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 Piedmont Gardens Health Facility during CMS and state inspections, most recent first.
The facility failed to document the use of bed and chair alarms in the care plans of three residents identified as at moderate risk for falls. Observations showed these residents had alarms in place, but their care plans were outdated and did not include this intervention. Staff interviews confirmed the importance of including alarms in care plans as part of a comprehensive fall prevention strategy.
Facility staff failed to perform proper hand hygiene and equipment disinfection, risking infection spread. A CNA did not sanitize hands before and after inserting hearing aids and before donning gloves for incontinence care. LNs did not clean a blood-stained glucometer or sanitize medication tray surfaces. Staff interviews confirmed non-compliance with facility policies on hand hygiene and infection control.
A resident's missing sweatpants were not promptly investigated by the facility, leading to the resident feeling upset and angry. Despite reports to CNAs, no theft and loss reports were filed, and the Social Services Director confirmed the lack of documentation. The facility's policy requires prompt investigation of such complaints, which was not followed in this instance.
Failure to Document Bed Alarm Use in Care Plans
Penalty
Summary
The facility staff failed to develop comprehensive care plans for the use of bed and chair alarms as fall prevention measures for three residents. Observations revealed that these residents had bed alarms attached to their beds or wheelchairs, yet their care plans did not document the use of these alarms. Interviews with staff, including an LVN and the DON, confirmed that bed alarms are used for residents at high risk of falls, but the care plans for these residents did not reflect this intervention. Record reviews showed that the care plans for these residents were outdated and did not include the use of bed alarms, despite the residents being identified as at moderate risk for falls. The facility's policy on bed and chair alarms emphasizes the need for comprehensive fall risk assessments and the inclusion of alarms in care plans as part of a multifaceted fall prevention strategy. However, the care plans for the residents in question were not updated to include the use of alarms, which is a critical component of their fall prevention strategy. Interviews with the DON and MDSC highlighted the importance of including bed alarms in care plans to ensure resident safety and compliance with facility policy.
Inadequate Hand Hygiene and Equipment Disinfection
Penalty
Summary
The facility staff, including a Certified Nursing Assistant (CNA) and Licensed Nurses (LNs), failed to perform proper hand hygiene while providing care to a resident. Specifically, CNA 3 did not perform hand hygiene before and after inserting hearing aids into the resident's ears and before donning gloves for incontinence care. During an interview, CNA 3 acknowledged the importance of hand hygiene to reduce infection transfer and admitted to not following the proper protocol. The Infection Preventionist (IP) confirmed that hand hygiene should be performed before and after donning gloves and emphasized its importance in preventing the spread of germs and infection. Additionally, the facility staff did not sanitize or disinfect the glucometer and medication tray surfaces during medication administration. The glucometer was observed with blood stains, and LVN 1 admitted it should have been cleaned after each use. Furthermore, LVN 2 placed used paper towels on the medication cart without sanitizing it afterward, which could lead to cross-contamination. The facility's policies on hand hygiene and infection control were not adhered to, as indicated by the observations and staff interviews.
Failure to Investigate Missing Personal Belongings
Penalty
Summary
The facility failed to promptly investigate and act upon complaints regarding a resident's missing personal belongings, specifically sweatpants. Resident 11 was admitted to the facility in August 2024, and their family representative reported the loss of two to three pairs of sweatpants over time. Despite notifying Certified Nursing Assistants (CNAs) about the missing items, the facility did not document or properly investigate the loss. The Social Services Director (SSD) and CNA1 searched for the missing items but did not find them, and no theft and loss reports were filed. The Director of Nursing (DON) stated that all staff should be alerted when a resident reports missing belongings, and a loss report should be completed. However, the SSD confirmed that no such reports were filed for Resident 11 from August 2024 to the date of the survey. The facility's policy requires prompt investigation of any complaints of misappropriation or mistreatment of resident property, which was not adhered to in this case. As a result, Resident 11 felt upset and angry about the unresolved issue of their missing sweatpants.
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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) |
|---|---|---|---|---|
| The Rehabilitation Center Of Oakland | 0.5 mi | ★★★★★ | 2 | 0 |
| Oakland Healthcare & Wellness Center | 0.7 mi | ★★★★★ | 12 | 0 |
| Lake Merritt Healthcare Center Llc | 0.8 mi | ★★★★★ | 8 | 0 |
| St Paul's Towers | 1.1 mi | ★★★★★ | 0 | 0 |
| Mcclure Post Acute | 1.2 mi | ★★★★★ | 16 | 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.