Above average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 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.
Unsanitary kitchen conditions were observed, including brownish buildup inside the ice machine on the water bin and tubing, debris on food shelves, trays, and hot boxes, dusty vents, cracked and chipped wall and flooring surfaces, and buildup around air-gap drainage and floor sink areas. A kitchen staff member also wore a mask without fully covering facial hair, and chemicals were stored in an open area next to clean pots and pans. Staff interviews showed the ice machine was only partially cleaned by kitchen staff, while the upper interior areas were not addressed.
Two residents were not served their meals at the same time as others seated at their tables, with one resident waiting 16 minutes after a tablemate was served and another waiting 27 minutes. An RN and the DSD stated residents seated together should eat at the same time for dignity. In addition, a resident with intact cognition was observed with facial hair and said staff had not offered to remove it, even though staff stated CNAs were supposed to offer facial hair removal for female residents as part of grooming and dignity.
Unsafe Medication Storage Practices: Staff left a damaged medication bottle labeled for a resident in a med cart, kept an expired OTC calcium bottle in another med cart, and left the central supply/OTC storage room doors unlocked while medications and supplies were stored inside. RN, LVN, DON, and HCC all acknowledged the items and doors should not have been left in that condition.
Failure to Use Required PPE During EBP Care: CNA 3 and CNA 4 provided ADL care and transferred a resident on EBP without wearing the required isolation gown. The resident had a chronic right foot ulcer with necrosis of bone and physician orders for EBP for the wound and neuropathic ulcer. Staff interviews confirmed that gowns and gloves were expected for EBP care, and the facility policy listed high-contact care activities such as dressing, bathing, transferring, toileting, and bed mobility as requiring gown and gloves.
A resident was given Azithromycin for cough and SOB/wheezing without clear infection symptoms. The record showed no fever or other signs of infection, and the RN/IP stated the resident had no SOB, no wheezing, and did not meet infection control criteria for infection. The physician continued the antibiotic based on a chest x-ray showing opacity, while the progress note documented cough, no SOB or fever, and right lung opacities.
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.
Unsanitary Kitchen Conditions and Improper Ice Machine Cleaning
Penalty
Summary
Food was not prepared and stored under sanitary conditions in the kitchen. During a kitchen tour, the ice machine was observed with brownish material buildup on the water bin and tubing inside the machine where water was present. The kitchen floor and tiles had cracked areas and brownish buildup, the vents had dusty blackish material, food shelves and trays had debris, and two hot boxes used to keep food hot had food debris. The kitchen wall had cracked and chipped paint with blackish discoloration, and the equipment air-gap drainage pipe and basin areas had yellowish brown buildup. A broom and dustpan were stored in the dry food storage room, and chemical and cleaning agents were stored in an open area next to clean pots and pans. The floor sink area next to the clean pots and pans had yellowish black buildup. During the observation, a kitchen staff member wore a face mask but had facial hair that was not fully covered by a beard restraint. The Food Service Director/Registered Dietician stated the ice machine was cleaned by an outside contractor twice a year and also stated kitchen staff wiped down the outside daily and cleaned the ice machine monthly. The Executive Chef stated the kitchen floor was cleaned daily and that it was okay to keep cleaning materials in an unsecured area next to clean pots and pans. A dietary staff member stated he cleaned the ice machine monthly but only washed the ice bucket and ice scoop and did not touch the upper area of the machine. Later, the inside of the ice machine was again observed with brownish buildup on the water bin and tubing, and the Administrator reviewed the concern and stated the facility used an outside contractor to sanitize the ice machine.
Delayed meal service and lack of facial hair grooming
Penalty
Summary
Two residents were not served food in a dignified manner during lunch service. Resident 90, whose BIMS score was 15 indicating intact mental status, had a care plan noting an ADL self-care performance deficit and an MDS showing setup or clean-up assistance for eating. During observation, Resident 90 sat at a table with another resident at 12:00 p.m., while the other resident received lunch at 12:20 p.m. Resident 90 stated at 12:36 p.m. that they wanted to know when they would get their food, and received lunch at 12:38 p.m. Resident 90 later stated the delay made them upset. Resident 18, whose care plan noted an ADL self-care performance deficit related to dementia and ability to feed self with cueing, sat at a table with three other residents at 12:00 p.m. The other residents received lunch between 12:25 p.m. and 12:27 p.m., while Resident 18 did not receive lunch until 12:52 p.m., when a CNA assisted with eating. Resident 90 was also not offered facial hair grooming. During observation, Resident 90 was seen with facial hair and stated they removed facial hair at home and staff had not offered to remove it, adding that the facial hair bothered them. RN 1 stated razors were stored in the utility room and CNAs were supposed to offer facial hair removal to female residents so they felt clean and for dignity. The DSD stated staff should have offered female residents facial hair removal for grooming and dignity. Resident 90’s care plan noted an ADL self-care performance deficit, and the MDS indicated setup or clean-up assistance for personal hygiene, including shaving.
Unsafe Medication Storage Practices
Penalty
Summary
The facility failed to ensure safe and secure medication storage when a damaged, crushed plastic medication bottle labeled for Resident 32 was found in the medication cart with crushed pills inside. RN 2 stated the bottle had been collected from Resident 32 upon admission and had not been used, and stated it should not have been stored in the med cart. The DON also stated the damaged bottle was not supposed to be in the med cart and should have been discarded according to facility policy. The facility also had an expired bottle of OTC calcium 600 mg tablets in a medication cart, with an opened date and an expiration date of 2026/05; LVN 1 stated it had expired the prior month and should not have been there. In addition, the central supply/OTC medication storage room was observed with the coded entry door wide open and the inner caged door unlocked while OTC medications and supplies were stored inside. Staff stated the doors were supposed to be locked when not attended, and the DON and HCC both stated the doors needed to remain locked because medications were stored there and residents could access them.
Failure to Use Required PPE During EBP Care
Penalty
Summary
The facility failed to follow infection prevention and control practices when CNA 3 and CNA 4 did not wear an isolation gown while providing ADL care to Resident 48, who had orders for Enhanced Barrier Precautions (EBP). Resident 48’s record showed a history of a chronic ulcer of the right foot with necrosis of bone, and physician orders directed staff to follow EBP for the right foot wound and right foot neuropathic ulcer. During observation, an EBP sign was posted at the head of Resident 48’s bed, and CNA 3 and CNA 4 were observed performing ADL care and transferring the resident from bed to wheelchair without wearing the required PPE gown. During interview, CNA 3 stated that staff are expected to wear PPE when providing care to residents on EBP and identified disposable gloves and a gown as proper PPE. RN 3 also stated that staff providing care to EBP residents are expected to wear disposable gowns and gloves. The facility policy titled Enhanced Barrier Precautions, revised February 10, 2026, listed high-contact resident care activities requiring gown and gloves, including dressing, bathing or showering, hygiene or grooming, transferring, changing briefs or assisting with toileting, bed mobility, device care or use, and prolonged high-contact contact with the resident’s room, equipment, clothing, or skin.
Inappropriate Antibiotic Use for Resident With No Clear Infection Symptoms
Penalty
Summary
The facility failed to ensure that one sampled resident was prescribed Azithromycin for cough and shortness of breath with an appropriate indication for use. Resident 77 was admitted with diagnoses including heart failure and acute respiratory failure with hypercapnia. The resident’s record showed Azithromycin was started for shortness of breath and wheezing, and the antibiotic time out noted no fever, no symptoms, and no further signs of infection. The record also showed the antibiotic order was reviewed with the physician and continued. The order summary listed Azithromycin 250 mg daily for pneumonia, and the MAR showed the resident received Azithromycin for 7 days. During interview and record review, the RN/IP and LVN/IP reviewed the Antibiotic Use Report and stated Resident 77 had no shortness of breath, no wheezing, and no symptoms of pneumonia, and that the symptoms did not meet infection control criteria for infection. The RN/IP stated the physician was informed of the lack of symptoms, and the physician ordered the antibiotic to continue because the chest x-ray showed opacity. The physician progress note documented cough, no shortness of breath or fever, and a chest x-ray showing right lung opacities with the resident on Azithromycin.
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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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
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| The Rehabilitation Center Of Oakland | 0.5 mi | ★★★★★ | 5 | 0 |
| Oakland Healthcare & Wellness Center | 0.7 mi | ★★★★★ | 12 | 0 |
| Lake Merritt Healthcare Center Llc | 0.8 mi | ★★★★★ | 6 | 0 |
| St Paul's Towers | 1.1 mi | ★★★★★ | 1 | 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 October 2026) and official state health department websites.