Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 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 Oakland Healthcare & Wellness Center during CMS and state inspections, most recent first.
The facility failed to prevent unauthorized entry or resident exit when staff left an alarmed emergency exit door open and unarmed for 35 minutes. The door, leading to public streets, did not trigger an alarm, contrary to facility policy. Staff interviews confirmed the doors were never locked but should have been alarmed to alert staff. The facility's policy required regular checks of the alarm system, but the system was not armed, posing a risk of unauthorized entry or resident elopement.
A facility failed to ensure nursing staff had the necessary competencies for safe resident care. An LVN without IV and blood withdrawal certification provided care for a resident's PICC line, despite the resident's complex medical needs requiring certified care. The DON confirmed the LVN's lack of certification, which was against facility policy and state regulations.
The facility failed to maintain a homelike environment, with issues such as missing window coverings, non-functional bathroom fixtures, and unclean bathrooms. A resident's room had a window that couldn't close, allowing smoke to enter, while another resident's bathroom had a faulty hot water knob. Multiple rooms had unclean bathrooms, and requests for cleaning were ignored. These deficiencies compromised resident comfort and safety.
The facility failed to complete necessary PASRR evaluations for several residents, including those with schizophrenia and bipolar disorder, potentially preventing them from receiving required mental health services. The facility did not resubmit Level I PASRR screenings for two residents after 30 days, did not complete a PASRR for a resident with bipolar disorder, and failed to conduct a Level II evaluation for a resident with schizophrenia.
The facility failed to employ a full-time qualified Dietary Services Supervisor to oversee food operations, as required by California Health and Safety Code. The Kitchen Manager, who was supposed to fulfill this role, worked part-time and lacked necessary qualifications, holding only a ServSafe certification. The Registered Dietitian was onsite only two days a week, indicating insufficient oversight, potentially jeopardizing the health of 92 residents.
The facility failed to store, prepare, and serve food safely, with issues including unrefrigerated Teriyaki sauce, expired and unlabeled dry food bins, scratched cutting boards, a sticky knife rack, dusty air vents, and unclean kitchen floors. These deficiencies were acknowledged by the Kitchen Manager and Registered Dietitian, posing risks of foodborne illness and contamination.
The facility failed to manage pest control effectively, as two residents reported roaches in their rooms. Despite complaints, the issues were not logged in the maintenance system, leading to a lack of action. Observations confirmed roaches in a resident's room and shared bathroom, and pest control services were not provided as needed.
Two residents in an LTC facility experienced deficiencies in pain management. One resident did not receive a pain assessment or medication before a wound dressing change, despite showing non-verbal pain cues. Another resident was given Tylenol instead of Norco for a pain level that required stronger medication, and staff failed to reassess and notify the physician for a pain management reevaluation. These actions were inconsistent with the facility's pain management policies.
The facility failed to administer medications as ordered for two residents, leading to a deficiency in pharmaceutical services. A resident with heart failure did not receive two prescribed medications during an observed medication pass due to unavailability and oversight. Another resident did not receive prescribed eye drops for glaucoma for two days, as confirmed by the DON, due to the medication being unavailable.
A facility failed to maintain a medication error rate of 5% or less, with an observed rate of 8.1%. An LVN was unable to administer potassium chloride to a resident due to a pharmacy delay, administered double the ordered dose of Vitamin D3, and omitted Minoxidil. These errors were confirmed during an observation and interview, contributing to the facility's non-compliance.
The facility failed to properly store and dispose of medications, as observed by surveyors. An emergency medication kit was found open and not replaced, containing controlled substances, insulin, and temperature-sensitive suppositories. Additionally, three boxes of expired Bisacodyl suppositories were stored with other medications. A nurse confirmed the risk of residents receiving ineffective treatment. The facility's policy requires immediate removal and disposal of outdated medications, which was not followed.
A facility failed to document hospice visits and assessments for a resident with cerebrovascular disease in their electronic medical record. Despite regular hospice visits, notes were only found in a Hospice Communication Binder, contrary to the facility's policy requiring inclusion in progress notes. This deficiency was confirmed by a LVN and the Hospice Clinical Director, highlighting a gap in maintaining complete clinical records.
Failure to Secure Emergency Exit Door
Penalty
Summary
The facility failed to ensure the safety of 90 sampled residents by not preventing unauthorized visitor entry or resident exit. This occurred when staff left the alarmed emergency exit back door open and unarmed for 35 minutes during the evening shift. Observations revealed that the door, which led to an access ramp with direct access to public streets, was opened without triggering an audible alarm. Interviews with staff, including a Certified Nursing Assistant and the Director of Nursing, confirmed that the emergency exit doors were never locked, but were equipped with alarms intended to alert staff when opened. However, the alarm was not functioning as expected during the observed period. The facility's policy and procedure on wandering and elopement required staff to ensure doors closed properly and that the maintenance department regularly checked the alarm system. A review of the facility's plan of correction from a previous survey indicated that door alarms should be engaged at all times, and staff were instructed to respond to alarms. Despite these measures, the alarm system was not armed, and staff did not respond to the open door, posing a risk of unauthorized entry or resident elopement.
Inadequate Competency in PICC Line Care
Penalty
Summary
The facility failed to ensure that nursing staff had the necessary competencies and skills to safely meet the care needs of a resident. Specifically, a Licensed Vocational Nurse (LVN) without an intravenous (IV) and blood withdrawal certification provided care for a resident's peripherally inserted central catheter (PICC). This resident had been admitted with diagnoses including surgical aftercare following digestive system surgery, short bowel syndrome, nutritional deficiency, and acquired absence of parts of the digestive tract. The resident's medical orders required specific PICC care and monitoring for signs of infection or bleeding. The Director of Nursing confirmed that three LVNs documented providing care to the resident during specific shifts, but only two had the necessary IV competency certificates. The LVN in question, who lacked the certification, was documented as providing care and monitoring for the resident's PICC line on multiple occasions. According to the Board of Vocational Nursing and Psychiatric Technicians, only LVNs certified in intravenous therapy are permitted to perform certain tasks related to PICC lines. The facility's policy also stipulated that only IV certified LVNs could perform specific procedures related to central lines, which the LVN in question was not certified to do.
Facility Maintenance Deficiencies Impact Resident Comfort and Safety
Penalty
Summary
The facility failed to maintain a homelike environment for its residents, as evidenced by several maintenance issues that were not addressed in a timely manner. Resident 39's room had a missing window covering, which the resident had requested multiple times for privacy and protection from heat. Despite the Maintenance Supervisor being aware of the issue and having the necessary blinds available, the installation was delayed due to time constraints. Resident 41's bathroom sink hot water knob was not functioning, and the issue was not documented in the Maintenance Logbook, leading to a delay in repairs. The Maintenance Supervisor acknowledged the problem but had not addressed it, resulting in the resident's care being compromised as staff had to obtain hot water from another location. Resident 58's room had a window that could not be closed completely, allowing outside air and cigarette smoke to enter the room. The family member expressed concern for the resident's health due to the smoke exposure. The Maintenance Supervisor was aware of the issue for over a month and had attempted in-house repairs before contacting an external company for window replacement. Temporary measures were planned to seal the window until the replacement could be completed. Additionally, the facility's smoking policy aimed to protect non-smoking residents, but observations showed residents smoking near bedroom windows, increasing the risk of second-hand smoke exposure. Multiple rooms, including Rooms 5, 6, 10, 11, 12, 16, and 19, had unclean bathroom environments with cracked flooring and blackish discoloration. Resident 85, who used one of these bathrooms, reported discomfort and stated that requests for cleaning were ignored. The Environmental Supervisor confirmed awareness of the issues but did not indicate any immediate action taken. The facility's policy emphasized providing a safe, clean, and comfortable environment, but these deficiencies demonstrated a failure to uphold these standards, potentially impacting residents' quality of life and well-being.
Failure to Complete PASRR Evaluations for Residents
Penalty
Summary
The facility failed to ensure that the Pre-Admission Screening Resident Review (PASRR) process was properly followed for four residents, potentially preventing them from receiving necessary mental health services. Resident 32 and Resident 67 were admitted with Level I PASRR screenings completed from the hospital, indicating no serious mental illness. However, both residents had diagnoses of schizophrenia, a serious mental disorder. The facility did not resubmit a new Level I PASRR screening for these residents after they remained in the facility for more than 30 days, as required. Resident 47 was admitted and readmitted to the facility with a PASRR coded zero, indicating no serious mental illness, despite having a diagnosis of bipolar disorder and being prescribed medication for it. The facility did not complete a PASRR for Resident 47, nor did they refer the resident to the State Mental Authority for specialized mental health services after the resident stayed in the facility for over 30 days. This oversight was confirmed during a review of the resident's clinical records by the MDS Coordinator and the Director of Nursing. Resident 57's records showed a diagnosis of schizophrenia and a requirement for a Level II Mental Health Evaluation Referral, as indicated by a positive result for mental illness on the Level I PASRR completed prior to admission. However, the facility did not complete the necessary Level II PASRR evaluation or set up a follow-up appointment for the evaluation. This deficiency was identified during a review of the resident's clinical records, where it was confirmed that no Level II PASRR was completed.
Failure to Employ Qualified Dietary Services Supervisor
Penalty
Summary
The facility failed to ensure proper oversight of its food service operations by not employing a full-time qualified Dietary Services Supervisor (DSS) to manage and oversee food operation services. According to the California Health and Safety Code, a health facility that employs a registered dietitian less than full-time must also employ a full-time dietetic services supervisor. The Kitchen Manager (KM), who was supposed to fulfill this role, was found to be working part-time and did not possess the necessary qualifications, as she was still in school for the DSS certification and only held a ServSafe certification. The Registered Dietitian (RD) was only onsite two days a week, further indicating insufficient oversight. A review of the KM's timecard report revealed that she worked less than the required 35 hours per week for several weeks, with hours ranging from 12.82 to 34.99 per week. The facility's policy and procedure for the DSS position required a graduate of a California State approved DSS course or CDM certification, which the KM did not have. During an interview, the Administrator acknowledged the part-time status of the RD and KM and confirmed that the ServSafe certification was not adequate for overseeing the facility's Dietary Services Department. This deficiency had the potential to jeopardize the health and well-being of 92 out of 93 residents who received food prepared in the kitchen.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure food was stored, prepared, and served in a safe and sanitary manner, as observed during a survey. A full container of Teriyaki sauce, labeled to be refrigerated after opening, was found stored in an unrefrigerated dry-goods storage area. The Kitchen Manager (KM) acknowledged that some unrefrigerated liquids could spoil and cause resident illness. Additionally, a dry food bin labeled polenta was found with an expired use-by date, and other bins for flour, thickener, and grain rice lacked use-by dates, which the KM admitted could lead to foodborne sickness and affect food quality. Further observations revealed that two of five cutting boards had deep white scratches, which could harbor food particles and lead to foodborne illness. The KM and Registered Dietitian (RD) confirmed that cutting boards should be changed frequently to prevent such risks. A knife rack was also found with a sticky brown residue, and the KM noted that this unclean area could transfer dirt and germs onto knives and subsequently onto resident food. The survey also identified an air conditioner unit with thick grey dust on top and in the vents, which was blowing air into the kitchen. The KM stated that the dust was cleaned to prevent contamination. Additionally, a corner of the kitchen floor had a buildup of food debris, which the KM acknowledged should have been cleaned thoroughly to prevent pest infestation. The facility's policies and procedures for food storage, handling, and maintenance were reviewed, highlighting the need for proper labeling, cleaning, and sanitation to avoid contamination and ensure food safety.
Failure in Pest Control Management
Penalty
Summary
The facility failed to provide effective pest control for two residents, resulting in complaints about roaches in their rooms. Resident 88 reported seeing a roach under her lunch tray and informed the MDS Coordinator, who communicated the issue in a facility meeting and group message. However, the report was not recorded in the maintenance log, which is crucial for ensuring follow-up actions. Similarly, Resident 55 reported roaches in his room multiple times to staff, including a Licensed Vocational Nurse, but his room was not listed on pest control invoices, indicating a lack of action. Observations confirmed the presence of roaches in Resident 55's room and a shared bathroom, along with a buildup of dirt. The Maintenance Staff acknowledged the importance of logging such reports to prevent oversight. The Pest Control Technician confirmed that only rooms listed on invoices were treated, and Resident 55's room was not among them, despite his willingness to have pest control services. The facility's policy requires staff to report pest sightings to the Housekeeping Supervisor for immediate action, but this protocol was not effectively followed.
Deficiencies in Pain Management for Two Residents
Penalty
Summary
The facility failed to provide necessary treatment and care services in accordance with professional standards of practice for two residents, leading to deficiencies in pain management. For Resident 41, a licensed nurse did not assess or offer pain medication before performing a wound dressing change. This resident, who was on palliative care and had a sacral pressure ulcer, exhibited non-verbal cues of pain during the procedure, such as tensing and moving away. The facility's policy required pain assessment and medication administration prior to such treatments, which was not followed in this instance. Resident 85 did not receive pain medication as ordered by the physician. Despite having a pain level that warranted the administration of Norco, the resident was given Tylenol instead. The resident frequently complained of pain, and the medication administration records showed inconsistencies with the physician's orders. Licensed nurses failed to reassess the routine use of as-needed pain medication and did not notify the physician for a reevaluation of the resident's pain management plan, as required by the facility's policy. Interviews with staff, including licensed vocational nurses and the director of nursing, revealed a lack of adherence to the facility's pain management policies. The staff acknowledged the expectation to follow physician orders and assess pain levels accurately before administering medication. However, documentation errors and misjudgments about the resident's pain levels led to inappropriate pain management, contributing to the deficiencies identified in the report.
Medication Administration Deficiency
Penalty
Summary
The facility failed to administer medications as ordered for two residents, leading to a deficiency in pharmaceutical services. Resident 54, who was admitted with a diagnosis of heart failure, did not receive two prescribed medications during an observed medication pass. The Licensed Vocational Nurse (LVN) was unable to locate the potassium chloride in the medication cart and stated that it had been ordered but not yet arrived. Additionally, the LVN confirmed that Minoxidil, prescribed to lower blood pressure, was not administered to Resident 54 during the same medication pass. Resident 58, who had an order for Latanoprost Ophthalmic Solution for glaucoma, did not receive the prescribed eye drops for two consecutive days. The Director of Nursing (DON) reviewed the Medication Administration Record (MAR) and noted that the medication was unavailable at the time of administration on those days, which was acknowledged as a medication error. These failures in medication administration had the potential to result in the worsening of the residents' medical conditions.
Medication Error Rate Exceeds Acceptable Limit
Penalty
Summary
The facility failed to maintain a medication error rate of five percent or less, resulting in an observed error rate of 8.1%. During a medication pass, a Licensed Vocational Nurse (LVN) was unable to administer potassium chloride to a resident because the medication had not arrived from the pharmacy. Additionally, the LVN administered two tablets of Vitamin D3, totaling 2000 units, instead of the ordered 1000 units. Furthermore, the LVN did not administer Minoxidil, a medication intended to lower blood pressure, to the resident. These errors were identified during an observation and interview with the LVN, where the medication orders were reviewed. The LVN acknowledged the errors, confirming that the Minoxidil was not administered and that two tablets of Vitamin D3 were given instead of one. These actions and inactions during the medication pass contributed to the facility's failure to maintain the required medication error rate, potentially impacting the resident's medical condition.
Improper Medication Storage and Disposal
Penalty
Summary
The facility failed to ensure proper storage and disposal of medications, as observed by Health Facilities Evaluators. During an inspection of the medication storage room, an emergency medication kit was found open and not replaced, containing controlled substances, insulin, and temperature-sensitive suppositories. Additionally, three boxes of Bisacodyl suppositories were discovered to be expired, yet they were stored with other over-the-counter medications. This was confirmed by a Licensed Vocational Nurse, who acknowledged that the expired medications posed a risk of residents receiving ineffective treatment. A review of the facility's policy and procedure on medication storage revealed that outdated, contaminated, or deteriorated medications should be immediately removed from stock, disposed of according to procedures, and reordered from the pharmacy. However, this protocol was not followed, leading to the potential for residents to receive ineffective medication.
Incomplete Documentation of Hospice Care for a Resident
Penalty
Summary
The facility failed to ensure that clinical records were complete and accurately documented for a resident receiving hospice care. The resident, who was admitted to the facility in 2019, was placed under hospice care in May 2024 due to a terminal diagnosis of cerebrovascular disease. However, the resident's electronic medical record did not contain any documentation of hospice visits or assessments. This lack of documentation was identified during a review of the resident's records and an interview with a Licensed Vocational Nurse (LVN), who confirmed that hospice visits occurred regularly but were not recorded in the facility's electronic medical record. The facility's policy required that hospice notes be included in the facility's progress notes and maintained in the resident's medical record. Despite this policy, hospice notes were only found in a Hospice Communication Binder, and there were no progress notes entered by facility nurses in the electronic medical record. The Hospice Clinical Director confirmed that hospice nurses were expected to document each visit in the Hospice Communication Binder and that the facility could request copies of hospice progress notes. This deficiency had the potential to impact the resident's care due to the lack of available information for the interdisciplinary team.
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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) |
|---|---|---|---|---|
| St Paul's Towers | 0.5 mi | — | 0 | 0 |
| The Rehabilitation Center Of Oakland | 0.5 mi | — | 1 | 0 |
| Mcclure Post Acute | 0.5 mi | — | 16 | 0 |
| Medical Hill Healthcare Center | 0.6 mi | — | 0 | 0 |
| Lake Merritt Healthcare Center Llc | 0.6 mi | — | 8 | 0 |
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