and use-by information.
Failure to provide requested grooming assistance: Two residents with decreased ability to perform self-care were observed with facial hair and overgrown fingernails, and both stated staff had not offered shaving or nail care in line with their preferences. One resident said the condition made them feel embarrassed, while the other wanted facial hair trimmed and nails kept short to avoid scratching skin and to feel clean and well-groomed.
Failure to Assess and Address Significant Weight Loss: A resident with cerebral infarction and depression had a documented significant weight loss after monthly weights showed a large drop from the prior month. The resident reported difficulty chewing and swallowing due to an ear infection, pain with biting and swallowing, and a recent loss of more than 20 lbs. Staff stated the change was not timely assessed or reported to the MD, RD, or responsible party, despite the resident’s nutritional risk and weight-monitoring order.
Failure to identify and address significant weight loss. Two residents had documented or reported weight loss that met the facility’s criteria for significant loss, but nursing and RD review did not show timely assessment or documented intervention. One resident had a rapid drop in weekly weight and reported chewing difficulty, while another resident with cerebral infarction and depression had a 37-lb. loss over less than three months, reported chewing and swallowing problems, and was later seen in the ED with jaw swelling, dehydration, and a dental abscess.
Failure to report unusual occurrence after resident fall with head laceration. A resident with a recent femur fracture, gait impairment, and mild cognitive impairment had an unwitnessed fall in a shared bathroom and sustained lacerations to the back of the head requiring two staples before transfer to acute care. The ADON stated the event was not reported to CDPH because it was believed to have been witnessed, although the EHR documented it as unwitnessed and the facility policy required reporting unusual occurrences within 24 hours.
The facility failed to prevent unauthorized entry or resident exit when staff left an alarmed emergency exit door open and unarmed for 35 minutes. The door, leading to public streets, did not trigger an alarm, contrary to facility policy. Staff interviews confirmed the doors were never locked but should have been alarmed to alert staff. The facility's policy required regular checks of the alarm system, but the system was not armed, posing a risk of unauthorized entry or resident elopement.
A facility failed to ensure nursing staff had the necessary competencies for safe resident care. An LVN without IV and blood withdrawal certification provided care for a resident's PICC line, despite the resident's complex medical needs requiring certified care. The DON confirmed the LVN's lack of certification, which was against facility policy and state regulations.
The facility failed to maintain a homelike environment, with issues such as missing window coverings, non-functional bathroom fixtures, and unclean bathrooms. A resident's room had a window that couldn't close, allowing smoke to enter, while another resident's bathroom had a faulty hot water knob. Multiple rooms had unclean bathrooms, and requests for cleaning were ignored. These deficiencies compromised resident comfort and safety.
The facility failed to complete necessary PASRR evaluations for several residents, including those with schizophrenia and bipolar disorder, potentially preventing them from receiving required mental health services. The facility did not resubmit Level I PASRR screenings for two residents after 30 days, did not complete a PASRR for a resident with bipolar disorder, and failed to conduct a Level II evaluation for a resident with schizophrenia.
The facility failed to employ a full-time qualified Dietary Services Supervisor to oversee food operations, as required by California Health and Safety Code. The Kitchen Manager, who was supposed to fulfill this role, worked part-time and lacked necessary qualifications, holding only a ServSafe certification. The Registered Dietitian was onsite only two days a week, indicating insufficient oversight, potentially jeopardizing the health of 92 residents.
The facility failed to store, prepare, and serve food safely, with issues including unrefrigerated Teriyaki sauce, expired and unlabeled dry food bins, scratched cutting boards, a sticky knife rack, dusty air vents, and unclean kitchen floors. These deficiencies were acknowledged by the Kitchen Manager and Registered Dietitian, posing risks of foodborne illness and contamination.
The facility failed to manage pest control effectively, as two residents reported roaches in their rooms. Despite complaints, the issues were not logged in the maintenance system, leading to a lack of action. Observations confirmed roaches in a resident's room and shared bathroom, and pest control services were not provided as needed.
Two residents in an LTC facility experienced deficiencies in pain management. One resident did not receive a pain assessment or medication before a wound dressing change, despite showing non-verbal pain cues. Another resident was given Tylenol instead of Norco for a pain level that required stronger medication, and staff failed to reassess and notify the physician for a pain management reevaluation. These actions were inconsistent with the facility's pain management policies.
The facility failed to administer medications as ordered for two residents, leading to a deficiency in pharmaceutical services. A resident with heart failure did not receive two prescribed medications during an observed medication pass due to unavailability and oversight. Another resident did not receive prescribed eye drops for glaucoma for two days, as confirmed by the DON, due to the medication being unavailable.
A facility failed to maintain a medication error rate of 5% or less, with an observed rate of 8.1%. An LVN was unable to administer potassium chloride to a resident due to a pharmacy delay, administered double the ordered dose of Vitamin D3, and omitted Minoxidil. These errors were confirmed during an observation and interview, contributing to the facility's non-compliance.
The facility failed to properly store and dispose of medications, as observed by surveyors. An emergency medication kit was found open and not replaced, containing controlled substances, insulin, and temperature-sensitive suppositories. Additionally, three boxes of expired Bisacodyl suppositories were stored with other medications. A nurse confirmed the risk of residents receiving ineffective treatment. The facility's policy requires immediate removal and disposal of outdated medications, which was not followed.
A facility failed to document hospice visits and assessments for a resident with cerebrovascular disease in their electronic medical record. Despite regular hospice visits, notes were only found in a Hospice Communication Binder, contrary to the facility's policy requiring inclusion in progress notes. This deficiency was confirmed by a LVN and the Hospice Clinical Director, highlighting a gap in maintaining complete clinical records.
Failure to Maintain ROM and Restorative Services
Penalty
Summary
The facility failed to provide preventive treatment and services to maintain and improve range of motion for three sampled residents with limited ROM and mobility impairments. Resident 6 was admitted with diagnoses including hemiplegia, diabetes, and repeated falls, and the MDS showed functional limitations in ROM on one side of the upper and lower extremities. The record showed the last PT evaluation and plan of treatment was dated 7/2/23 with no documented PT evaluation after that, and no OT evaluation record was provided. RNA staff stated Resident 6 was not on the RNA program because there was no order, while nursing staff described the resident as contracted, bed bound, and unable to move the legs, with the left arm and hand also contracted. Resident 75 was admitted with chronic kidney disease requiring renal dialysis and muscle weakness, and the MDS showed functional limitations in ROM in both lower extremities. During observation, the resident was lying in bed and stated she was no longer receiving therapy because of insurance authorization and felt she needed more therapy exercises. RNA staff stated she was not on the RNA program because there was no order. The OT discharge summary showed OT services ended with a recommendation to request new authorization, and the care plan identified an ADL self-care performance deficit related to impaired balance and limited mobility. Resident 26 was initially admitted and later readmitted, and the MDS showed moderate cognitive impairment with limited ROM and impairment on one side of the upper and lower extremities. Diagnoses included generalized muscle weakness and osteoarthritis of both hands. RNA staff stated the resident was not on the RNA program because there was no order. The OT discharge summary recommended Restorative ROM, Restorative Splint and Brace program, bilateral upper extremity AROM, and a right resting hand splint, while the physician order report included PT/OT/ST evaluation and treatment as indicated and a right hand therapy order due to contracture. The resident stated staff used to put a splint on his right hand but had stopped, and the care plan showed the resident required extensive to total assistance to turn and reposition in bed.
Food Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to store food in accordance with professional standards for safety when kitchen staff had uncovered facial hair while working in the kitchen. During an observation on 1/12/26 at 9:24 a.m., the Dietary Supervisor had uncovered facial hair while in the facility kitchen. The facility's policy titled, Dietary Department - Infection Control, revised 2/29/24, stated that hair, beard, and mustache should be covered with an effective hair restraint while in the kitchen and food storage areas. During a later observation on 1/12/26 at 9:42 a.m., the kitchen refrigerator contained cranberry sauce with a use by date of 12/27/25 and salad dressing with a use by date of 12/30/25. During an observation on 1/12/26 at 10:18 a.m., the resident refrigerator contained a smoothie with an expiration date of 1/5/26, one pack of ready to eat chicken not labeled with resident name or date, one unknown food item not labeled with date, and one unknown food item not labeled with resident name or date. The Registered Dietician stated that food beyond its use by date or expired should have been thrown out, and that food in the resident refrigerator should have been labeled with the date it was opened or brought in, the use by date, and resident name.
Failure to Provide Requested Grooming Assistance
Penalty
Summary
The facility failed to ensure that two residents received nail care and shaving in accordance with their preferences. Resident 30 was admitted in December 2025 with a diagnosis of need for assistance with personal care and had a BIMS score of 12. During observation and interview on 1/12/26, Resident 30 was seen with facial hair and long, dirty fingernails and stated staff did not offer to shave or cut and clean the fingernails. Resident 30 said the facial hair and long dirty nails made them feel embarrassed. The care plan, revised 12/9/25, documented decreased ability to perform self care related to impaired activity intolerance, impaired balance/safety, impaired coordination, pain limiting function, and weakness. Resident 95 was admitted in October 2025 with diagnoses including cerebral infarction, depression, and atherosclerosis of the extremities with gangrene on bilateral legs. The care plan, revised 12/3/25, documented decreased ability to perform self care related to decreased range of motion, impaired activity intolerance, impaired balance/safety, impaired coordination, and weakness. During observation and interview on 1/14/26, Resident 95 had long fingernails and facial hair around the chin and jaw area and stated nursing staff had not offered assistance with trimming facial hair or fingernails. Resident 95 stated a preference for facial hair to be trimmed because of discomfort looking like a man and wanted fingernails kept short to prevent scratching the skin, particularly the lower legs with an existing wound, and to feel clean and well-groomed.
Failure to Assess and Address Significant Weight Loss
Penalty
Summary
The facility failed to timely assess and intervene when Resident 95 had a significant change in condition related to weight loss. Resident 95 was admitted with diagnoses of cerebral infarction and depression, and the care plan identified potential nutritional problems with a goal to remain within 5% of the admission weight of 264 lbs. and to notify the physician for significant weight loss. The record also showed a physician order for monthly weights and a dietitian assessment recommending gradual weight loss of 0.5 lbs. to 4 lbs. per month. On 1/1/26, the resident’s monthly weight was documented as 228.0 lbs., compared with 254.8 lbs. on 12/1/25, reflecting a loss of 26.8 lbs. in one month. During observation, the resident stated having difficulty chewing and swallowing related to an ongoing ear infection, reported a recent weight loss of more than 20 lbs. within one week, and appeared unable to talk, bite down on food, or swallow without pain. Staff interviews indicated the weight loss was not addressed at the time it was identified, and the LVN and ADON stated an assessment should have been completed and the physician, RD, and responsible party should have been notified.
Failure to Identify and Address Significant Weight Loss
Penalty
Summary
The facility failed to identify significant weight loss and failed to implement interventions for two residents. For one resident admitted with a diagnosis of nontraumatic chronic subdural hemorrhage, weekly weights showed a drop from 134.4 lbs. to 123.2 lbs. in one week. The resident stated having difficulty chewing food and losing weight. A restorative nursing assistant reported giving the weekly weights to the charge nurse, and an LVN stated the loss was significant and should have triggered a change-of-condition assessment. The resident’s EHR did not show that such an assessment was completed or that an intervention was documented for the weight loss. For another resident admitted with diagnoses of cerebral infarction and depression, the care plan identified nutritional risk and set a goal to remain within 5% of 264 lbs., with physician notification required for significant weight loss. The resident reported difficulty chewing and swallowing related to an ear infection and stated losing more than 20 lbs. within one week. The RD stated the resident had only been assessed on admission, was not aware of the reported weight changes or chewing and swallowing difficulties, and that monthly weight monitoring should have been completed to track changes and allow timely evaluation and intervention. The resident’s January weight had not been completed when reviewed, and the LVN stated the scale may have been inaccurate at the time of weighing. Record review showed the resident’s weights decreased from 264 lbs. to 227 lbs. over less than three months, a loss of 37 lbs. or about 14% body weight. The resident was later seen in the ED with diagnoses of a periapical abscess with facial involvement, jaw swelling, and dehydration, and received IV Lactated Ringer’s solution. The DON stated weight logs should have been reviewed and entered into the EHR, and that a significant weight change should have prompted an IDT review to identify the cause and provide interventions. The facility policy defined significant weight loss as 5% and/or 5 lbs. in one month and required IDT evaluation for any resident weight varying by 5% in 30 days.
Failure to Report Unusual Occurrence After Resident Fall With Head Laceration
Penalty
Summary
The facility failed to report an unusual occurrence to the California Department of Public Health within 24 hours after Resident 4 had an unwitnessed fall and sustained lacerations to the back of the head that required two staples before being sent to an acute care hospital. Resident 4 was admitted in November 2025 with diagnoses of a right femur fracture, abnormalities of gait and mobility, and mild cognitive impairment. During an interview, Resident 4 stated the fall occurred in the shared bathroom when a family member from the other room suddenly opened the door while holding the doorknob, causing the resident to lose balance and fall. During record review and interview, the ADON stated the incident was not reported because the fall was believed to have been witnessed by a family member and therefore did not require reporting to CDPH. However, the EHR documented the event as an unwitnessed fall with injury, and the ADON acknowledged that the resident’s head injury required two staples. The facility policy titled Unusual Occurrence Reporting stated that unusual occurrences are to be reported to the appropriate agency within 24 hours by telephone and then confirmed in writing.
Failure to Secure Emergency Exit Door
Penalty
Summary
The facility failed to ensure the safety of 90 sampled residents by not preventing unauthorized visitor entry or resident exit. This occurred when staff left the alarmed emergency exit back door open and unarmed for 35 minutes during the evening shift. Observations revealed that the door, which led to an access ramp with direct access to public streets, was opened without triggering an audible alarm. Interviews with staff, including a Certified Nursing Assistant and the Director of Nursing, confirmed that the emergency exit doors were never locked, but were equipped with alarms intended to alert staff when opened. However, the alarm was not functioning as expected during the observed period. The facility's policy and procedure on wandering and elopement required staff to ensure doors closed properly and that the maintenance department regularly checked the alarm system. A review of the facility's plan of correction from a previous survey indicated that door alarms should be engaged at all times, and staff were instructed to respond to alarms. Despite these measures, the alarm system was not armed, and staff did not respond to the open door, posing a risk of unauthorized entry or resident elopement.
Inadequate Competency in PICC Line Care
Penalty
Summary
The facility failed to ensure that nursing staff had the necessary competencies and skills to safely meet the care needs of a resident. Specifically, a Licensed Vocational Nurse (LVN) without an intravenous (IV) and blood withdrawal certification provided care for a resident's peripherally inserted central catheter (PICC). This resident had been admitted with diagnoses including surgical aftercare following digestive system surgery, short bowel syndrome, nutritional deficiency, and acquired absence of parts of the digestive tract. The resident's medical orders required specific PICC care and monitoring for signs of infection or bleeding. The Director of Nursing confirmed that three LVNs documented providing care to the resident during specific shifts, but only two had the necessary IV competency certificates. The LVN in question, who lacked the certification, was documented as providing care and monitoring for the resident's PICC line on multiple occasions. According to the Board of Vocational Nursing and Psychiatric Technicians, only LVNs certified in intravenous therapy are permitted to perform certain tasks related to PICC lines. The facility's policy also stipulated that only IV certified LVNs could perform specific procedures related to central lines, which the LVN in question was not certified to do.
Facility Maintenance Deficiencies Impact Resident Comfort and Safety
Penalty
Summary
The facility failed to maintain a homelike environment for its residents, as evidenced by several maintenance issues that were not addressed in a timely manner. Resident 39's room had a missing window covering, which the resident had requested multiple times for privacy and protection from heat. Despite the Maintenance Supervisor being aware of the issue and having the necessary blinds available, the installation was delayed due to time constraints. Resident 41's bathroom sink hot water knob was not functioning, and the issue was not documented in the Maintenance Logbook, leading to a delay in repairs. The Maintenance Supervisor acknowledged the problem but had not addressed it, resulting in the resident's care being compromised as staff had to obtain hot water from another location. Resident 58's room had a window that could not be closed completely, allowing outside air and cigarette smoke to enter the room. The family member expressed concern for the resident's health due to the smoke exposure. The Maintenance Supervisor was aware of the issue for over a month and had attempted in-house repairs before contacting an external company for window replacement. Temporary measures were planned to seal the window until the replacement could be completed. Additionally, the facility's smoking policy aimed to protect non-smoking residents, but observations showed residents smoking near bedroom windows, increasing the risk of second-hand smoke exposure. Multiple rooms, including Rooms 5, 6, 10, 11, 12, 16, and 19, had unclean bathroom environments with cracked flooring and blackish discoloration. Resident 85, who used one of these bathrooms, reported discomfort and stated that requests for cleaning were ignored. The Environmental Supervisor confirmed awareness of the issues but did not indicate any immediate action taken. The facility's policy emphasized providing a safe, clean, and comfortable environment, but these deficiencies demonstrated a failure to uphold these standards, potentially impacting residents' quality of life and well-being.
Failure to Complete PASRR Evaluations for Residents
Penalty
Summary
The facility failed to ensure that the Pre-Admission Screening Resident Review (PASRR) process was properly followed for four residents, potentially preventing them from receiving necessary mental health services. Resident 32 and Resident 67 were admitted with Level I PASRR screenings completed from the hospital, indicating no serious mental illness. However, both residents had diagnoses of schizophrenia, a serious mental disorder. The facility did not resubmit a new Level I PASRR screening for these residents after they remained in the facility for more than 30 days, as required. Resident 47 was admitted and readmitted to the facility with a PASRR coded zero, indicating no serious mental illness, despite having a diagnosis of bipolar disorder and being prescribed medication for it. The facility did not complete a PASRR for Resident 47, nor did they refer the resident to the State Mental Authority for specialized mental health services after the resident stayed in the facility for over 30 days. This oversight was confirmed during a review of the resident's clinical records by the MDS Coordinator and the Director of Nursing. Resident 57's records showed a diagnosis of schizophrenia and a requirement for a Level II Mental Health Evaluation Referral, as indicated by a positive result for mental illness on the Level I PASRR completed prior to admission. However, the facility did not complete the necessary Level II PASRR evaluation or set up a follow-up appointment for the evaluation. This deficiency was identified during a review of the resident's clinical records, where it was confirmed that no Level II PASRR was completed.
Failure to Employ Qualified Dietary Services Supervisor
Penalty
Summary
The facility failed to ensure proper oversight of its food service operations by not employing a full-time qualified Dietary Services Supervisor (DSS) to manage and oversee food operation services. According to the California Health and Safety Code, a health facility that employs a registered dietitian less than full-time must also employ a full-time dietetic services supervisor. The Kitchen Manager (KM), who was supposed to fulfill this role, was found to be working part-time and did not possess the necessary qualifications, as she was still in school for the DSS certification and only held a ServSafe certification. The Registered Dietitian (RD) was only onsite two days a week, further indicating insufficient oversight. A review of the KM's timecard report revealed that she worked less than the required 35 hours per week for several weeks, with hours ranging from 12.82 to 34.99 per week. The facility's policy and procedure for the DSS position required a graduate of a California State approved DSS course or CDM certification, which the KM did not have. During an interview, the Administrator acknowledged the part-time status of the RD and KM and confirmed that the ServSafe certification was not adequate for overseeing the facility's Dietary Services Department. This deficiency had the potential to jeopardize the health and well-being of 92 out of 93 residents who received food prepared in the kitchen.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure food was stored, prepared, and served in a safe and sanitary manner, as observed during a survey. A full container of Teriyaki sauce, labeled to be refrigerated after opening, was found stored in an unrefrigerated dry-goods storage area. The Kitchen Manager (KM) acknowledged that some unrefrigerated liquids could spoil and cause resident illness. Additionally, a dry food bin labeled polenta was found with an expired use-by date, and other bins for flour, thickener, and grain rice lacked use-by dates, which the KM admitted could lead to foodborne sickness and affect food quality. Further observations revealed that two of five cutting boards had deep white scratches, which could harbor food particles and lead to foodborne illness. The KM and Registered Dietitian (RD) confirmed that cutting boards should be changed frequently to prevent such risks. A knife rack was also found with a sticky brown residue, and the KM noted that this unclean area could transfer dirt and germs onto knives and subsequently onto resident food. The survey also identified an air conditioner unit with thick grey dust on top and in the vents, which was blowing air into the kitchen. The KM stated that the dust was cleaned to prevent contamination. Additionally, a corner of the kitchen floor had a buildup of food debris, which the KM acknowledged should have been cleaned thoroughly to prevent pest infestation. The facility's policies and procedures for food storage, handling, and maintenance were reviewed, highlighting the need for proper labeling, cleaning, and sanitation to avoid contamination and ensure food safety.
Failure in Pest Control Management
Penalty
Summary
The facility failed to provide effective pest control for two residents, resulting in complaints about roaches in their rooms. Resident 88 reported seeing a roach under her lunch tray and informed the MDS Coordinator, who communicated the issue in a facility meeting and group message. However, the report was not recorded in the maintenance log, which is crucial for ensuring follow-up actions. Similarly, Resident 55 reported roaches in his room multiple times to staff, including a Licensed Vocational Nurse, but his room was not listed on pest control invoices, indicating a lack of action. Observations confirmed the presence of roaches in Resident 55's room and a shared bathroom, along with a buildup of dirt. The Maintenance Staff acknowledged the importance of logging such reports to prevent oversight. The Pest Control Technician confirmed that only rooms listed on invoices were treated, and Resident 55's room was not among them, despite his willingness to have pest control services. The facility's policy requires staff to report pest sightings to the Housekeeping Supervisor for immediate action, but this protocol was not effectively followed.
Deficiencies in Pain Management for Two Residents
Penalty
Summary
The facility failed to provide necessary treatment and care services in accordance with professional standards of practice for two residents, leading to deficiencies in pain management. For Resident 41, a licensed nurse did not assess or offer pain medication before performing a wound dressing change. This resident, who was on palliative care and had a sacral pressure ulcer, exhibited non-verbal cues of pain during the procedure, such as tensing and moving away. The facility's policy required pain assessment and medication administration prior to such treatments, which was not followed in this instance. Resident 85 did not receive pain medication as ordered by the physician. Despite having a pain level that warranted the administration of Norco, the resident was given Tylenol instead. The resident frequently complained of pain, and the medication administration records showed inconsistencies with the physician's orders. Licensed nurses failed to reassess the routine use of as-needed pain medication and did not notify the physician for a reevaluation of the resident's pain management plan, as required by the facility's policy. Interviews with staff, including licensed vocational nurses and the director of nursing, revealed a lack of adherence to the facility's pain management policies. The staff acknowledged the expectation to follow physician orders and assess pain levels accurately before administering medication. However, documentation errors and misjudgments about the resident's pain levels led to inappropriate pain management, contributing to the deficiencies identified in the report.
Medication Administration Deficiency
Penalty
Summary
The facility failed to administer medications as ordered for two residents, leading to a deficiency in pharmaceutical services. Resident 54, who was admitted with a diagnosis of heart failure, did not receive two prescribed medications during an observed medication pass. The Licensed Vocational Nurse (LVN) was unable to locate the potassium chloride in the medication cart and stated that it had been ordered but not yet arrived. Additionally, the LVN confirmed that Minoxidil, prescribed to lower blood pressure, was not administered to Resident 54 during the same medication pass. Resident 58, who had an order for Latanoprost Ophthalmic Solution for glaucoma, did not receive the prescribed eye drops for two consecutive days. The Director of Nursing (DON) reviewed the Medication Administration Record (MAR) and noted that the medication was unavailable at the time of administration on those days, which was acknowledged as a medication error. These failures in medication administration had the potential to result in the worsening of the residents' medical conditions.
Medication Error Rate Exceeds Acceptable Limit
Penalty
Summary
The facility failed to maintain a medication error rate of five percent or less, resulting in an observed error rate of 8.1%. During a medication pass, a Licensed Vocational Nurse (LVN) was unable to administer potassium chloride to a resident because the medication had not arrived from the pharmacy. Additionally, the LVN administered two tablets of Vitamin D3, totaling 2000 units, instead of the ordered 1000 units. Furthermore, the LVN did not administer Minoxidil, a medication intended to lower blood pressure, to the resident. These errors were identified during an observation and interview with the LVN, where the medication orders were reviewed. The LVN acknowledged the errors, confirming that the Minoxidil was not administered and that two tablets of Vitamin D3 were given instead of one. These actions and inactions during the medication pass contributed to the facility's failure to maintain the required medication error rate, potentially impacting the resident's medical condition.
Improper Medication Storage and Disposal
Penalty
Summary
The facility failed to ensure proper storage and disposal of medications, as observed by Health Facilities Evaluators. During an inspection of the medication storage room, an emergency medication kit was found open and not replaced, containing controlled substances, insulin, and temperature-sensitive suppositories. Additionally, three boxes of Bisacodyl suppositories were discovered to be expired, yet they were stored with other over-the-counter medications. This was confirmed by a Licensed Vocational Nurse, who acknowledged that the expired medications posed a risk of residents receiving ineffective treatment. A review of the facility's policy and procedure on medication storage revealed that outdated, contaminated, or deteriorated medications should be immediately removed from stock, disposed of according to procedures, and reordered from the pharmacy. However, this protocol was not followed, leading to the potential for residents to receive ineffective medication.
Incomplete Documentation of Hospice Care for a Resident
Penalty
Summary
The facility failed to ensure that clinical records were complete and accurately documented for a resident receiving hospice care. The resident, who was admitted to the facility in 2019, was placed under hospice care in May 2024 due to a terminal diagnosis of cerebrovascular disease. However, the resident's electronic medical record did not contain any documentation of hospice visits or assessments. This lack of documentation was identified during a review of the resident's records and an interview with a Licensed Vocational Nurse (LVN), who confirmed that hospice visits occurred regularly but were not recorded in the facility's electronic medical record. The facility's policy required that hospice notes be included in the facility's progress notes and maintained in the resident's medical record. Despite this policy, hospice notes were only found in a Hospice Communication Binder, and there were no progress notes entered by facility nurses in the electronic medical record. The Hospice Clinical Director confirmed that hospice nurses were expected to document each visit in the Hospice Communication Binder and that the facility could request copies of hospice progress notes. This deficiency had the potential to impact the resident's care due to the lack of available information for the interdisciplinary team.
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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) |
|---|---|---|---|---|
| St Paul's Towers | 0.5 mi | ★★★★★ | 0 | 0 |
| The Rehabilitation Center Of Oakland | 0.5 mi | ★★★★★ | 2 | 0 |
| Mcclure Post Acute | 0.5 mi | ★★★★★ | 16 | 0 |
| Medical Hill Healthcare Center | 0.6 mi | ★★★★★ | 6 | 0 |
| Lake Merritt Healthcare Center Llc | 0.6 mi | ★★★★★ | 8 | 0 |
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