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 San Leandro Healthcare Center during CMS and state inspections, most recent first.
A resident with MDD, PTSD, and intact cognition was involved in a loud verbal altercation with a CNA after asking for help unlocking a bathroom door. An LVN separated them after hearing the argument, and the resident later felt threatened and was unable to sleep through the night. The facility’s dignity policy requires staff to always speak respectfully to residents.
A resident with cognitive communication deficit, age-related cognitive decline, and epilepsy was not afforded participation in the person-centered care planning process when a requested care conference was not scheduled. The resident’s representative and the LTCO repeatedly sought a meeting, but after an initial postponement due to hospitalization, no rescheduled conference was confirmed or documented before the resident returned to the hospital, despite the facility policy stating residents and their representatives may request meetings and should receive advance notice.
The facility failed to ensure that residents understood the binding arbitration agreements they signed, as well as their right to rescind these agreements within 30 days. Three residents with intact cognitive status had arbitration agreements with unchecked sections meant to confirm their understanding and receipt of the agreements. Interviews revealed that the residents did not recall having the agreements explained to them, and a staff member admitted to being unfamiliar with the process.
The facility's arbitration agreements for three residents failed to meet regulatory standards by not including provisions for selecting a neutral arbitrator or a convenient venue. The Administrator confirmed these omissions, which could lead to residents not understanding their rights.
The facility failed to provide a clean and comfortable environment for four residents in two rooms. A shared bathroom was observed with a towel on the floor and a dirty toilet seat with brown particles. The Social Worker confirmed these findings, acknowledging the need for cleanliness to prevent infection. This was contrary to the facility's policy on maintaining a homelike environment.
A facility failed to complete and transmit the Discharge MDS for a resident discharged over 120 days ago. The resident was discharged in July, but the required MDS was not completed or sent to CMS by November. This resulted in the resident being inaccurately listed as active in the facility's records.
A resident's Admission MDS was inaccurately coded with active diagnoses of Pneumonia and Septicemia, despite no evidence of these conditions. Observations and staff interviews confirmed the resident showed no symptoms or treatments for these infections, and the MDS Coordinator found no supporting documentation in the clinical records.
A facility failed to implement a comprehensive ADL care plan for a resident with multiple health issues, including paraplegia and respiratory failure. The resident, dependent on staff for personal hygiene, did not receive timely care due to staff refusal to assist, stemming from the resident's history of verbal aggression. The facility's policies on ADLs and abuse prevention were not effectively followed, leading to inappropriate staff assignments and lack of care.
A facility failed to provide adequate ADL care for a resident with Cerebral Palsy, who was observed with long, broken fingernails and black particles under the nails. A CNA confirmed the condition and stated that licensed nurses did not request nail trimming. An LVN was unaware of the issue but acknowledged the importance of nail care for infection prevention. The facility's policy requires daily cleaning and regular trimming of nails.
A resident with hemiplegia used a hot water bag to keep warm, with assistance from multiple CNAs who did not ensure appropriate water temperature or communicate its use to the charge nurse. The LVN and DON were unaware of any orders for the hot water bag, which posed a risk for burns, contrary to the facility's safety policy.
The facility failed to properly reconcile and dispose of controlled drugs, as observed with oxycodone and MS Contin blister packs that were popped and taped shut without proper documentation or destruction. The facility's policy requiring dual nurse verification and timely disposal of discontinued medications was not followed.
The facility had 18 rooms with multiple beds that did not meet the required 80 square feet per resident, providing only 70 to 73 square feet per bed. Despite this, observations showed adequate space for care provision, and no resident complaints or safety concerns were reported.
Failure to Maintain Resident Dignity During Verbal Altercation
Penalty
Summary
The facility failed to ensure Resident 1 was treated with respect and dignity when CNA 1 loudly argued with the resident. Resident 1 was admitted in August 2025 with diagnoses including major depressive disorder and post-traumatic stress disorder, and the MDS assessment showed a BIMS score of 15, indicating intact cognitive status. During the incident, Resident 1 requested that CNA 1 unlock the bathroom door, but CNA 1 did not assist, and the interaction escalated into a verbal altercation. Licensed Vocational Nurse 1 reported hearing loud arguing around midnight and separated Resident 1 and CNA 1. LVN 1 stated that both became somewhat aggressive and heard CNA 1 tell Resident 1 to go to his room and return to sleep in a loud manner. The resident calmed down after being separated. The IDT note documented that Resident 1 felt threatened and was unable to sleep through the night. The facility's dignity policy stated that residents are to be cared for in a manner that promotes self-worth, self-esteem, and well-being, and that staff are required to always speak respectfully to residents.
Failure to Schedule Requested Care Plan Meeting
Penalty
Summary
The facility failed to ensure Resident 2 was afforded the right to participate in the care planning process when a care conference meeting was not scheduled despite repeated requests from the resident’s representative. Resident 2 was admitted in March 2025 with diagnoses including cognitive communication deficit, age-related cognitive decline, and epilepsy, and Resident Representative 1 was responsible for care. During review of the social service notes, the Social Worker stated that Long Term Care Ombudsman 1 requested a care plan meeting with Resident Representative 1 and Resident 2 by email, and the meeting was initially set for 10/28/25 but was postponed because Resident 2 was hospitalized from [DATE] to 10/30/25. After Resident 2 returned to the facility on [DATE], Resident Representative 1 informed the Social Worker on 11/1/25 that the resident had returned, but no confirmation or discussion occurred about rescheduling the care plan meeting. Resident 2 remained in the facility from 10/30/25 until being taken to the hospital again on 11/12/25 without a care plan meeting being held, and there was no documentation in the clinical record of coordination to set up the meeting. The Long Term Care Ombudsman stated that follow-up emails were sent asking about the meeting, and on 11/17/25 Resident Representative 1 reported that no meeting had been scheduled. The facility policy stated that residents and their legal representatives are encouraged to attend and participate in the development of the person-centered care plan and have the right to request meetings, with sufficient advance notice provided.
Failure to Ensure Residents Understand Arbitration Agreements
Penalty
Summary
The facility failed to ensure that residents understood the binding arbitration agreements they were entering into, as well as their right to rescind these agreements within 30 days. This deficiency was identified for three residents, all of whom had intact cognitive status as indicated by their BIMS scores of 15. The arbitration agreements for these residents had sections that were supposed to be checked to confirm that the residents had reviewed the voluntary arbitration program guide, received a copy of the agreement, and were aware of their right to rescind the agreement. However, these sections were left blank, indicating that these steps were not completed. Interviews with the residents revealed that they did not recall having the arbitration agreements explained to them, and they were not aware of their right to rescind the agreements. Additionally, a Patient Care Coordinator admitted to not being familiar with the arbitration agreement process and was unsure if residents could rescind the agreement after signing. The facility administrator acknowledged that the boxes on the agreements should have been checked to verify that the residents received and reviewed the documents, and the failure to do so could result in residents not understanding their rights.
Deficient Arbitration Agreement Lacks Neutrality and Convenience
Penalty
Summary
The facility failed to provide a binding arbitration agreement that met regulatory requirements, potentially compromising residents' rights. During a review of arbitration agreements for three randomly selected residents, it was found that the agreements did not include provisions for selecting a neutral arbitrator agreed upon by both parties or for choosing a venue convenient to both parties. In a concurrent interview and record review, the Administrator acknowledged that the agreements lacked these sections, posing a risk that residents might not fully understand their rights.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and comfortable homelike environment for four residents residing in two of the 25 rooms. During an observation and interview with the Social Worker, it was noted that the shared bathroom between two rooms had a towel on the floor and the toilet seat was dirty with brown particles. The Social Worker confirmed these observations and acknowledged that the bathroom should always be kept clean to prevent the risk of infection. The facility's policy and procedure on maintaining a homelike environment, revised in February 2021, emphasizes the importance of a clean, sanitary, and orderly environment, which was not adhered to in this instance.
Failure to Transmit Discharge MDS for a Discharged Resident
Penalty
Summary
The facility failed to complete and transmit the Discharge Minimum Data Set (MDS) for a resident who was discharged over 120 days ago. The resident, admitted in June 2024, was discharged on July 12, 2024, but the required Discharge MDS was neither completed nor transmitted to the Centers for Medicare and Medicaid Services (CMS) as of November 6, 2024. According to the CMS Resident Assessment Instrument (RAI) Version 3.0 User Manual, the discharge MDS should be completed within 14 calendar days of discharge and transmitted within 14 days following the completion date. This oversight resulted in the resident being inaccurately reflected as an active resident in the facility's records.
Inaccurate MDS Coding for Resident Diagnoses
Penalty
Summary
The facility failed to accurately assess and code the active diagnoses for a resident in the Admission Minimum Data Set (MDS) assessment. Specifically, the resident's admission MDS was incorrectly coded to indicate active diagnoses of Pneumonia and Septicemia during the look-back period, despite the resident not having these conditions. This error resulted in an outdated and inaccurate reflection of the resident's medical and clinical status. Observations and interviews with the resident and facility staff revealed no signs or symptoms of Pneumonia or Septicemia. The resident was able to communicate effectively, showed no respiratory distress, and was not on antibiotics for any infection. Both the Certified Nursing Assistant and the Licensed Vocational Nurse confirmed the absence of any infection-related symptoms or treatments. The MDS Coordinator also found no documentation supporting the active diagnoses in the resident's clinical records, highlighting the importance of accurate MDS assessments for developing appropriate care plans.
Failure to Implement Comprehensive ADL Care Plan
Penalty
Summary
The facility failed to implement a comprehensive-centered ADL plan of care for a resident, identified as Resident 17, who was admitted with multiple diagnoses including morbid obesity, acute and chronic respiratory failure, chronic pain syndrome, paraplegia, and knee pain. The resident was totally dependent on staff for toileting hygiene and lower body dressing, as indicated in the Minimum Data Set (MDS) assessment. Despite having a care plan that required staff assistance for personal hygiene and other ADLs, the facility did not ensure the provision of care due to staff refusal to attend to the resident. This refusal was partly due to the resident's history of verbal aggression and racial insults towards staff, which led to a CNA refusing to enter the resident's room and switching assignments without management's knowledge. The Director of Nursing (DON) and other staff interviews revealed that the assigned CNA refused to assist the resident due to previous incidents of verbal aggression. The facility's policy and procedure for ADLs and abuse prevention were not effectively implemented, as evidenced by the lack of adequate staffing and oversight to prevent burnout and stressful working situations. The Patient Care Coordinator was unaware of the issues between the CNA and the resident, leading to inappropriate staff assignments. This lack of communication and oversight resulted in the resident not receiving timely personal hygiene care, as the staff failed to follow the care plan that required them to attend to the resident in pairs.
Failure to Provide Adequate Nail Care for Resident
Penalty
Summary
The facility failed to provide adequate Activities of Daily Living (ADL) care for Resident 157, who was observed with long, broken fingernails and black particles under the nails. Resident 157 was admitted with multiple diseases, including Cerebral Palsy, which affects movement, balance, and posture. During an observation, the resident's nails were noted to be in poor condition, which was confirmed by CNA 2, who stated that the licensed nurses did not request nail trimming. LVN 1 was unaware of the resident's nail condition and acknowledged the importance of maintaining short and clean nails to prevent infection and skin injury. The facility's policy on nail care, revised in February 2018, requires daily cleaning and regular trimming of nails.
Inadequate Supervision of Hot Water Bag Use
Penalty
Summary
The facility failed to safely administer and provide adequate supervision to a resident using a hot water bag, which placed the resident at risk for skin burns. The resident, who had an intact mental status and a diagnosis of hemiplegia, used the hot water bag to keep warm in her cold room. Multiple Certified Nursing Assistants (CNAs) were involved in filling the hot water bag with hot water, but none of them ensured the water temperature was appropriate or communicated the use of the hot water bag to the resident's charge nurse. The CNAs also did not supervise the resident while she used the hot water bag. The Licensed Vocational Nurse (LVN) and the Director of Nursing (DON) were unaware of any physician orders or progress notes regarding the use of the hot water bag. The DON stated that hot water bags should not be used in the facility due to the risk of burn injuries. The facility's policy and procedure emphasized the importance of making the environment free from accident hazards and ensuring resident safety and supervision, which was not adhered to in this case.
Failure in Controlled Drug Reconciliation and Disposal
Penalty
Summary
The facility failed to establish a proper system for the disposition of controlled drugs, leading to inaccurate reconciliation of medications. During an observation and interview, it was found that a blister pack of oxycodone hydrochloride, a controlled pain medication, had two blisters that were popped and taped shut without the required signatures from two licensed nurses. The Controlled Drug Record-Individual Patient's Narcotic Record (CDR-IPNR) for oxycodone showed discrepancies, with one blister lacking any signature and another having a crossed-out entry with only one signature. This indicates a failure to adhere to the facility's policy requiring dual nurse verification for popped medications. Additionally, a blister pack of MS Contin, another controlled pain medication, was found in the narcotic file cabinet with a popped and taped blister. The Director of Nursing acknowledged that the medication was for a discharged resident and should have been destroyed and signed off by two licensed nurses, rather than being returned to the blister pack. The facility's policy mandates the disposal of controlled substances within three days of discontinuation, but this was not followed. Furthermore, the facility could not provide a policy addressing the handling of popped blister packs during the survey.
Deficiency in Room Size Requirements
Penalty
Summary
The facility was found to have 18 rooms with multiple beds that did not meet the required minimum of 80 square feet per resident. The rooms in question provided between 70 and 73 square feet per bed, which is below the regulatory standard. This deficiency was identified through observation and interviews conducted with the facility's Administrator. Despite the inadequate square footage, it was observed that there was sufficient space for residents and staff to move about without obstruction, and residents had adequate personal space and privacy. During the survey, it was noted that residents were able to ambulate in their rooms without difficulty, and there were no complaints from residents 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. The surveyors recommended granting a waiver due to the observed adequacy of space for care provision and the lack of resident complaints or adverse effects.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 760 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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) |
|---|---|---|---|---|
| Bancroft Healthcare Center | 0.1 mi | ★★★★★ | 0 | 0 |
| Jones Convalescent Hospital | 0.2 mi | ★★★★★ | 0 | 0 |
| Washington Center | 1.8 mi | ★★★★★ | 0 | 0 |
| Alameda County Medical Center D/p Snf | 2 mi | ★★★★★ | 0 | 0 |
| All Saint's Subacute & Transitional Care | 2.1 mi | ★★★★★ | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for San Leandro Healthcare Center.
100% money-back within 48 hours.
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.