San Leandro Healthcare Center

Inspectors wroteBased on observation, interview and record review the facility failed to ensure one of three sample selected residents (Resident 1) was treated with respect and dignity, when the facility's staff talked to Resident 1 disrespectfully on two separate occasions as a reaction towards Resident 1's difficult behaviors towards direct care staff. This deficient practice resulted in Resident 1 feeling bad, disrespected and threatened.

Inspectors wroteBased on interview and record review, for one of two sampled residents (Resident 1), the facility failed to ensure Resident 1 was treated with respect and dignity when Certified Nursing Assistant (CNA) 1 loudly argued with Resident 1. This failure had resulted in Resident 1's emotional distress. During a review of Resident 1's admission Record (AR) dated 11/18/25, the AR indicated Resident 1 was admitted to the facility in August 2025 with diagnoses that included major depressive disorder (a mental health condition causing persistent sadness, hopelessness, and loss of interest in activities, significantly impacting daily life) and post-traumatic stress disorder (a mental health condition that can develop after experiencing or witnessing a traumatic event, such as combat, assault, or a natural disaster). [...]

Inspectors wroteBased on interview and record review, for one of two sampled residents (Resident 2), the facility failed to ensure Resident 2 was afforded the right to participate in the care planning process when care conference meeting was not scheduled despite repeated requests from Resident 2's representative. This failure had the potential to result in Resident 2 being uninformed about treatment objectives and care plan. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to verify that residents understood binding arbitration agreements (a formal method of dispute resolution where a third party makes a decision instead of the dispute going to court) and/or that they were aware they could rescind the agreement within 30 days for 3 of 3 sampled residents (Resident 18, Resident 13, and Resident 49). This failure had the potential for residents to enter into an agreement without understanding their rights.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a binding arbitration agreement (a formal method of dispute resolution where a third party makes a decision instead of the dispute going to court) that met the regulations. This failure had the potential for residents to enter into an agreement that did not protect their rights.

Inspectors wroteBased on observation and interview, the facility failed to provide clean and comfortable home like environment for 4 residents residing in two of 25 rooms in the facility when the shared bathroom in these 2 rooms had a towel on the floor and the toilet seat was dirty with brown particles on the toilet seat. This failure placed all 4 residents residing in these rooms at increased risk for healthcare-associated infections (HAIs), which could result in longer recovery times, additional medical treatments, and even hospitalizations and negatively impact the residents' overall well-being and quality of life.

Inspectors wroteBased on interview and record review, the facility failed to complete and transmit Discharge Minimum Data Set (MDS, an assessment tool to guide patient care) for one of one sampled resident (Resident 11) to Centers of Medicare and Medicaid Services (CMS) for over 120 days. This failure resulted in reflecting Resident 11 as an active resident while he was already discharged from the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to accurately assess and code active diagnosis for one of 21 sampled residents (Resident 31) in the admission Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan) assessment when Resident 31's admission MDS assessment was inaccurately coded with a Yes for diagnoses of Pneumonia (an infection of one or both lungs caused by bacteria, viruses or fungi causing difficulty in breathing, cough, fever, and chills) and Septicemia (a life-threatening blood infection) during the look back period). During this period, Resident 31 did not have active Pneumonia and Septicemia. This failure resulted in an outdated and inaccurate reflection of Resident 31's medical/clinical status.

Inspectors wroteBased on interview and record review, for one of five sampled residents (Resident 17) reviewed for activities of daily living (ADL) care, the facility failed to implement a comprehensive-centered ADL plan of care. This failure had the potential to result in delayed provision of care.

Inspectors wroteBased on observation and record review the facility failed to provide Activities of Daily Living (ADL) for one of 17 sample selected residents (Resident 157), when Resident 157 was observed with long, broken finger nails and black particles under nails. This failure placed Resident 157 at risk for skin damage and infection and also affect his comfort and dignity, contributing to a lower quality of life and possible emotional distress.

Inspectors wroteBased on the observation, interview and record review, the facility failed to safely administer and provide adequate supervision to one of 21 sampled residents (Resident 18) while using a hot water bag (a rubber container designed to hold hot water to apply warmth to specific areas of the body) on her body to keep herself warm for over 24 hours. This failure placed Resident 18 at risk for skin burns.

Inspectors wroteBased on observation, interview and record review, the facility failed to establish a system of disposition of controlled drugs for accurate reconciliation when blister packs (also called a bubble pack, blister pack, a card that packages doses of medication within small, clear, or light-resistant, amber-colored plastic bubbles [or blisters] and each pack is secured by a strong, paper-backed foil that protects the pills until dispensed) of controlled medications with popped and taped shut blisters were stored. This failure had the potential to result in inaccurate reconciliation of controlled medications.

Inspectors wroteBased on observation and interview, the facility had 18 rooms (Rooms 7, 8, 9, 10, 11, 12, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, and 25) with multiple beds that provided less than 80 square feet (sq. ft.) per resident who occupied these rooms. This deficient practice had the potential to result in inadequate space for the delivery of care to each of the residents in each room, or for storage of the residents' belongings. After observation and interview, there was adequate space for residents and staff to move about without obstruction. Recommend granting waiver.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three discharged residents (Resident 1) had a safe and appropriate discharge location based on his medical needs when Resident 1 who was legally blind was discharged to an independent living facility where resident sustained falls. This failure placed Resident 1 at risk for adverse health outcomes that had the potential to cause serious complications and psychosocial harm.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 37 out of 37 residents with regular diet received enough protein on a regular basis. This practice failure had a potential of malnutrition and protein deficiency for 37 residents on regular diet who were residing at the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two of two sample selected non-English speaking residents (Resident 108 and 110) had an appropriate communication system in place when Residents 108 and 110 did not have a written translation of vital information (communication board) at the bed side. This failed practice resulted in Residents 108 and 110 not being able to communicate effectively with staff and to express their needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow its policies and procedures for oxygen administration and ensure oxygen supplies were maintained according to the operator's manual for three (Resident 39, 5, and 20) of four sampled residents receiving oxygen therapy, when staff did not document oxygen flow and rationale of Resident 39's oxygen therapy and Resident 39, 5, and 20's oxygen concentrator (an electronically operated device that separates oxygen from room air and provides high concentration of oxygen directly through a nasal cannula, a lightweight tube with one end split into two prongs which are placed in the nostrils and from which a mixture of air and oxygen flows) filter was covered with a thick layer of gray, fluffy matter. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure pharmacy medication cart storage were clean and orderly, when various items were found in the narcotic box of Medication Cart (Med Cart) 1 and 2, and loose pills were found in Med Cart 1. This deficiency had the potential to result in medication diversion.

Inspectors wroteBased on observation, interview and record review, the facility failed to obtain contracts, memorandum of understanding, or other agreements with third parties to provide dialysis services for three of four sampled residents (Resident 4, 43, 28) who were receiving dialysis treatments (the process of removing excess water, impurities from the blood of people whose kidneys could no longer perform these functions normally). This failure had the potential for Resident 4, 43, and 28 to receive inadequate or inappropriate dialysis care.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure infection control policies and procedures were followed for one (Resident 39) of three sampled residents when: 1. Certified Nursing Assistant 1 (CNA 1) did not wear a gown while providing care for Resident 39 and CNA 1 did not perform hand hygiene after removing soiled incontinent briefs and applying clean briefs to Resident 39; 2. Resident 39's foley catheter (a thin, flexible tube placed in the bladder to drain urine) tubing was touching the floor; and 3. Resident 39's room did not have a dedicated PPE trash bin. These deficient practices had the potential to transmit infectious microorganisms and increase the risk of infection for residents and staff.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain the privacy for one (Resident 34) of 14 sampled residents when staff did not pull the privacy curtain when giving Resident 34 a bed bath. This deficient practice resulted in Resident 34 feeling his privacy was not honored.

Inspectors wroteBased on interview and record review, the facility failed to ensure to inform the ombudsman (an official appointed to investigate individuals' complaints against maladministration, especially that of public authorities) for one of three sample selected discharged residents (Resident 54) when, Resident 54 left the facility unplanned after signing an AMA (leaving Against Medical Advice). This failure practice had the potential for Resident 54 to be in an unsafe environment and not have access to medical intervention.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide an environment that was free from accidents for one (Resident 39) of one sample resident when the facility did not implement interventions to reduce the risk for falls for Resident 39 who had a history of frequent falls. This deficient practice had the potential for Resident 39 to experience a fall.

Inspectors wroteBased on observation and interview, the facility had 18 rooms (Rooms 7, 8, 9, 10, 11, 12, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, and 25) with multiple beds that provided less than 80 square feet (sq. ft.) per resident who occupied these rooms. This deficient practice had the potential to result in inadequate space for the delivery of care to each of the residents in each room, or for storage of the residents' belongings. After observation and interview, there was adequate space for residents and staff to move about without obstruction. Recommend granting waiver.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow proper food handling practices when a dietary staff member during trayline (a system of food preparation in which trays move along an assembly line) did not change gloves and wash her hands after she opened two cabinet drawers while wearing gloves and then returned to trayline. This deficient practice had the potential to result foodbourne illness.

Inspectors wroteBased on observation, interview and record review, for two of 17 sampled residents (Resident 188 and 3) the facility failed to ensure food was served under sanitary conditions when Rehabilitation Nurse Assistant (RNA) 1 did not perform hand hygiene (wash hands with soap and water or use an alcohol based hand rub) while serving meals to Residents 188 and 3 and [NAME] (CK) 2 attempted to store a tray of food that was previously placed on Resident 3's overbed table. For Resident 188 and Resident 3, this deficient practice had the potential to result foodborne illness.

Inspectors wroteBased on observation, interview, and record review, for two (Resident 20 and 28) of 17 sampled residents the facility failed to maintain the privacy of personal care information when signs indicating personal care instructions for Residents 20 and 28 were posted in locations visible to other residents and visitors. This failure had the potential to result in Resident 20's and Resident 28's personal care information to be viewed by other residents and visitors.

Inspectors wroteBased on observation and record review, the facility had 18 resident (Rt) rooms (7, 8, 9, 10, 11, 12, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25) with multiple beds that provided less than 80 square feet (sq.ft) per resident who occupied these rooms. This failure had the potential to result in inadequate space for the delivery of care to each of the resident in each room, or for storage of the residents' belongings.