Alameda Oaks Nursing Center

Inspectors wroteBased on interviews and record review, the facility failed to ensure that all alleged violations involving the reasonable suspicion of a crime were reported immediately to a law enforcement entity for its political subdivision, within two hours if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 2 (Resident #2 and Resident #3 ) of 5 residents reviewed for abuse/neglect. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide reasonable accommodation of resident needs and preferences for one (Resident #1) of four residents reviewed for call light placement. The facility failed to ensure Resident #1's call light was within reach. This failure could place residents at risk of needs and accommodation being unmet. [...]

Inspectors wroteBased on record review and interview, the facility failed to develop a baseline care plan that included the instructions needed to provide effective and person-centered care of the residents, for one (Resident #1) of five residents reviewed for base line care plans for newly admitted residents. 1) The facility did not develop a baseline care plan that addressed Resident #1's diabetes mellitus when he was admitted on [DATE]. This failure could place residents at risk of not having their needs met and increase the risk of adverse events regarding diabetes mellitus exacerbation or complications.

Inspectors wroteBased on interviews and record review, the facility failed to maintain clinical records on each resident that were complete and accurately documented in accordance with accepted professional standards and practices for 1 of 5 residents (Resident #1) reviewed for accuracy and completeness of clinical records. The facility failed to accurately document oxygen use by Resident #1 nine times during the month of August 2025 in the MAR. This failure could result in residents' records not accurately reflecting the residents' status or condition.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents participated in the care planning process with the resident and the resident's representative for 1 of 5 residents (Resident #1) reviewed for comprehensive care plans in that: The facility failed to ensure care plan meetings were held with Resident #1 and/or the resident's representative. This failure could place residents at risk of not being involved in developing the plan for the care they will receive.

Inspectors wroteBased on interview and record review the facility failed to immediately inform the resident, consult with the resident's physician, and notify, consistent with his or her authority, the resident's representative when there was a significant change in the resident's physical, mental, or psychosocial status for 1 of 5 residents (Resident #1) reviewed for change in condition. The facility failed to ensure Resident #1's RP was notified immediately when her oxygen saturation fell to 82% on 08/14/2025. This failure could place residents at risk of their representative being unaware of their change in condition.

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 3 of 3 residents (Residents #1, #2, and #3), reviewed for pharmaceutical services, in that: 1. LVN A failed to administer Resident #1's Morphine at his scheduled time on 10/09/25.2. LVN A failed to administer Resident #3's Tramadol at her scheduled time on 10/09/25.3. LVN B administered Resident #2's Tramadol without an order in place.

Inspectors wroteBased on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 3 of 3 residents (Resident #1, #2 and #3) reviewed for medical records accuracy, in that: 1. Facility staff failed to document Resident #1's administered tramadol on his medication administration record in September 2025 and October 2025. 2. Facility staff failed to document Resident #2's administered tramadol on her medication administration record in September 2025 and her administered morphine in October 2025. 3. Facility staff failed to document Resident #3's administered Morphine on her medication administration record in October 2025. [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed and 1 of 1 nutrition room for storage, preparation, and sanitation.1. The facility failed to ensure dinnerware was cleaned and dried properly.2. The facility failed to ensure the pots, pans, and utensils used to cook and prepare food were in good working condition. 3. The facility failed to ensure items in the refrigerator and freezer were labeled, dated, and sealed properly.4. The facility failed to ensure items in the refrigerator and freezer were not expired.5. The facility failed to ensure boxes in the freezer were not stacked to the ceiling.6. The facility failed to ensure the steam table wells were clean. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents had a right to personal privacy and confidentiality of their personal and/or medical records for 7 of 10 residents reviewed for residents' rights. The facility failed to ensure LVN-D locked and/or closed the medication cart computer screen and left multiple residents' information exposed. The facility also failed to ensure LVN-D turned over or put away paperwork or report sheets with multiple residents' information on it. This failure could place residents at risk of resident-identifiable information being accessed by unauthorized persons.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident. Consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in comprehensive assessment for 1 (Resident #70) of 6 residents reviewed for care plans. The facility failed to ensure Resident #70's care plan was implemented by not having the resident's call light within reach on 08/04/25 at 2:10 PM. This failure could place residents at an increased risk of needs going unmet or harm.

Inspectors wroteBased on, interview, and record review the facility failed ensure, in accordance with accepted professional standards and practices, to maintain medical records on each resident that was complete and accurately documented for one resident 1 of 7(Resident #00) residents reviewed for medical records. The facility failed to ensure Resident #00's MARS was revised to reflect the accuracy of times the resident took hydrocodone-Acetaminophen Tablet 10-325 milligrams taken as needed for pain control on 04/09/2025. This failure could place residents at risk for not receiving appropriate and timely pain care relief to meet their current needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for 1 of 5 residents (Resident #54) reviewed for infection control practices. 1. The facility failed to ensure the ADON (who was also the ICP) knew the proper technique for cleansing the wound and keeping it clean during wound care. 2. The facility failed to ensure CNA-C performed hand hygiene between providing Resident #54 incontinent care and applying a clean brief. These fails could place residents at risk for cross contamination and infection.

Inspectors wroteBased on interviews and record reviews, the facility failed to provide and document sufficient preparation and orientation of resident representatives to ensure safe and orderly transfer or discharge from the facility. The facility failed to provide written transfer notices to residents, representatives, and the local ombudsman in a language and manner they understand. This failure could place residents at risk of not receiving information regarding their options, rights, and protection from inappropriate transfers or discharges.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure residents were treated with respect and dignity and care for each resident in a manner and in an environment, that promoted maintenance or enhancement of his or her quality of life, for one Resident (Resident #2) of 5 residents reviewed for dignity issues. On 04/29/2025 at 11:04AM and 11:55AM Resident #2's foley catheter drainage bag did not have a privacy bag, leaving the urine visually exposed to visitors and staff. This failure could place residents at risk of feeling uncomfortable or embarrassed and could decrease a residents' self-esteem and/or quality of life.

Inspectors wroteBased on interviews and record review, the facility failed to ensure that all alleged violations involving the reasonable suspicion of a crime were reported immediately to a law enforcement entity for its political subdivision, within two hours if the events that caused the allegation involved abuse or resulted in serious bodily injury, or not later than 24 hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury, for 1 (Resident #1 ) of 5 residents reviewed for abuse/neglect. The facility failed to report to the local law enforcement agency within the allotted time frame of 24 hours on 11/24/2024 around 2 PM when Resident #1 notified LVN A that LVN B allegedly had thrown her into a wheel chair. This failure could place all residents at increased risk for potential abuse due to unreported allegations of abuse.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 (Resident #1) of 5 residents reviewed for quality of care. The facility failed to have a nurse evaluate Resident #1 after an unwitnessed fall. Resident #1 sustained a left distal femoral shaft fracture and a right tibia and fibula fracture. The noncompliance was identified as PNC. The PNC began on 08/29/24 and ended on 09/05/24. The facility had corrected the noncompliance before the investigation began. The failure could affect residents, resulting in not receiving needed care to maintain optimal health and placing them at risk for injury or deterioration in their condition.

Inspectors wroteBased on interview and record review, the facility failed to ensure that each resident received adequate supervision for one Resident (Resident #2) of three residents reviewed for supervision. The facility failed to ensure Resident #2 received adequate supervision and did not exit the facility through the front door. This failure could place residents requiring supervision at risk for injury and accidents.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for sanitation. 1. The facility failed to ensure the ice machine was clean. 2. The facility failed to ensure drinking glasses were clean. 3. The facility failed to ensure non-stick pans were not eroded. 4. The facility failed to ensure pots and pans were not dented. 5. The facility failed to ensure pest control was effective. 6. The facility failed to ensure personal items were not on prep carts or in walk-ins. 7. The facility failed to ensure proper cleaning was done according to their daily kitchen cleaning log. 8. The facility failed to ensure the walk-in freezer was in good operating condition. 9. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 1 walk-in freezers, 1 of 1 walk-in refrigerators, 1 of 1 air intake vent, and 1 vent hood reviewed for essential equipment in the kitchen. The facility failed to ensure the walk-in freezer was free of ice build-up, the door properly closed, and the inside light was bright enough. The facility failed to ensure the light in the walk-in refrigerator was bright enough. The facility failed to ensure the air intake and return air vent was clean. The facility failed to ensure the vent hood lights and the exhaust fan worked. These failures could place the residents at risk of potential fire hazards.

Inspectors wroteBased on interview and record review, the facility failed to ensure that seight residents (Resident #4, Resident #32, Resident #23, Resident #26, Resident #22, Resident #28, Resident #18, and Resident #38) of twenty-four residents reviewed for professional standards, received care in accordance with professional standards of practice and the comprehensive person-centered care plan. 1.) The facility did not ensure that the Physician Order for monthly weight was followed for Resident #4. 2.) The facility did not ensure that the Physician Order for weekly weights was followed for Resident #32. 3.) The facility did not ensure that the Physician Order for monthly weight was followed for Resident #23. 4.) The facility did not ensure that the Physician Order for monthly weight was followed for Resident #26. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to maintain as effective pest control program for 1 of 1 kitchen reviewed for sanitation. There were ants on a prep table on and around the can opener, all over the top of the prep table, and crawling up the wall into a crack. There was evidence of rodent droppings on the kitchen floor adjacent to the wall. There was a hole in the baseboard adjacent to the floor near the rodent droppings. These failures could place residents at risk of living in an unsafe, unsanitary environment, and cross contamination of food.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services with reasonable accommodation of resident needs and preferences, for 1 of 5 residents (Resident #300) reviewed for accommodation of needs. The facility did not provide Resident #300 an accessible call light that she could physically use. This failure could place residents who utilized call lights at risk for not having his/her needs met, help in event of an emergency or place residents with a history of falls at risk for additional falls and injuries.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the residents' right to privacy for 1 of 10 residents (Residents #22] reviewed for privacy. The facility failed to ensure Resident #22's bedroom door was closed for privacy as she requested. This failure could place residents at risk of having their bodies exposed to the public, resulting in emotional distress and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that residents who needed respiratory care were provided such care consistent with professional standards of practice, physicians orders, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 1 (Resident #23) residents reviewed for respiratory care. The facility failed to ensure Resident #23's oxygen tubing was changed every night shift on Sunday as ordered. This failure places residents at an increased risk of infection leading to a decline in health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store all drugs and biologicals in locked treatment cart for 1 of 1 treatment cart reviewed for storage of drugs. The facility's treatment/medication cart was left unlocked by the nurse's station (only one nurse's station) with the drawers facing outward. This deficient practices could affect residents who have medications in the nurse's treatment/medication cart and could result in lost medications, drug diversion, harm due to accidental ingestion of unprescribed medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, which included measurable objectives and time frames to meet resident's medical, nursing, and mental and psychological needs that were identified in the comprehensive assessment for 1 out of 3 residents (resident #1) reviewed for care plans. The facility failed to ensure care plans used by the hospice agency contained two person Hoyer lift transfer instructions. The hospice agency staff transferred Resident #1 using one person and no Hoyer lift, and because of that Resident #1 was injured. This failure could place residents at risk for their medical, physical, and psychosocial needs not being met.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents' right to formulate an advance directive for 2 of 4 residents (Resident #8 and #38) reviewed for advanced directives, in that: 1. Resident #8's DNR was executed incorrectly and was therefore invalid. 2. The facility failed to ensure Resident #38's OOH-DNR was reinstated by obtaining a DNR order upon readmission following a recent hospitalization. This failure could place residents at-risk of having their end of life wishes dishonored, and of having CPR performed against their wishes.

Inspectors wroteBased on interview and record review the facility failed to develop and implement policies and procedures for screening through the employee misconduct registry to determine whether the individual is designated as unemployable for 14 of 19 staff (the DM, AD, LVN C, RN D, RN E, RN F, CNA G, CNA H, CNA I, CNA J, CNA K, CNA L, CNA M and CNA N) reviewed for employment registry screenings, in that: The DM, AD, LVN C, RN D, RN E, RN F, CNA G, CNA H, CNA I, CNA J, CNA K, CNA L, CNA M and CNA N did not have current employment registry screenings. This failure could place residents at risk for abuse, neglect, exploitation, and misappropriation of property.

Inspectors wroteBased on record review and interview, the facility failed to employ a qualified social worker on a full-time basis, for 1 of 1 social services staff reviewed, in that: The facility, licensed for 146 beds, did not employ a full-time qualified social worker with a minimum of a bachelor's degree in social work or a bachelor's degree in a human services field including, but not limited to, sociology, gerontology, special education, rehabilitation counseling, and psychology and one year of supervised social work experience in a health care setting working directly with individuals. This failure could place residents at risk of social service and psychosocial needs not being met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident's a right to a dignified existence for 1 of 18 residents (Resident #51) reviewed for dignity, in that: Resident #51's catheter bag did not have a privacy cover while the resident was in a common area of the facility. This failure could lead to residents' loss of self-esteem and feelings of dignity.

Inspectors wroteBased on interview and record review, the facility failed to ensure the care plan was revised in a timely manner for 1 of 18 residents (Resident #15), in that: Resident #15's care plan had not been revised to reflect the discontinuation of her hemodialysis treatment. This failure could affect residents who receive care at the facility and could result in missed or inadequate care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents who needed respiratory care were provided such care, consistent with professional standards of practice, for 1 of 14 residents (Residents #38) reviewed for respiratory care, in that: Resident #38's nebulizer mask was unbagged and resting on top of the resident's bedside table. This failure could place residents who required respiratory treatments at risk of receiving inadequate respiratory treatments and could result in a decline in health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 1 of 1 supply room on the facility's 300 hall, in that: The doorknob and locking mechanism on the supply room door on the facility's 300 hall was inoperable and as a result, the door was unable to be secured. The supply room contained potential hazardous materials. This failure could place residents at risk of living in an unsafe environment.