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 Washington Center during CMS and state inspections, most recent first.
The facility failed to lock medication carts when not in view, risking unauthorized access. Observations showed nurses leaving carts unlocked in hallways, containing medications like Lasix and Eliquis. Staff interviews confirmed the carts should be locked when unattended. The DON and Administrator emphasized the importance of securing carts, aligning with facility policy.
The facility failed to ensure accurate MDS assessments for three residents, leading to potential inaccuracies in care plans. One resident was incorrectly coded as receiving anticoagulant medication, while two others had behaviors not reflected in their MDS. Interviews confirmed these discrepancies, and the facility's policy emphasized the need for accurate assessments.
A facility failed to implement enhanced barrier precautions (EBP) for a resident with a gastrostomy tube, risking infection spread. Despite the care plan and orders requiring gown and gloves during high-contact activities, an RN administered medication with only gloves. Interviews with the DON and Administrator confirmed the need for gowns per facility policy for residents at high risk, including those with indwelling devices.
Failure to Secure Medication Carts
Penalty
Summary
The facility failed to ensure that medication carts were locked when not in the direct view of nursing staff, leading to potential unauthorized access to medications. During observations, a registered nurse left a medication cart labeled Lower 200 unlocked and unattended in the hallway while administering medication to a resident. The cart contained medications such as Lasix, Eliquis, and nitroglycerin. Interviews with various nursing staff, including registered nurses and licensed vocational nurses, confirmed that medication carts should be locked when not in sight to prevent unauthorized access. Further observations revealed another instance where a medication cart was left unlocked and unattended in the hallway. A licensed vocational nurse admitted to being responsible for the cart and acknowledged that it should have been locked due to the medications it contained, including Eliquis, Lisinopril, and Lasix. The Director of Nursing and the Administrator both stated that medication carts must be locked when unsupervised to ensure safety and privacy. The facility's policy on medication storage also indicated that medications should be stored securely and accessed only by authorized personnel.
Inaccurate MDS Assessments for Three Residents
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) for three residents, which could lead to inaccurate care plans and inadequate care provisions. Resident 78 was admitted with a medical history that included orthopedic aftercare, and a quarterly MDS indicated the resident was administered an anticoagulant medication, which was incorrect as per the Order Summary Report. The MDS Coordinator acknowledged the mistake during an interview, emphasizing the importance of accurate medication coding to prevent interference with other medications and side effects. Resident 12, admitted in 2018, had a quarterly MDS indicating moderate cognitive impairment with no behaviors or hallucinations, despite the Medication Administration Record showing episodes of hallucinations and behaviors. Similarly, Resident 28, admitted in 2021, had a significant change in status MDS indicating no behaviors, while records showed episodes of restlessness and yelling. Interviews with the Social Service Designee confirmed these inaccuracies, and both the Director of Nursing and the Administrator expressed expectations for accurate MDS coding. The facility's policy on resident assessments emphasized the need for MDS assessments to reflect information in progress notes, care plans, and resident observations.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure staff implemented enhanced barrier precautions (EBP) for one of the sampled residents, which had the potential to result in the spread of infection. The resident, admitted on 02/27/2024, had a medical history including encephalopathy, sepsis, enterococcus, methicillin-resistant staphylococcus aureus infection, and gastrostomy status. The resident's care plan, initiated on 05/17/2024, required EBP related to gastrostomy tube placement, directing staff to use gown and gloves during high-contact resident care activities. An order dated 08/07/2024, specified EBP due to tube feeding every shift. During an observation on 11/05/2024, a registered nurse (RN) entered the resident's room to administer medications via a feeding tube, wearing only gloves and no gown, despite acknowledging that a gown was necessary due to EBP precautions. Interviews with the Director of Nursing (DON) and the Administrator confirmed that gowns were required for residents at high risk and that staff were expected to comply with facility protocols. The facility's policy on Enhanced Standard/Barrier Precautions outlined the use of gown and gloves during high-contact activities for residents at increased risk of MDRO acquisition, including those with indwelling devices like feeding tubes.
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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 San Leandro
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| All Saint's Maubert | 1.2 mi | ★★★★★ | 0 | 0 |
| All Saint's Subacute & Transitional Care | 1.2 mi | ★★★★★ | 2 | 0 |
| Alameda County Medical Center D/p Snf | 1.2 mi | ★★★★★ | 0 | 0 |
| Kaiser Permanente Post-acute Care Center | 1.7 mi | — | 0 | 0 |
| San Leandro Healthcare Center | 1.8 mi | ★★★★★ | 2 | 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.