The Rehabilitation Center of Oakland

Inspectors wroteBased on interview and record review:1. For three of three sampled residents (Resident 9, Resident 10, and Resident 11) the facility failed to ensure accurate representations of change in condition (COC, any sudden and marked adverse change in the resident's condition which is manifested by signs and symptoms different than usual) had documented entries that were signed by licensed nurses (LNs) in real time. 2. The facility failed to provide complete, accurate, and prompt recordings of clinical services and documentation on Interdisciplinary Team (IDT, a group of health care professionals with various areas of expertise who work together toward the goals of their residents) Meeting Notes as the events of clinical discussion occurred in real time during IDT meetings. [...]

Inspectors wroteBased on interview and record review the facility failed to maintain their compliance and ethics program when the facility did not promote honest and ethical behavior in all work-related activities. This failure resulted in false medical records and reports and placed the residents in the facility at risk of receiving unsafe care. 1. A review of the facility census, dated 6/2/26, indicated a mixed gender room arrangement between a male resident, Resident 1 who at this time was transferred to the hospital for a medical procedure and a female resident, Resident 2, newly admitted to the facility on this day, at 6:20 p.m. A review of the facility census, dated 6/3/26, indicated Resident 1 returned from the hospital at 3:20 a.m., and was placed in B bed, while Resident 2's A bed now showed as vacant when Resident 2 moved to an all-female room with two other female residents. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure two of two sampled residents (Resident 1 and Resident 2 ) and/or their individual Resident Representatives (RRs) were notified of the mixed gender room arrangement when male resident, Resident 1's unexpected return to facility following less than a 24-hour hospitalization stay, was placed together in a room with newly admitted female resident (Resident 2). This failure resulted in Resident 1 and Resident 2's inappropriate room accommodation, roomed in with the person not of their choice, and without individual consent or advanced written notifications in place. [...]

Inspectors wroteBased on interview and record review, for one of eleven sampled residents (Resident 1), the facility did not provide Resident 1 and Resident Representative 1 (RR 1) a written seven (7) day Bed Hold (holding or reserving a resident's bed while the resident is absent from the facility for therapeutic leave [absences for purposes other than required hospitalization] or hospitalization) Agreement when Resident 1 was transferred to the hospital and sent back to the facility the same day, in less than 24 hours. This failure resulted in Resident 1 and/or RR1 not having a written notification of the facility's Bed Hold Agreement prior to hospitalization and led Resident 1 not to be able to return to his previous room following an unexpected less than 24-hour stay at the hospital. A review of Resident 1's Face Sheet, printed on 6/11/26, indicated Resident 1 was admitted to the facility in 2025. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to honor one out of 3 residents (Resident 1) the right to retain personal possessions when Resident 1's personal possessions were not listed in detail and verified at admission. This failure had the potential to cause Resident 1 to feel their belongings were not treated with respect and had the potential to result in Resident 1 missing items without documentation of ownership. During a review of Resident 1's admission Record, printed 3/17/26, the Record indicated Resident 1 was admitted to the facility in 2024 with a diagnosis of depression. [...]

Inspectors wroteBased on interview and record review, the facility failed to protect personal belongings for one resident (Resident 1), when Resident 1's clothes and personal items were missing and were not accounted for. This failure had compromised the right of Resident 1 to retain personal possessions. A review of the admission record for Resident 1 indicated that Resident 1 was admitted on [DATE], and initially admitted [DATE] with diagnoses that included diabetes, hypertension, and end-stage kidney disease on dialysis. Resident 1 was discharged on 10/9/24. During a telephone interview on 8/12/25, at 8:48 a.m. with Resident 1's Responsible Party (RP), RP stated that upon discharge, Resident 1 had missing personal items. RP stated Resident 1's missing personal items were reported to Social Services Director (SSD) 2 during Resident 1's stay in 2024. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to assist one of five sampled residents (Resident 1) to push the wheelchair safely, while she was sitting in her unlocked wheelchair, sliding down the slope of the ramp (ramp is a slope or an incline, a surface that tilts from one level to another) to enter the smoking patio on the left side of the facility. This failure resulted in Resident 1 falling out of wheelchair facing downwards, sustaining a contusion (bruise caused by direct blow to the body that can cause damage to the surface of the skin and to deeper tissues as well) of nose, closed fracture (broken bone) of nasal bone and feeling embarrassed.

Inspectors wroteBased on interview and record review, the facility failed to protect one of five sampled residents (Resident 4) from physical abuse, when Resident 5, with a known of history of aggressive behavior, hit Resident 4 with a bed power cord (a thick electrical cord that connects the hospital bed with a power outlet). The failure resulted in Resident 4 suffering from a bleeding facial/scalp wound and received and hospitalization for further care.

Inspectors wroteBased on interview and record review, the facility failed to ensure Certified Nursing Assistant (CNA) 2 did not have access to facility residents and their personal care, after one of five sampled residents (Resident 3) alleged that CNA 2 hit him. CNA 2 continued to provide care to Resident 3 and at least 18 other residents for 12 more hours after the allegation was made. This failure placed Resident 3 and other residents at the facility at risk for abuse and further complications.

Inspectors wroteBased on observation, interview, and document review, the facility failed to store, prepare, and distribute food in a safe and sanitary manner when: 1. Fish being prepared to be served for lunch, which included time/temperature controlled for safety (TCS) foods (foods such as meat, including fish, are high potential for bacteria growth), was stored in the freezer with a temperature of 30 degrees (*) Fahrenheit (F), above 0 *F the food inside a freezer number (#) 2 will not be safe temperature for storage and may be at risk for bacterial growth, spoilage and food borne illness; [...]

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure kitchen staff were routinely trained and evaluated for competency skills when: 1. Cook failed to thaw fish safely in a sink. 2. Cook failed to report out of range temperatures on 9/9/24. 3. Dietary Manager was not able to state appropriate thawing procedures. 4. Dietary Manager was not able to state the importance of keeping freezer at proper temperature. These failures had the potential to result in food borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assist four out of eight sampled residents (Resident 30, 46, 48, 52) with personal hygiene when: 1. Resident 30 and Resident 46's long facial hair was not shaved. 2. Resident 48 and Resident 52's fingernails were not clean and trimmed. These failures resulted in Resident 30 feeling yuck, Resident 46 feeling crutty and unkept and placed Resident 48 and Resident 52 at risk for getting infections from lack of proper hygiene and injuring themselves with long fingernails.

Inspectors wroteBased on interview and record review the facility failed to ensure 4 Certified Nursing Assistants (CNAs) and 1 Licensed Vocational Nurse (LVN) had the appropriate competencies to care for residents when the facility did not complete Orientation Evaluation Checklists for LVN 1 and CNA 3, and Annual Performance Evaluations for CNAs 1, 2 and 4. This failure had the potential for resident care to be provided in an unsafe and incompetent manner.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure proper storage and labeling of medication and biologicals (made from a variety of natural sources human, animal, or microorganisms and are used to treat, prevent, or diagnose diseases and medical conditions) for one of one sample medication room and two of two medication carts when: 1. Three opened vials of Tuberculin Purified Protein Derivative (PPD- indicated to aid diagnosis of tuberculosis infection (TB) in persons at increased risk of developing active disease) was unlabeled and undated with an open date. 2. Two activase (a clot-busting medication. It helps the body to produce a substance that dissolves unwanted blood clots.) vials for a discharged resident (Resident 222) were stored in the refrigerator. 3. Thirteen expired Influenza (common respiratory illness. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain and observe infection control practices when: 1. Certified Nursing Assistant (CNA) 6 picked up a soiled linen on the floor of Resident 37 and Resident 58's room and disposed the soiled linen in the cart across Resident 37 and Resident 58's room. 2. Licensed Vocational Nurse (LVN) 3 did not perform hand hygiene and did not put on a new pair of gloves prior to administering eye drops to Resident 51. 3. LVN 3 did not remove gloves after applying topical medication (a medication that is applied to a particular place on or in the body.) to Resident 20. 4. Resident 17, 22 and 44's nasal cannula tubing was undated, unlabeled and was touching the floor. These failures had the potential for cross contamination and spread of infections among residents at the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one of one sampled resident (Resident 30) was treated with dignity and respect when Resident 30 attended activity wearing facility gown and disposable undergarment was soaking wet with urine. This failure had the potential to negatively impact Resident 30's sense of self-worth and self-esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 4 sampled residents (Resident 11), had a Doctor's Order for supplemental oxygen before they received the supplemental oxygen. This failure had the potential for Resident 11 to receive supplemental oxygen inappropriately and in an unsafe manner.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light (a device used by a patient to signal his or her need for assistance) was within reach for one of three sampled Residents (Resident 56). This deficient practice resulted in the delay of care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two sampled Residents (Resident 1) had staff identify themselves with name badges while they received care. This failure had the potential to cause Resident 1 emotional distress and anxiety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement their Policy and Procedure (P&P) for one of four sampled residents when Resident 1's social security card, a watch, and other personal items reported missing were not investigated thoroughly and documented. This failure placed resident 1 at risk for emotional distress, potential financial hardship and affected Resident 1's sense of security and well-being.

Inspectors wroteBased of observation, interview, and facility document review, the facility failed to ensure: 1. There was adequate supervisory oversight for the Food and Nutrition Department; 2. Food was ordered in the right quantity for the planned menu; and 3. The RD inspected the resident food refrigerator located in the nursing station. These failures had the potential to result in unsafe and unsanitary practices in regard to food storage, food preparation, and food service, as well as result in an inadequate supply of food for the planned menu to meet the nutritional needs of the residents all of which could in turn affect the safety and wellbeing of 52 residents who ate food by mouth out of a facility census of 54.

Inspectors wroteBased on observation, interview, and facility record, the facility failed to ensure kitchen staff were competent for job duties performed when Certified Nursing Assistant/Diet Aide 1 (CNA 1) washed dishes in the kitchen and did not know the appropriate sanitizer strength and did not ensure appropriate wash water temperature for the dish machine (Cross-reference F812). This failure had the potential to result in contamination of dishware, utensils, and food leading to illness for 52 residents who received food from the kitchen out of a facility census of 54.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to store, prepare, and distribute food in a safe and sanitary manner when: 1. The dish washing machine not reaching the required minimum temperature for the wash cycle and leaking. (Cross reference F908) 2. Hand Hygiene protocol was not followed. 3. Expired food items were found in the dry storage room. 4. Multiple dry food items did not have a use by date or open date on them. 5. Sanitizer strength for food contact surface using red bucket was not an appropriate strength. 6. There was no air gap (a gap of air between the floor and a drainpipe to prevent backflow of sewage into the equipment) for food preparation sink. 7. Toaster was not cleaned regularly and had buildup of black and brown residue. 8. Microwave was not cleaned and had food residue on the top inside surface. 9. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its policy and procedure to ensure safe and sanitary storage and consumption of food brought in for residents from outside the facility when outside food belonging to 52 residents were not labeled upon storage or discarded after two days. This failed practice had the potential for consumption of unsafe food and cause foodborne illness to 52 residents who ate food by mouth out of a census of 54 residents.

Inspectors wroteBased on interview and document review, the facility failed to ensure registry staff were vaccinated for COVID-19 (a serious respiratory disease) when 8 of 23 registry staff did not receive the COVID-19 booster immunization and one vaccine exempt registry staff did not meet the religious exemption criteria. This failure had the potential for unvaccinated staff to increase the spread of COVID-19 and its complications of severe illness, hospitalization and/or death to residents they cared for and other staff that worked in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain essential equipment when there were issues with dish washing machine not reaching the required minimum temperature for the wash cycle and leaking. (Cross reference 812) This failure had the potential for equipment not functioning as per manufacturers guidance resulting in ineffective ware washing processes and in turn could cause contamination of food, leading to foodborne illness for 52 residents who received food from the kitchen and negatively affect residents ' well-being out of a census of 54

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide personal care and grooming for four of 24 residents (Residents 165, 265, 6, and 12) who were unable to perform activities of daily living when: 1. Resident 165's fingernails and toenails were long, jagged, with brown substances underneath them; 2. Resident 265's fingernails were long with dark brown substances underneath them, and Resident 265 had dried food crumbs around his mouth and clothes; 3. Resident 6's fingernails were very long, with dark brown substance underneath his nails; and 4. Resident 12's fingernails were long with thick black matter underneath and Resident 12's legs were dry, cracked, and scaly. These deficient practices had the potential for unmet personal care needs for Residents 165, 265, 6, and 12.

Inspectors wroteBased on interview and record review, the facility failed to conduct a timely performance review and in-service training program for two of three sampled Certified Nursing Assistants (CNA 1 and 4) when CNA 1 and 4 did not complete their CNA skills observation checklist and 12-hour mandatory in-services within the past 12 months. This failure had the potential for residents to receive incompetent care from CNA 1 and 4.

Inspectors wroteBased on interview and record review, the facility failed to provide dementia (chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes and impaired reasoning) training to three of three sampled certified nursing assistants (CNA 1, 4 and 5) when mandatory dementia training was not completed by CNA 1, 4, and 5 in the last 12 months. This failure had the potential for unmet care needs of residents with dementia by CNA 1, 4 and 5.

Inspectors wroteBased on observation, interview, and record review the facility failed to store refrigerated medications, in accordance to facility policy which requires storage of medications between 36-46 degrees Fahrenheit (F). The medications were stored at temperatures that were too cold. This failure exposed patients to compromised medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Pharmacy Consultant (PC)'s monthly recommendations were acted upon for five of 24 sampled residents (Resident 12, 13, 19, 22 and 37) when the PC's recommendations were not reviewed for Resident 12, 13, 19, 22 and 37 who were prescribed psychotropic drugs (medications used to stabilize or improve mood, mental status or behavior) for five consecutive months, from March through July 2022. This failure had the potential for unnecessary medications to be given to Resident 12, 13, 19, 22, and 37.

Inspectors wroteBased on observations, interviews, and document reviews the facility failed to be free of medication error rates of five percent or greater when two medication errors were observed out of 32 opportunities. The medication error rate was calculated as followed: two divided by 32 then multiplied by 100, which was equal to 6.2 percent. This failure resulted in multiple medication errors.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure 37 of 74 sampled residents received or were offered the pneumococcal vaccine when 37 of 74 residents did not have a record of the pneumococcal vaccine in their records. This failure had the potential risks of spreading bacterial infection and causing respiratory complications to residents.

Inspectors wroteBased on interview and record review, the facility failed to issue a notice of Transfer/Discharge to one of three closed record sampled residents (Resident 61) or the resident's representative and to the Office of the Ombudsman when Resident 61 was transferred to the acute care hospital. This failure had the potential to result in the lack of coordination and support for Resident 61 while he was in the acute care hospital.

Inspectors wroteBased on interview and record review, the facility failed to follow their Policy and Procedure (P&P) to provide a written bed hold agreement notice to one of three closed record sampled residents (Resident 61) when Resident 61 was not provided the Bed Hold Agreement before being transferred to the hospital. This failure had the potential for Resident 61 to not be informed of the rights and benefits of bed hold and return policy to the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Remove expired stock from treatment cart three (two expired skin staple removal kits, and one bottle of povidone iodine (disinfecting) solution). This failure had the potential for use of expired, and potentially less effective items. 2. Label two opened bottles of liquid nutritional supplements with either a date opened or expiration date. This failure had the potential for use of expired nutritional supplements which could lead to gastrointestinal distress. 3. Label a white colored cream in a medication cup in treatment cart three with type of cream, resident name, or date. This failure had the potential to result in use of expired cream on the wrong resident and/or for the wrong reason.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, and served food under sanitary conditions when: 1. Multiple food items were outdated, unlabeled, and undated; 2. Staff belongings were stored on a 3 step ladder next to refrigerator 3 and 4; 3. Freezer 1 had brown sticky residue on the bottom shelves, and unlabeled ice cream bowls. These failures had the potential to cause food contamination or food borne illness.

Inspectors wroteBased on an observation, interview, and record review, the facility failed to maintain a comfortable and sanitary environment for both residents by: 1. In room [ROOM NUMBER] and room [ROOM NUMBER] the sliding closet doors did not close, the floors had fluffy particulates under the beds, and there was a thick, brown, sticky substance on the areas between the sliding doors and the clothes racks. 2. A certified nursing assistant (CNA 2) left a basin of water used for grooming on the over-bed table for one of 12 residents (Resident 229). 3. In room [ROOM NUMBER] the closet door was missing, and was replaced by a stained curtain. These failures had the potential for residents to not experience a clean, homelike environment.

Inspectors wroteBased on an observation, interview and record review, the facility failed to provide grooming assistance for one (Resident 229) of twelve sampled residents. For Resident 229, the failure to provide grooming assistance resulted in presence of brown substances under her fingernails, and facial hair.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow physician orders to flush the feeding tube (a tube inserted through the nose or mouth into the stomach to deliver food, fluid, and/or medications) between administration of different medications for one of 16 sampled residents (Resident 7). This failure resulted in Resident 7 not receiving flush solution according to physician instructions.

Inspectors wroteBased on interview and record review, the facility failed to provide a fortified diet (a diet structured to provide more calories than a regular diet) for one (Resident 229) of 14 residents. For Resident 229 this failure had the potential to result in weight loss.

Inspectors wroteBased on an observation, interview, and record review, the facility failed to ensure one of 12 sampled residents (Resident 38) received oxygen at a rate of two liters per minute (LPM), according to physician orders, and that the use of oxygen and monitored oxygen saturation levels were documented. For Resident 38, the administration of four LPM of oxygen, had the potential to result in development of adverse effects from excessive oxygen delivery, including lung damage and difficulty breathing. The failure to document oxygen saturation (oxygen saturation is a measurement of the percentage of oxygen in the blood, with a maximum value of 100 percent), or administration of oxygen, had the potential to result in inaccurate assessment of patient care needs.