Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
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 Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
Multiple residents with cognitive impairment experienced physical abuse, including bruising and altercations, due to failures in following care plans and recognizing abuse. Staff did not consistently identify or report injuries as potential abuse, and required investigations were not initiated in several cases.
The facility did not report potential abuse and injuries of unknown origin to the State Survey Agency within the required timeframe for two residents. One resident with severe cognitive impairment was found with an unexplained large bruise, and another resident, unable to complete a cognitive interview, was discovered with facial bruising and skin tears after an incident involving a CNA. Staff failed to follow policy requiring immediate reporting of such incidents.
The facility did not thoroughly investigate allegations of abuse involving two residents, failing to conduct required interviews, suspend involved staff, or report incidents to the state agency. In one case, a resident with severe cognitive impairment was found with a large bruise, but the investigation was incomplete and did not follow policy. In another case, a resident was found with bruising and skin tears while alone with a CNA, but no investigation or state reporting occurred.
A resident with a UTI was prescribed Cefuroxime after lab results identified Proteus Mirabilis, but the Infection Preventionist did not complete the required infection screening evaluation to confirm the appropriateness of the antibiotic. The monthly infection log lacked documentation for this case, and staff interviews revealed inconsistent processes for ensuring infection screening evaluations were performed for residents receiving antibiotics.
Failure to Protect Residents from Physical Abuse and Inadequate Abuse Investigation
Penalty
Summary
The facility failed to protect multiple residents from physical abuse, as evidenced by several incidents involving both staff and resident-to-resident altercations. One resident, who was severely cognitively impaired, was found with a large bruise on the left upper arm after being transferred by a family member without staff assistance, contrary to the care plan. The incident was not identified or reported as an injury of unknown source by the nursing staff or administration, and the required abuse investigation protocols were not initiated at the time. Several other residents with dementia were involved in physical altercations initiated by another resident with a history of poor impulse control and behavioral symptoms. This resident was observed hitting or slapping other residents on multiple occasions, resulting in injuries such as swelling and bruising. Although staff separated the residents and updated care plans after each incident, the initial responses did not prevent further occurrences, and the facility did not consistently recognize these events as abuse requiring immediate intervention. Additionally, a resident with a history of combative behavior was found with a bruised and swollen lip and skin tears after being alone with a CNA. The nurse on duty did not know how the injuries occurred and did not consider the possibility of staff-to-resident abuse. The incident was not treated as a potential abuse case, and the necessary investigative steps were not taken at the time. These failures demonstrate lapses in the facility's adherence to its own abuse prevention policies and procedures.
Failure to Timely Report Suspected Abuse and Injuries of Unknown Origin
Penalty
Summary
The facility failed to ensure timely reporting of potential abuse and injuries of unknown origin to the State Survey Agency (SSA) for two residents. In the first instance, a resident with severe cognitive impairment was found with a large bruise on the left upper arm. The injury was not observed by staff, and its source could not be explained. Although the facility's policy required reporting such injuries to the SSA within two hours, the incident was not reported because staff did not initially suspect abuse. The Assistant Director of Nursing (ADON) later acknowledged that the injury met the definition of an injury of unknown source and should have been reported. In the second case, another resident, who was unable to complete a cognitive interview, was found with a bruise on the upper lip, a swollen lower lip, and two dry skin tears on the arm after being heard yelling while a CNA was present. The LPN who discovered the injuries did not report them to the abuse coordinator, and the ADON, who was the DON at the time, did not report the incident to the SSA, believing the injuries likely occurred during care. The facility's administrator confirmed that all suspicious bruising and potential abuse allegations were to be reported within two hours, but this protocol was not followed in either case.
Failure to Investigate Alleged Abuse and Follow Facility Policy
Penalty
Summary
The facility failed to conduct thorough investigations into allegations of abuse for two residents out of a sample of seven reviewed for abuse. For one resident with severe cognitive impairment, a large bruise was observed on the left upper arm. The facility's incident report attributed the injury to the resident's granddaughter not following the transfer plan, but did not interview the resident's roommate or other residents, nor did it conduct skin assessments on other residents in the same unit. The certified nurse aide involved was not suspended during the investigation, and the incident was not reported to the State Survey Agency as required by policy. Interviews revealed that the family disputed the facility's conclusion and believed the incident should have been investigated as abuse, especially since the roommate reportedly heard the resident scream during the night. For another resident, bruising and skin tears were identified while a CNA was alone in the room with the resident. There was no Facility Reported Incident (FRI) submitted for this event, and the Assistant Director of Nursing confirmed that no investigation into potential abuse was completed. The administrator acknowledged that an FRI is required for such incidents and that all allegations of abuse should be investigated, but this did not occur in this case. The facility's policies require that all allegations of abuse be thoroughly investigated, including interviews with relevant staff, residents, and witnesses, as well as protection of residents during investigations. In both cases, these procedures were not followed, as key interviews and assessments were omitted, staff were not suspended as required, and incidents were not reported to the appropriate authorities.
Failure to Complete Infection Screening Evaluation for Antibiotic Stewardship
Penalty
Summary
The facility failed to maintain an effective antibiotic stewardship program as required by its own policy and regulatory standards. Specifically, the Infection Preventionist (IP) did not complete an infection screening evaluation to determine if the correct antibiotic was ordered for a resident diagnosed with a urinary tract infection (UTI). The resident, who had a history of encephalopathy and Alzheimer's Disease, was noted to have discharge, prompting a urinalysis and culture. Laboratory results identified Proteus Mirabilis, which was susceptible to Cefuroxime, and the antibiotic was subsequently ordered. However, the infection screening evaluation for this case was not documented in the monthly infection log, and the IP confirmed that this evaluation was missed during her monthly review of infection reports. Interviews with facility staff, including the DON and Regional Clinical Nurse, revealed that while cultures were performed if ordered by a physician, there was no consistent process to ensure infection screening evaluations were completed for all residents receiving antibiotics. The DON acknowledged that wound audits were conducted monthly to assess antibiotic appropriateness but had not been completed for this resident. The IP stated her responsibility was to ensure correct antibiotic administration based on lab results, but she missed this particular case. The facility's failure to follow its antibiotic stewardship policy and ensure proper infection screening evaluations contributed to the deficiency.
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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) |
|---|---|---|---|---|
| Arbor Ridge Rehabilitation And Healthcare Center | 1.5 mi | — | 0 | 0 |
| Complete Care At Wayne Hills Rehab & Resp Center | 1.6 mi | — | 18 | 0 |
| Llanfair House Care & Rehabilitation Center | 2.2 mi | — | 0 | 0 |
| Phoenix Center For Rehabilitation And Pediatrics | 2.9 mi | — | 1 | 0 |
| Lakeland Nursing & Rehab | 3.2 mi | — | 0 | 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.