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 St Paul's Towers during CMS and state inspections, most recent first.
A facility failed to meet food safety standards, with unclean equipment, improperly labeled food, and unsanitary practices. Observations revealed black residue on kitchen tools, missing or expired use-by dates on food, a leaking sink pipe, and improper storage of dishwashing gloves, posing contamination risks.
The facility failed to properly dispose of garbage and refuse, as dumpsters were found uncovered and a laundry bin was used as a garbage receptacle. This was confirmed by the Environmental Services Manager and Registered Dietician, who acknowledged the need for covered dumpsters to prevent pest infestation. The facility's policy and the 2022 Federal Food Code require garbage containers to have tight-fitting lids.
A nurse in an LTC facility left an Oxycontin tablet unattended on a medication cart while assessing a resident's pain level. The resident, with conditions like intervertebral disc disorder and scoliosis, was prescribed Oxycontin for severe pain. The nurse later combined the tablet with other medications before administration. Both the nurse and the DON acknowledged this was against facility policy, which mandates secure handling of controlled substances.
A resident's PRN order for Oxycodone-Acetaminophen lacked clear guidelines for administering one versus two tablets, leading to potential unnecessary dosing. Despite a Consultant Pharmacist's recommendation for clarity, the order remained unchanged, posing a risk of adverse effects. The facility's policy required clear indications for medication use, which were not followed.
A resident was prescribed Temazepam on a PRN basis for insomnia without an end date or rationale for continued use beyond 14 days, contrary to regulations. Despite recommendations from the Consultant Pharmacist to include a stop date, the facility continued the medication following the medical doctor's order, who did not consider Temazepam a psychotropic drug. This oversight placed the resident at risk for unnecessary prolonged use of the medication.
Food Safety and Sanitation Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to professional standards for food safety, as evidenced by several observations during a kitchen inspection. A braising pan, rolling pin, storage bins, citrus juicer, kitchen drawer, and juice dispenser machine were found with black particles, residue, or chipped paint, indicating inadequate cleaning and maintenance. The Dietary Manager (DM) acknowledged the presence of dirt and residue, and there was no documentation of cleaning for the juice machine, which is a violation of the 2022 Federal Food Code requiring food-contact surfaces to be clean to sight and touch. Additionally, the facility did not properly label or manage food items in the refrigerators. Nine containers of balsamic dressing, cut lettuce, cut tomatoes, mayonnaise, a bag of bread, mozzarella cheese, burrata cheese, and a bag of prosciutto were either missing use-by dates or were beyond their use-by dates. The DM confirmed that all opened food should have use-by dates and should not be kept past these dates. The Registered Dietician (RD) expressed concern about the risk of salmonella from improperly dated cheeses and prosciutto, as well as the risk of contamination from the unclean juice dispenser. The facility also had issues with the three-compartment sink, which had a leaking pipe and a toilet plunger stored underneath, posing a risk of cross-contamination. The DM admitted the plunger should not be stored in the kitchen. Furthermore, dishwashing gloves were improperly stored on top of the wastewater tank and reused without proper sanitation, which the DM acknowledged as a bad habit of the kitchen staff. These practices violate the 2022 Federal Food Code, which requires multiuse gloves to be washed, rinsed, and sanitized between uses.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to properly dispose of garbage and refuse, as observed during a survey. Three dumpsters located by the side of the facility were found to be full of trash bags and were not closed or covered. Additionally, a laundry bin, which was designated for the use of residents' soiled laundry, was improperly used as a garbage receptacle. This improper disposal of waste was confirmed during interviews with the Environmental Services Manager (ESM) and the Registered Dietician (RD), both of whom acknowledged that the dumpsters should be covered to prevent pest and rodent infestation. The facility's policy and procedure, revised in August 2022, also indicated that garbage containers should be maintained in good condition with lids or covers to prevent harboring and feeding of pests. Furthermore, the 2022 Federal Food Code requires that receptacles and waste handling units for refuse used outside the food establishment should have tight-fitting lids, doors, or covers.
Unattended Oxycontin Tablet on Medication Cart
Penalty
Summary
The facility failed to maintain professional standards during medication administration for a resident when a licensed nurse left an Oxycontin tablet unattended on top of the medication cart. The resident had multiple diagnoses, including intervertebral disc disorder and scoliosis, and was prescribed Oxycontin for severe pain. During a medication pass, the nurse prepared the Oxycontin tablet and placed it on the cart, leaving it unattended while entering the resident's room to assess pain levels. The nurse later returned to the cart, prepared additional medications, and combined them with the Oxycontin tablet before administering them to the resident. The nurse acknowledged the mistake, stating that the medication should have been stored securely or taken into the room. The Director of Nursing confirmed that leaving medications unattended was against the facility's standards. The facility's policy required controlled substances to be handled with special care and medication carts to be locked when out of sight.
Failure to Provide Clear PRN Medication Guidelines
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs. Specifically, the issue involved a resident who had a PRN order for Oxycodone-Acetaminophen, a controlled substance used for pain relief, without clear indications for when to administer one tablet versus two tablets. This lack of clarity in the medication order was identified during a review of the resident's Medication Administration Record (MAR) for the months of August and September. The Consultant Pharmacist (CP) had noted in a Medication Regimen Review (MRR) that the nursing staff should have clear guidelines for administering the medication, but this recommendation was not followed. During interviews, a Registered Nurse (RN) acknowledged that the PRN order was not corrected according to the CP's recommendation, which could have led to the resident receiving an unnecessary dose of the medication. The CP confirmed that the order was confusing for the licensed nurses and posed a risk of unnecessary dosing, which could result in adverse effects such as sedation. The facility's Policy and Procedures on Medication Therapy, revised in June 2023, emphasized the need for each resident's medication regimen to be free from unnecessary drugs and required clear indications for medication use, which were not adhered to in this case.
Failure to Ensure Appropriate Use of Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic drugs, specifically Temazepam, which was prescribed on a PRN basis for insomnia without an end date or rationale for continued use beyond 14 days. The resident's Order Summary Report indicated an active order for Temazepam with no specified end date, and the Consultant Pharmacist's Medication Regiment Review recommended twice that a stop date be included, as per regulations. Despite these recommendations, the facility continued the use of Temazepam without a stop date, following the medical doctor's order. The Director of Nursing acknowledged the lack of documentation from the medical doctor justifying the continued use of Temazepam without a stop date. The medical doctor stated that he did not consider Temazepam a psychotropic drug, which led to the oversight. The facility's policy and procedures indicated that psychotropic drugs, including hypnotics like Temazepam, should not be used for excessive duration without evidence of therapeutic benefit or clinical evidence warranting continued use. This oversight placed the resident at risk for unnecessary prolonged use of a psychotropic medication.
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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) |
|---|---|---|---|---|
| Lake Park Healthcare Center | 0.4 mi | ★★★★★ | 3 | 0 |
| Oakland Healthcare & Wellness Center | 0.5 mi | ★★★★★ | 12 | 0 |
| Lake Merritt Healthcare Center Llc | 0.6 mi | ★★★★★ | 8 | 0 |
| Medical Hill Healthcare Center | 0.7 mi | ★★★★★ | 6 | 0 |
| Mcclure Post Acute | 0.7 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.