Below 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 The Rehabilitation Center Of Oakland during CMS and state inspections, most recent first.
A resident with depression and intact cognition reported that staff refused to complete an inventory of their personal items and later reported many belongings missing. Review of records showed the resident's Personal Effects Inventory Form was undated, unsigned, and incomplete, and the resident's belongings had not been fully inventoried. A Theft and Loss Report documented alleged loss of multiple boxes of clothing with a stated monetary value. The SW and RN supervisor acknowledged that the inventory should have been completed at admission and that the facility was responsible for safeguarding resident property, as required by facility policies on theft/loss and resident rights.
A resident with multiple chronic conditions was discharged without receiving an inventory of their personal belongings, and several items were reported missing. The responsible party had reported the missing items to Social Services, but there was no documentation in the Theft and Loss Log or in the discharge records. Staff confirmed that required procedures for inventorying and returning personal property at discharge were not followed, resulting in the resident's belongings not being properly accounted for.
A resident with impaired mobility and moderate cognitive impairment was left to navigate a ramp alone in her wheelchair while a CNA assisted another resident, resulting in the resident falling out of her wheelchair and sustaining a nasal fracture and contusion. The care plan required assistance and monitoring for mobility, but these were not followed, leading to the incident.
A resident with a history of aggressive behavior and cognitive impairment physically assaulted another resident with a bed power cord, causing significant injury and hospitalization. Despite documented risks and a behavior care plan, the facility failed to prevent the incident, and staff discovered the assault after hearing a shout from the shared room.
A resident with intact memory alleged physical abuse by a CNA, prompting a 911 call and police response. Despite the facility's policy requiring immediate removal of accused staff, the CNA continued to provide care to the resident and at least 18 others for 12 hours after the allegation. Staff interviews and records confirmed the CNA was not removed from resident care areas as required.
The facility failed to maintain safe and sanitary food storage and preparation practices, leading to Immediate Jeopardy. Fish was improperly thawed and stored at unsafe temperatures, and the kitchen was found to be unsanitary with dirty equipment and expired food items. Staff did not follow proper hygiene protocols, contributing to the risk of foodborne illness.
The facility failed to ensure kitchen staff were trained and evaluated for competency, leading to improper food safety practices. Fish fillets were thawed incorrectly and stored in a freezer at unsafe temperatures. The Dietary Manager and staff lacked knowledge of proper procedures, and competency evaluations were not conducted as required by facility policy.
The facility failed to assist residents with personal hygiene, leaving two residents with long facial hair and two others with overgrown, dirty fingernails. Despite policies emphasizing personal care, documentation was inadequate, and staff did not provide necessary assistance, leading to discomfort and potential infection risks.
The facility failed to ensure appropriate competencies for four CNAs and one LVN due to missing Orientation Evaluation Checklists and Annual Performance Evaluations. The DSD confirmed these evaluations were not conducted, and the DON highlighted their importance for assessing staff competency. The facility lacked a Policy and Procedure for these evaluations.
A facility failed to properly store and label medications, including unlabeled Tuberculin vials, improperly stored activase vials for a discharged resident, and expired Influenza vaccines. Expired medications for three residents were found in a medication cart, and two inhalers were undated. The DON and LVN acknowledged these lapses, which contravened the facility's policies on medication storage and labeling.
The facility failed to adhere to infection control practices, including improper handling of soiled linen by a CNA, inadequate hand hygiene by an LVN during medication administration, and unlabeled, floor-touching nasal cannula tubing for residents. These actions contravened the facility's policies, posing potential infection risks.
A resident was observed in an activity room wearing a facility gown and a disposable undergarment that was soaking wet with urine, causing liquid to drip onto the floor. This was noted during an interview with the AD, who confirmed that the resident's condition affected their dignity. Other residents were wearing personal clothes, highlighting the lack of respect and dignity afforded to this resident.
A resident with Acute and Chronic Respiratory Failure was observed using an oxygen concentrator without a Doctor's Order. The facility's policy requires oxygen to be administered per physician orders, which was not adhered to, as confirmed by the ADON.
A resident's call light was found on the floor, out of reach, leading to a delay in care. The resident, who required extensive assistance due to multiple health issues, was unable to request help. A CNA admitted to not checking the call light, and the DON confirmed the expectation for staff to ensure call lights are accessible.
The facility failed to ensure that staff members, including registry staff, wore identification (ID) badges while providing care to a resident with multiple diagnoses, including arthritis and anxiety disorder. This oversight led to the resident's emotional distress and anxiety, as they were unable to identify the staff members caring for them. Interviews and observations confirmed that several staff members were not wearing ID badges, despite the facility's policy requiring them.
Failure to Complete and Verify Resident Personal Effects Inventory
Penalty
Summary
The facility failed to honor a resident's right to retain personal possessions by not completing and verifying a detailed personal effects inventory at admission. The resident, who had a diagnosis of depression and an intact cognitive status as evidenced by a BIMS score of 14, reported that staff refused to complete an inventory of their items. The resident stated they were missing many items and felt upset, disrespected, and insulted. Review of the resident's admission record confirmed the admission occurred in 2024, and the resident's cognitive status was intact at the time of the deficiency. During review of the resident's Personal Effects Inventory Form and Theft and Loss Report with the social worker, it was found that the inventory form was undated, not signed, and not completed, and the resident's belongings had not been fully inventoried. The Theft and Loss Report documented an alleged loss of four boxes of clothes valued at $971.17, with the social worker indicating they were waiting for receipts from the resident to resolve the claim. The RN supervisor stated that the resident's personal items should have been inventoried and the inventory form completed at admission, readmission, or return from the hospital, and acknowledged the facility's responsibility to safeguard residents' belongings. Facility policies on Theft and Loss and Resident Rights required completion and updating of inventory lists and affirmed residents' rights to retain and use personal possessions.
Failure to Account for and Protect Resident's Personal Belongings at Discharge
Penalty
Summary
The facility failed to protect and account for the personal belongings of a resident who was admitted with multiple diagnoses, including diabetes, hypertension, and end-stage kidney disease on dialysis. Upon discharge, the resident and their responsible party reported missing personal items, which had been previously reported to the Social Services Director during the resident's stay. There was no inventory of the resident's personal items provided to the resident or family at discharge, and the facility's Theft and Loss Log did not contain any record of the missing items. The Medical Records Director was able to provide an inventory list from admission, but not from discharge, and an additional inventory form was found to be incomplete, lacking a date and signature. Interviews with facility staff, including the current Social Services Director and the Director of Nursing, confirmed that there was no documented inventory of the resident's belongings at discharge, and no information about the inventory was included in the discharge summary. Facility policy required that all personal belongings be accounted for and documented upon discharge, with the resident or representative signing the inventory form. The failure to follow these procedures resulted in the resident's personal items not being properly tracked or returned, compromising the resident's right to retain their possessions.
Resident Fall Due to Inadequate Wheelchair Assistance on Ramp
Penalty
Summary
A deficiency occurred when a resident with impaired physical mobility and moderate cognitive impairment was not adequately assisted while using a wheelchair to access the facility's smoking patio. The resident, who had a history of falls and was at high risk for further incidents, was being escorted to the smoking area by a CNA. The ramp leading to the patio had uneven boards and cracks, and although it was equipped with nonskid straps, the first two boards created a divot that could pose a hazard. On the day of the incident, the CNA attempted to assist two wheelchair-bound residents simultaneously, pushing one while the other, who believed she was being assisted, was left to navigate the ramp alone. The resident lost control of her wheelchair, went down the ramp too quickly, and fell out, sustaining a nasal contusion and a closed fracture of the nasal bone. The resident expressed embarrassment and required emergency medical attention for her injuries. Interviews with staff confirmed that it was not safe for one staff member to push two wheelchairs at once, as both hands are needed to safely assist a single resident. The care plan for the resident indicated a need for assistance with mobility and monitoring for environmental barriers, but these measures were not effectively implemented at the time of the incident, directly leading to the resident's fall and injury.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
A resident with vascular dementia and moderate cognitive impairment was physically abused by another resident who had a known history of aggressive behavior. The aggressor, who was cognitively intact but had diagnoses of dementia, psychosis, and anxiety, struck the victim with a bed power cord, resulting in a bleeding facial and scalp wound that required hospitalization. The incident occurred in a shared room, and staff responded after hearing a shout and found the aggressor swinging the cord and the victim bleeding heavily. Prior documentation indicated that the aggressor had a behavior care plan noting a potential for physical aggression and a history of conflicts with previous roommates, including threats of violence. Despite these known risks, the two residents were placed together, and the facility failed to prevent the incident. The facility's abuse prevention policy prohibits all forms of abuse and requires systems to promote an environment free from abuse, but these measures were not effectively implemented in this case.
Failure to Remove CNA from Resident Care After Abuse Allegation
Penalty
Summary
The facility failed to ensure that a Certified Nursing Assistant (CNA) was immediately removed from resident care duties after an allegation of physical abuse was made by a resident. The resident, who had intact short-term memory and was admitted in April 2022, called 911 and reported being physically hurt by the CNA. Paramedics and police responded to the incident, and the resident specifically alleged that the CNA had kicked him. Despite this, facility records and interviews confirmed that the CNA continued to work both the evening and night shifts, providing care to the resident who made the allegation as well as at least 18 other residents for approximately 12 hours after the incident was reported. Interviews with facility staff, including the Director of Nursing (DON) and Licensed Vocational Nurse (LVN), revealed a lack of clarity and communication regarding the removal of the CNA from resident care areas. The DON was under the impression that the CNA had been sent home, but sign-in records showed otherwise. The CNA himself stated that he was not informed by facility staff about the abuse allegation and continued his assigned duties. Facility policy required immediate removal and suspension of any employee accused of abuse pending investigation, but this protocol was not followed in this case.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to store, prepare, and distribute food in a safe and sanitary manner, leading to a situation of Immediate Jeopardy. Fish intended for lunch was improperly thawed and stored in a freezer with a temperature of 30 degrees Fahrenheit, which is above the safe storage temperature of 0 degrees Fahrenheit. This improper storage and thawing of fish posed a risk of bacterial growth and foodborne illness. The surveyors identified this issue during an observation and interview with the Dietary Manager, who acknowledged the improper practices. Additionally, the facility's kitchen and food storage areas were found to be unsanitary and not in compliance with professional standards. The three-compartment sink, meant for cleaning and sanitizing utensils, was used for food preparation. Equipment such as the industrial can opener and blender were dirty, and the reach-in freezer contained food items that were not frozen solid. Moldy and unusable foods were not discarded, and multiple refrigerated items were stored beyond their use-by dates. These conditions were observed during interviews and inspections with the Dietary Manager and other staff members. Furthermore, staff members did not adhere to proper hygiene practices. The Activity Director and other staff did not wear hair coverings or wash their hands upon entering the kitchen. A scoop was improperly stored inside a powdered thickener container, and the garbage disposal and bin were found to be dirty and malodorous. These lapses in hygiene and sanitation were noted during observations and interviews with the facility's staff, highlighting a systemic issue in maintaining a safe and sanitary food service environment.
Deficiencies in Kitchen Staff Training and Food Safety Practices
Penalty
Summary
The facility failed to ensure that kitchen staff were routinely trained and evaluated for competency skills, leading to several deficiencies in food safety practices. During an interview, the Dietary Manager (DM) and a cook (CK 1) revealed that fish fillets were improperly thawed in a sink and were intended to be served for lunch. The fish was taken from a freezer with a temperature reading of 30 degrees Fahrenheit, which is above the safe storage temperature of zero degrees Fahrenheit. The Registered Dietician (RD 1) confirmed that the fish was not safe to serve due to the risk of bacterial growth. Further observations and interviews highlighted that the DM and kitchen staff lacked knowledge of proper food safety procedures. The DM was unable to state appropriate thawing procedures or the importance of maintaining the freezer at the correct temperature. Additionally, CK 1 admitted to not thawing fish under running water, which is a recommended practice to prevent bacterial growth. The RD 1 emphasized that the fish prepared for lunch was unsafe, and produce with freezer burns should not be used. The report also revealed that there was a lack of competency evaluations for the dietary staff. CK 1 stated she had not been evaluated since the current DM's employment, and the DM admitted to not conducting competency checks for the staff. The facility's policy required competency assessments upon hire, annually, and as needed, but these were not being performed. The Dietary Quality Control Review indicated that staff and DM competencies were not met, highlighting a systemic issue in ensuring food safety and staff competency in the facility.
Deficiency in Personal Hygiene Assistance
Penalty
Summary
The facility failed to assist four out of eight sampled residents with personal hygiene, specifically in shaving facial hair and maintaining clean and trimmed fingernails. Resident 30 and Resident 46 were observed with long facial hair, which they expressed discomfort about, stating that staff did not offer assistance with shaving. The facility's documentation system for recording shaving assistance was found to be inadequate, with missing records and unclear procedures for documenting such care. Resident 48 and Resident 52 were found with overgrown and dirty fingernails, which posed a risk of infection, especially for Resident 48, who had undergone surgery and required substantial assistance with personal hygiene. Despite being cognitively intact, Resident 48 reported discomfort and lack of assistance from staff in maintaining nail hygiene. Staff members acknowledged the issue but indicated a lack of directive to include nail care in their routine assistance. The facility's policies on resident rights and grooming emphasize the importance of personal care and hygiene, yet the implementation was lacking. The Director of Nursing confirmed the absence of documentation for nail care and acknowledged the expectation for staff to maintain residents' nail hygiene. The failure to adhere to these policies resulted in residents feeling unkempt and at risk for infections due to inadequate personal hygiene care.
Lack of Competency Evaluations for Nursing Staff
Penalty
Summary
The facility failed to ensure that four Certified Nursing Assistants (CNAs) and one Licensed Vocational Nurse (LVN) had the appropriate competencies to care for residents. This was due to the absence of completed Orientation Evaluation Checklists for LVN 1 and CNA 3, and the lack of Annual Performance Evaluations for CNAs 1, 2, and 4. The Director of Staffing Development (DSD) confirmed during interviews and record reviews that these evaluations were not conducted as required. The DSD acknowledged that these evaluations are crucial for assessing the competency of the staff and identifying areas where training is needed. The Director of Nursing (DON) further stated that the DSD was responsible for completing the Annual Performance Evaluations annually from the date of hire and more frequently if there were resident concerns. The DON emphasized the importance of these evaluations in verifying the competency of CNAs and LVNs before they begin working on the floor. However, it was revealed that the facility did not have a Policy and Procedure in place for conducting Annual Performance Evaluations or Orientation Evaluation Checklists, which contributed to the oversight.
Improper Storage and Labeling of Medications in LTC Facility
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications and biologicals, as observed in the medication room and on medication carts. Three opened vials of Tuberculin Purified Protein Derivative (PPD) were found unlabeled and undated, lacking an open date, which is crucial as the vials expire 30 days after opening. The Director of Nursing (DON) acknowledged that the nurse responsible should have labeled the vials with the open date. Additionally, two activase vials for a discharged resident were improperly stored in the refrigerator, and the DON confirmed that these should have been placed in the medication destruction container, as per the facility's policy. Further observations revealed thirteen expired Influenza vaccine vials stored in the refrigerator, which should have been moved to the medication destruction container. The facility's policy mandates that expired medications be stored separately and destroyed. Moreover, expired medications for three active residents were found in the medication cart, including Sertraline, Metformin, and Humulin R insulin, with the latter being uncapped and past its 31-day usage period. The Licensed Vocational Nurse (LVN) stated that the medication cart is checked monthly for expired medications, but these were overlooked. Lastly, two opened inhalers for a resident were found undated and unlabeled with an open date. The facility's policy requires medications to be stored following the manufacturer's recommendations, which include discarding the inhaler six weeks after opening or when the counter reads zero. The LVN confirmed the absence of an open date on the inhalers, indicating a lapse in adherence to proper medication storage protocols.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain proper infection control practices in several instances. A Certified Nursing Assistant (CNA) was observed picking up soiled linen from the floor in a resident's room and disposing of it in a cart without using a plastic bag, contrary to the facility's policy. This action could potentially lead to the spread of infection as the soiled linen was not contained during transport. A Licensed Vocational Nurse (LVN) did not perform hand hygiene or change gloves before administering eye drops to a resident. The LVN used the same gloves to touch the resident's surroundings and then proceeded to administer the medication, which is against the facility's policy that requires hand hygiene before and after administering eye drops. Additionally, the LVN did not remove gloves after applying topical medication to another resident, which is also a breach of the facility's guidelines. Furthermore, the nasal cannula tubing for three residents was found to be undated, unlabeled, and touching the floor. This oversight poses an infection control issue as the tubing should be labeled with the date of change and should not be in contact with the floor. The facility's policy mandates that oxygen tubing be changed and labeled every seven days to ensure sanitary conditions.
Resident Dignity Compromised Due to Inadequate Care
Penalty
Summary
The facility failed to ensure that a resident was treated with dignity and respect, as observed during an activity session. The resident was found sitting in a wheelchair wearing a facility gown, with a disposable undergarment that was soaking wet with urine, causing liquid to drip onto the floor. This was in contrast to other residents in the room who were wearing personal clothes. During an interview with the Activity Director, it was confirmed that the resident's condition affected their dignity. The facility's policy on Resident Rights, dated 1/1/12, mandates that employees treat all residents with kindness, respect, and dignity, which was not adhered to in this instance.
Failure to Obtain Doctor's Order for Oxygen Therapy
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 11, had a Doctor's Order for supplemental oxygen before receiving it. Resident 11 was admitted with multiple diagnoses, including Acute and Chronic Respiratory Failure with Hypoxia. During an observation, Resident 11 was seen using an oxygen concentrator at a rate of 2 liters via nasal cannula without a prior Doctor's Order. Upon review of Resident 11's records, it was confirmed that there was no Doctor's Order for the oxygen concentrator until a later date. The Assistant Director of Nursing confirmed that residents require a Doctor's Order for oxygen to prevent potential harm. The facility's policy on oxygen therapy mandates that oxygen be administered per physician orders, which was not followed in this instance.
Failure to Ensure Call Light Accessibility
Penalty
Summary
The facility failed to ensure that the call light was within reach for Resident 56, leading to a delay in care and services. During an observation, the call light was found on the floor behind the resident's bed, and the resident's urinary collection bag was full and heavy. The resident, who had intact cognitive status and required extensive assistance due to multiple diagnoses including muscle weakness and polyneuropathy, stated that they could not ask for help because the call light was not within reach. This situation was confirmed by a Certified Nursing Assistant (CNA) who admitted to not checking the call light upon arrival. The Director of Nursing (DON) acknowledged that the nursing staff is expected to ensure that call lights are within reach, especially for residents like Resident 56 who require extensive assistance. The resident's care plan highlighted the importance of having the call light within reach and responding promptly to requests for assistance. The facility's policy on the communication-call system also mandates that call cords be placed within the resident's reach to enable prompt communication with nursing staff.
Failure to Ensure Staff Wore Identification Badges
Penalty
Summary
The facility failed to ensure that staff members, including registry staff, wore identification (ID) badges while providing care to residents. This deficiency was observed in the case of a resident who had multiple diagnoses, including arthritis and anxiety disorder, and had a perfect score on the Brief Interview for Mental Status (BIMS), indicating full cognitive function. The resident and their responsible party reported issues with staff not identifying themselves, which contributed to the resident's emotional distress and anxiety. During interviews and observations, it was confirmed that several staff members, including registry staff, were not wearing ID badges, and the facility had previously received deficiencies related to this issue. The facility's administrator and scheduling staff acknowledged the importance of wearing ID badges for resident identification and confirmed that all staff, including registry staff, were supposed to wear them. Despite this, registry staff were not provided with ID badges, and this oversight led to the resident's inability to identify the staff members caring for them. The facility schedule confirmed the assignment of registry staff to the resident, further highlighting the failure to ensure proper identification of caregivers.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 1,073 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — 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 Oakland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Oakland Healthcare & Wellness Center | 0.5 mi | ★★★★★ | 12 | 0 |
| Piedmont Gardens Health Facility | 0.5 mi | ★★★★★ | 0 | 0 |
| Mcclure Post Acute | 0.8 mi | ★★★★★ | 16 | 0 |
| Medical Hill Healthcare Center | 0.8 mi | ★★★★★ | 6 | 0 |
| Lake Merritt Healthcare Center Llc | 1 mi | ★★★★★ | 8 | 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.