Oakland Healthcare & Wellness Center

Inspectors wroteBased on observation, interview and record review, the facility failed to provide preventive treatment and services to maintain and improve range of motion (ROM is one aspect of exercise important for increasing or maintaining joint function) for three of four sampled residents (Residents 6, 75, and 26). This failure had the potential to result in further decline in Residents 6, 75, and 26's ROM. 1. A review of Resident 6's admission record (AR), undated, indicated Resident 6 was admitted on [DATE] with diagnoses that included hemiplegia (paralysis affecting one side of the body, often the face arm, leg, usually from brain or spinal cord injury), diabetes, and repeated falls. [...]

Inspectors wroteBased on observation, staff interview, and record review, the facility failed to store food in accordance with professional standards for safety when: Kitchen staff had uncovered facial hair while in the kitchen. Beyond use by date food items were stored in the kitchen refrigerator. Unlabeled, undated and expired food items were stored in the resident refrigerator. These failures had the potential for contamination of food resulting in food borne illness for the 97 residents who lived at the facility. During an observation on 1/12/26, at 9:24 a.m., the Dietary Supervisor (DS) had uncovered facial hair while in the facility kitchen. During an observation on 1/12/26, at 9:42 a.m., the kitchen refrigerator had cranberry sauce with a use by date of 12/27/25 and salad dressing with a use by date of 12/30/25. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of 25 sampled residents (Residents 30 and 95) received nail care and shaved in accordance with their preferences. This failure had the potential to cause Residents 30 and 95 to feel embarrassed and undignified. During a review of Resident 30's admission Record, printed 1/15/26, the Record indicated Resident 30 was admitted to the facility in December 2025 with a diagnosis of need for assistance with personal care. During a review of Resident 30's Brief Interview for Mental Status (BIMS, is a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score of eight to twelve is an indication of moderate impairment.), dated 12/9/25, the record indicated Resident 30's BIMS score was 12. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure timely assessment and intervention to one of two sampled residents (Resident 95) when Resident 95 had a significant change in condition related to weight loss. This failure placed Resident 95 at risk for malnutrition (body does not receive enough nutrients), dehydration (insufficient body fluid), decline in functional status, and emotional discomfort. During a review of Resident 95's admission Record (AR), printed on 1/13/25, the AR indicated Resident 95 was admitted to the facility in October 2025 with diagnoses of cerebral infarction (brain tissue dies because it doesn't get enough blood) and depression (a serious mood disorder causing persistent sadness, loss of interest in enjoyable activities, and impacts daily life). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to identify significant weight loss and implement interventions for two out of four sampled residents (Resident 28 and 95). These failures had the potential to result in continuous, unplanned weight loss for Residents 28 and 95.1. During a review of Resident 28's admission Record, dated 1/15/26, the admission Record indicated Resident 1 was admitted in the facility on 12/25/25 with an admission diagnosis of nontraumatic chronic subdural hemorrhage (bleeding under the brain's outer covering, occurring without significant head injury). During an interview on 1/12/26 at 11:46 a.m. with Resident 28, Resident 28 stated having difficulty chewing food and losing weight. During a concurrent interview and record review on 1/15/26 at 9:19 a.m. [...]

Inspectors wroteBased on interview and record review, the facility failed to report an unusual occurrence report within 24 hours to the California Department of Public Health (CDPH) when one of two sampled residents (Resident 4) had an unwitnessed fall and sustained lacerations (cuts) on the back of the head after being found and was sent to acute care hospital. This failure delayed regulatory oversight and placed Resident 4 at increased risk of repeated falls and additional injury, while also putting other residents at risk for similar harm. During a review of Resident 4's admission Record printed on 1/15/26, the admission Record indicated Resident 4 was admitted to the facility in November 2025 with diagnoses of right femur fracture (broken leg), abnormalities of gait and mobility and mild cognitive impairment. During an interview on 1/12/26 at 3:23 p.m. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 90 of 90 sampled residents were prevented from unauthorized visitor entry or resident exit from the facility when facility staff failed to close the alarmed emergency exit back door and arm the emergency exit alarm for 35 minutes during the evening shift. This failure had the potential to result in unauthorized visitor entry and/or unwitnessed resident elopements potentially resulting in resident injury.

Inspectors wroteBased on interview and record review, the facility failed to assure nursing staff possessed the competencies and skill sets necessary to provide nursing services to meet the residents' care needs safely for one of one sampled resident (Resident 1), when a Licensed Vocational Nurse(LVN), without an intra-venous(IV-a medical technique that involves administering fluids, medications, or nutrients directly into a vein) and blood withdrawal certificate provided care for Resident 1's peripherally inserted central catheter (PICC- a thin, flexible tube that is inserted into a vein in the upper arm and threaded into a large vein in the chest). This failure had the potential to result in improper infusion of ordered TPN (Total Parenteral Nutrition-a method of feeding that provides nutrients directly into a vein, bypassing the gastrointestinal tract) and cause infection and complications. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure maintenance services to maintain a comfortable, sanitary, and homelike environment when: 1. For Resident 39, room had a missing window covering. 2. For Resident 41, bathroom sink hot water knob was not in good working condition. 3. For Resident 58, room window could not be closed completely. 4. Multiple rooms (Rooms 5, 6, 10, 11,1 2, 16, and 19) had unclean and unpleasant bathroom environments. These failures to ensure a homelike environment had the potential to decrease residents' quality of life, comfort, and well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure four (Resident 32, 47, 57 and 67) of five sampled resident's Pre-admission Screening Resident Review (PASRR) was referred to the appropriate state mental authority for evaluation and determination when; 1. Facility did not resubmit a new Level 1 PASRR screening for Residents 32, 47, 67 that remained in the facility longer than 30 days. 2. Facility did not refer Resident 57 for level 2 PASRR evaluation. These failures had the potential to prevent residents from receiving appropriate required mental health services.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure the oversight of food service operations when the facility did not employ a full-time qualified Dietary Services Supervisor, defined as working 35 hours per week, to manage and oversee food operation services for the facility. This failure had the potential to jeopardize the health and well-being of the 92 of 93 residents who received food prepared in the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored, prepared and served in a safe and sanitary manner when: 1. A ¼ full container of Teriyaki sauce labeled refrigerate after opening was stored in un-refrigerated dry- goods storage 2. A dry food bin marked polenta was ready for use with an expired use-by date, and dry food bins for flour, thickener and grain rice had no use-by dates 3. Two of five cutting boards had deep white scratches 4. A knife rack had sticky brown residue on top 5. An air conditioner unit had thick grey dust on top, and in the air vents 6. The corner of kitchen floor was unclean with food debris buildup These failures placed the residents at risk for food-borne illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide effective pest control for two out of 93 residents. This failure had the potential to result in residents being bothered by roaches.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure necessary treatment and care services in accordance with professional standards of practice, comprehensive assessment and care plan for two of two sampled residents (Resident 41 and Resident 85) when: 1. For Resident 41, license nurse (LN) did not assess or offer pain medication before wound dressing change was performed. 2. Resident 85 did not receive pain medication as ordered by the physician. License nurses did not reassess routine use of as needed pain medication. These failures had the potential for Resident 41 and Resident 85 to suffer from unnecessary pain and emotional distress, and to not receive the necessary care and services to ensure effective pain management.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that two of three sampled residents (Residents 54 and 58) were administered medication to meet their needs. Resident 54 was not given two medications as ordered during an observed medication pass and Resident 58 was not giving prescribed eye drops for two days. These failures had the potential to result in residents' medical conditions worsening.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure it maintained a medication error rate of five percent or less. The facility medication error rate was 8.1%, with three errors observed during 37 opportunities. This failure had the potential to result in residents' medical conditions worsening.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure drugs were stored and disposed of in the proper manner. Three boxes of rectal suppositories were expired, and one emergency medication kit was left open and not replaced. These failures had the potential to result in residents receiving ineffective medication.

Inspectors wroteBased on interview and record review, the facility failed to ensure clinical records were complete and accurately documented for one of 40 sampled residents (Resident 41) when Resident 41's Hospice Care (a medical care for people focused on palliation [focused on providing relief from pain and other symptoms of a serious illness] of a terminally ill patient's pain and symptoms and attending to their emotional and spiritual needs at the end of life) Notes were not readily accessible and Hospice Care Visits/Assessments were not accurately documented in resident's electronic medical record. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow proper sanitation, food handling, and food storage practices when: 1. Refrigerator 2 contained the following items: A container which held raw cucumbers, bell peppers and asparagus bunches: the cucumbers and bell peppers were nine days past the use by date on the container label; there was no label for the asparagus. A bag of cilantro leaves with part of the leaves discolored, and no use by date on the bag label. An unlabeled container with a discolored yellow bell pepper. An unlabeled container with a head of wilted cabbage. 2. The freezer had an undated sealed bag of French bread. 3. The freezer section of the freestanding white refrigerator had an undated bag of whipped topping. 4. [NAME] 2 did not perform hand hygiene in between tasks during tray line (serving and plating of food). [...]

Inspectors wroteBased on observation, interview, and record review, for one (Resident 133) of 11 sampled residents, the facility failed to develop a baseline care plan within 48 hours of admission. This failure had the potential to result in unmet care needs for Residents 133.

Inspectors wroteBased on observation, interview, and record review, for one (Resident 45) of 11 sampled residents, the facility failed to develop a comprehensive care plan within seven days of completion of the Minimum Data Set (MDS, a resident assessment tool used to guide care). This failure had the potential to result in unmet care needs for Residents 45.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide weekly showers to one of twenty residents (Resident 27) as requested by Resident 27's emergency contact. This failure resulted in Resident 27's not receiving preferred bathing services (a weekly shower) and had the potential to result in decreased comfort and hygiene.

Inspectors wroteBased on interview and record review, for one of twenty sampled residents (Resident 29), the facility failed to arrange for surgery for treatment of a left eye cataract. (A cataract is a cloudy area in the lens of the eye that leads to a decrease in vision.) The failure to arrange for Resident 29's eye surgery resulted in delayed treatment to improve Resident 29's vision in his left eye for five months and 13 days.

Inspectors wroteBased on observation, interview, and record review, for one of eight sampled residents (Resident 74) with limited range of motion (ROM, a joint or body part with limited range of motion, cannot move through its normal range of motion; also known as contractures,), the facility failed to: 1. Apply knee immobilizer (a removable brace to maintain stability of the knee) daily to resident's right (R) knee as ordered by the physician. 2. Provide resident with ROM exercises three times a week as ordered by the physician, and according to the plan of care. These failures resulted in unmet care needs for Resident 74 and had the potential to result in decreased range of motion.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure the two alarms on the South Station emergency exit were functional: the emergency exit alarm and the Wanderguard alarm. (Wanderguard is a system to alert caregivers when residents are attempting to exit a facility unsupervised. It is a two-part system: a bracelet worn by the resident, and a sensor installed on an exit. When the bracelet passes across the sensor, there is an audible alarm.) The failure to ensure the audible alarms worked on the South Station emergency exit door resulted in one (Resident 70) of 11 sampled residents entering the patio balcony without authorization or supervision and had the potential for unsafe wandering by other residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow policies and procedures for infection control for one (Resident 133) of 11 sampled residents when Certified Nurse Assistant 1 (CNA 1) entered Resident 133's room without wearing required personal protective equipment (PPE, protective items or garments worn to protect the body or clothing from hazards that can cause injury). The failure to wear PPE necessary for a resident with contact and droplet precautions (Contact and droplet precautions are actions implemented to prevent the spread of infection based upon the transmission mode of direct or indirect contact with respiratory secretions from the resident or environmental surfaces contaminated with respiratory secretions) had the potential to result in transmission and spread of infection.

Inspectors wroteBased on observations, interviews, and record reviews, for one (Resident 70) of three sampled residents who smoked, the facility failed to ensure smoking policies and procedures were followed when Resident 70 smoked in an area designated as a non-smoking area. The failure to ensure Resident 70 smoked in area with a readily available fire extinguisher, an ashtray made of a noncombustible material, and a metal container with a self-closing cover for emptying ashtrays, had the potential to result in a fire.