Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Medical Hill Healthcare Center during CMS and state inspections, most recent first.
A resident with a history of stroke and requiring personal care assistance reported being handled roughly and spoken to inappropriately by a CNA. The Social Service Director did not treat the complaint as suspected abuse due to the resident's confusion, resulting in the incident being filed only as a grievance and not reported to authorities or thoroughly investigated, contrary to facility policy.
A facility failed to report an alleged sexual assault involving a resident with anxiety and schizophrenic disorders to the appropriate authorities within the required timeframe. The Neurobehavioral Unit Director received the report from the resident's conservator, but the allegation could not be substantiated due to the resident's inability to focus and recall the incident. Despite this, the facility's policy required immediate reporting to the state licensing agency, ombudsman, and law enforcement, which was not done.
The facility failed to provide timely account statements and transaction receipts for residents' personal funds, affecting four residents. Residents and their conservators were not informed about account balances or spending details, impacting their rights to access funds for personal purchases. Interviews revealed that the Business Office Manager was behind in sending out quarterly reports and did not provide receipts, despite the facility's policy requiring management and accounting of residents' personal funds.
A staff member failed to maintain proper hand hygiene during meal service, handling food with gloved hands without changing gloves or washing hands after touching non-food items. This breach in sanitary practices had the potential to affect all residents receiving meals.
The facility failed to ensure accurate MDS assessments for two residents, leading to incorrect documentation of visual and nutritional statuses. A resident who was legally blind was inaccurately recorded as having adequate vision, while another resident was incorrectly documented as receiving parenteral feeding and having a feeding tube. The MDS Nurse and the Dietary Director were responsible for these inaccuracies, as confirmed by the DON and the Administrator.
A facility failed to resubmit a Level I PASRR for a resident who stayed longer than 30 days, despite having severe cognitive impairment and active mental health diagnoses. The resident was initially exempt from the PASRR due to a 30-day Exempted Hospital Discharge. Interviews with staff confirmed the oversight, but no documentation showed the PASRR was resubmitted.
A resident undergoing dialysis exceeded their prescribed daily fluid restriction due to the facility's failure to monitor and communicate the restriction effectively. Despite having a care plan in place, the resident's fluid intake records showed multiple instances of excess consumption. Staff interviews revealed a lack of awareness and communication regarding the fluid restriction, and the resident had access to a water pitcher without proper monitoring.
A facility failed to transcribe an oxygen order into the EHR for a resident with respiratory needs. Despite a handwritten order for oxygen being documented, it was not entered into the EHR until a survey was conducted. Observations showed the resident receiving oxygen, but there was no documentation in the administration records. Interviews confirmed the oversight occurred after the resident's return from a transfer.
Failure to Timely Report and Investigate Alleged Abuse
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident who had a history of cerebral infarction and required assistance with personal care. The resident's responsible party informed the facility that a female CNA was rough and rude during care, and the resident described being handled roughly and spoken to inappropriately by the CNA. Despite this, the Social Service Director (SSD) did not treat the complaint as an allegation of abuse, citing the resident's confusion and inability to recall details during an interview. The incident was only filed as a grievance, and no further investigation or follow-up, such as interviewing the roommate or monitoring for psychosocial changes, was conducted. The SSD reported the incident to the Abuse Coordinator, who determined the allegation was unfounded due to the resident's confusion. The Director of Staff Development and the Director of Nursing both acknowledged that the allegation should have been treated as suspected abuse, reported, and investigated according to policy, which requires immediate reporting to state and local agencies. The facility's policy defines 'immediately' as within two hours for allegations involving abuse or serious bodily injury, but this protocol was not followed in this case.
Failure to Report Alleged Sexual Assault
Penalty
Summary
The facility failed to report an allegation of sexual assault involving a resident to the appropriate authorities within the required timeframe. The incident involved a resident who was admitted to the facility with anxiety disorder and schizophrenic disorder. The Neurobehavioral Unit Director (NBUD) received a report of the alleged sexual assault from the resident's conservator. An investigation was conducted, but the allegation could not be substantiated due to the resident's inability to focus and recall the incident. Despite this, the facility's policy required immediate reporting of such allegations to the state licensing certification agency, the local/state ombudsman, and law enforcement officials. During interviews, the NBUD and the facility's Administrator acknowledged that the allegation should have been reported to the proper authorities, but it was not. The facility's policy and procedure on abuse, neglect, exploitation, or mistreatment clearly stated that any suspicion of abuse should be reported immediately, defined as within two hours of the allegation. The failure to report the allegation as required had the potential to result in a lack of protection for residents alleging abuse.
Failure to Provide Timely Account Statements and Receipts for Residents' Personal Funds
Penalty
Summary
The facility failed to provide timely account statements and transaction receipts for residents' personal funds, affecting four residents. The facility did not notify residents or their conservators about the amount of funds in their personal accounts, track spending, or submit quarterly report statements on time. This failure impacted the residents' rights to have informed and easy access to their funds for personal purchases. Resident 1, admitted in July 2023 with a diagnosis of malignant neoplasm of the bladder neck and a BIMS score of 7 indicating moderately impaired cognitive status, had a conservator who sent $50 monthly for personal expenses. However, the conservator was unaware of the account balance or spending details, as they had not received quarterly statements or itemized receipts. Resident 2, with a BIMS score of 14 indicating cognitive intactness, was unaware of the funds available in their account and had not received any quarterly reports. Resident 3, with a BIMS score of 15 indicating cognitive intactness, last made purchases nine months ago but did not receive itemized receipts or quarterly account statements. Resident 4, with a BIMS score of 6 indicating severe cognitive impairment, and their conservator also did not receive quarterly reports or receipts. Interviews with facility staff revealed that the Business Office Manager was behind in sending out quarterly reports and did not provide receipts to residents or conservators, despite the facility's policy requiring management and accounting of residents' personal funds.
Failure in Hand Hygiene During Meal Service
Penalty
Summary
The facility failed to ensure that staff prepared and served food in a sanitary manner, as observed during a meal service. A staff member, identified as [NAME] #4, was seen handling plates and serving utensils with gloved hands but did not change gloves or wash hands after leaving the meal service line to retrieve food items from the oven. This occurred multiple times during the meal service, where [NAME] #4 handled grilled cheese sandwiches and pasta with gloved hands without performing hand hygiene or changing gloves, despite handling non-food items such as the oven door. During interviews, [NAME] #4 did not recall touching the pasta with her hands but acknowledged that she should not have touched food items while on the serving line. She also admitted that she should have washed her hands and changed gloves after handling non-food items. The Dietary Director confirmed that staff should use utensils rather than their hands while plating foods on the meal service line. This failure in hand hygiene practices had the potential to affect all 115 residents receiving meals from the dietary department.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for two residents, leading to deficiencies in documenting their visual and nutritional statuses. Resident #2, who was legally blind, had an MDS assessment indicating adequate vision, which was incorrect. The MDS Nurse confirmed that the resident's visual status was not captured accurately, despite the resident's care plan indicating impaired visual function. The Director of Nursing (DON) and the Administrator both acknowledged that the MDS should accurately reflect the resident's condition, and the MDS Nurse was responsible for ensuring this accuracy. Resident #86's MDS assessment inaccurately documented the resident as receiving parenteral/intravenous feeding and having a feeding tube, which was not the case. The Dietary Director, responsible for the dietary section of the MDS, admitted to coding the section incorrectly. The DON reiterated that each department was responsible for their section of the MDS and its accuracy, with the MDS Nurse overseeing the overall accuracy. The Administrator also confirmed the responsibility of the MDS Nurse in ensuring the MDS accurately reflected the resident's true condition.
Failure to Resubmit PASRR for Resident Exceeding 30-Day Stay
Penalty
Summary
The facility failed to ensure a Preadmission Screening and Resident Review (PASRR) was completed for a resident who remained in the facility longer than 30 days. The resident was admitted from a hospital with diagnoses including schizophrenia, bipolar disorder, and anxiety disorder, and was initially exempt from a Level I PASRR due to a 30-day Exempted Hospital Discharge. However, the facility did not resubmit the Level I PASRR Screening as required when the resident's stay exceeded 30 days. The resident's care plan indicated risks for decreased psychosocial wellbeing and other mental health issues, and the Minimum Data Set (MDS) assessment showed severe cognitive impairment with active diagnoses of anxiety disorder, bipolar disorder, and schizophrenia. Interviews with the MDS Nurse, Director of Nursing, and Administrator confirmed that the PASRR should have been resubmitted, but there was no documented evidence of this action being taken.
Failure to Monitor Fluid Restrictions for Dialysis Resident
Penalty
Summary
The facility failed to monitor and implement physician-prescribed fluid restrictions for a resident undergoing renal dialysis. The resident had a physician's order for a daily fluid restriction of 1200 mL, which was not adhered to, as evidenced by documentation showing the resident exceeded this limit on multiple occasions. The facility's policy on fluid management required verification of physician orders and adherence to specific instructions, but these were not effectively followed. The resident, who was cognitively intact and required assistance with eating, was admitted with end-stage renal disease and was dependent on dialysis. Despite having a care plan that included monitoring fluid intake and output, the resident's fluid intake records showed numerous days where the intake exceeded the prescribed limit. Interviews with staff revealed a lack of awareness and communication regarding the resident's fluid restrictions, contributing to the oversight. Observations and interviews indicated that the resident had access to a thermal water pitcher, which was not monitored for consumption. The Dietary Director admitted that the fluid restriction was not reflected on meal tickets, and the Director of Nursing acknowledged the expectation for fluid restrictions to be communicated and monitored across departments. The Administrator also expected adherence to fluid restriction orders, but the lack of communication and monitoring led to the deficiency.
Failure to Transcribe Oxygen Order into EHR
Penalty
Summary
The facility failed to ensure that an order for oxygen use was transcribed into the electronic health record (EHR) for a resident reviewed for respiratory care. The resident, who was admitted with a medical history including end-stage renal disease, malignant neoplasm of the rectum, anemia, and pneumonia, required intermittent oxygen due to shortness of breath. A handwritten order for oxygen was documented on a Comprehensive Physician's Order Sheet on January 24, 2024, but was not transcribed into the resident's EHR until March 12, 2024, during the survey. Observations revealed that the resident's oxygen concentrator was infusing oxygen at varying rates, yet there was no documentation in the Treatment Administration Record or Medication Administration Record for February and March 2024 regarding the administration of oxygen. Interviews with a registered nurse and the Director of Nursing confirmed that the order for oxygen was not transcribed into the active physician's orders after the resident's return to the facility following a transfer. This oversight resulted in a failure to maintain accurate and complete medical records in accordance with professional standards.
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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 Oakland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mcclure Post Acute | 0 mi | — | 16 | 0 |
| Oakland Healthcare & Wellness Center | 0.6 mi | — | 12 | 0 |
| St Paul's Towers | 0.7 mi | — | 0 | 0 |
| The Rehabilitation Center Of Oakland | 0.8 mi | — | 1 | 0 |
| Lake Park Healthcare Center | 1 mi | — | 3 | 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 August 2026) and official state health department websites.