Alameda Center for Rehabilitation and Healthcare

In the surveyor’s words

From the most serious findings on record at Alameda Center for Rehabilitation and Healthcare, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Dec 21, 2023

  Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to handle potentially hazardous foods and maintain kitchen sanitation in a manner intended to prevent the spread of food borne illness. This deficient practice was evidenced by the following: On 12/12/23 from 9:26 AM to 11:25 AM, the surveyor conducted a tour of the main kitchen in the presence the Food Service Director (FSD) and observed the following: At 10:11 AM, the surveyor observed a dish machine temperature log which was filled out for the afternoon (for lunch time). The FSD stated, They signed this early, I don't know why. At 10:24 AM, the surveyor observed orzo pasta wrapped in clear plastic with a use by date of 12/3. […]

• No harm, potential for more than minimal, widespreadF922Dec 21, 2023

  Based on observation and interview, it was determined that the facility failed to maintain the designated emergency supply of water needed for residents in the event of a loss of normal water supply. This deficient practice was evidenced by the following: On 12/12/23 at 11:00 AM, the surveyor met with facility [NAME] President of Operations, the Licensed Nursing Home Administrator (LNHA), the Director of Nursing and the Infection Preventionist for an entrance conference meeting. The facility was licensed for 250 beds and the facility census was 227 (the number of residents who currently resided at the facility). On 12/12/23 at 12:18 PM, the surveyor conducted a kitchen tour with the Food Service Director (FSD). The surveyor observed two pallets of water in the basement. […]

• No harm, potential for more than minimal, widespreadF886Nov 3, 2021

  Based on interview, and review of facility documentation, it was determined that the facility failed to test unvaccinated staff for COVID-19 at a frequency based on the county COVID-19 level of community transmission. This deficient practice was identified for 5 of 5 unvaccinated staff members in the facility reviewed for COVID-19 testing and was evidenced by the following: According to the U.S. Centers for Disease Control and Prevention (CDC) guidelines, Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 [COVID-19] Spread in Nursing Homes updated 9/10/21 included, In nursing homes located in counties with substantial to high community transmission, unvaccinated HCP should have a [CONDITION(S)] test twice a week. […]

• No harm, potential for more than minimal, patternF677Dec 29, 2025

  Complaint: 2587228Based on interviews, medical record review, and review of other pertinent facility documents on 12/29/2025, it was determined that the facility failed to provide documented evidence of care provided to residents (Resident #1, Resident #2, Resident #3, and Resident #7). This deficient practice occurred for 4 of 4 residents reviewed.The deficient practice was evidenced by the following:1.According to the admission Record (AR), Resident #1 was admitted to the facility with diagnoses which included but were not limited to: dementia, diabetes, and muscle weakness.According to the most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 10/4/2025, Resident #1 had a Brief Interview for Mental Status (BIMS) score of 3 out of 15, which indicated the resident's… […]

• No harm, potential for more than minimal, patternF584Jul 3, 2025

  Based on observation, interview, and pertinent facility documentation, it was determined that the facility failed to maintain a homelike environment that was clean, safe, and sanitary. This deficient practice was identified for 3 of 5 unit pantries (Units 2, 3, and 4). This deficient practice was evidenced by the following: On 06/30/2025 at 10:32 AM, the surveyor inspected the Unit 3 pantry in the presence of the Licensed Practical Nurse and Unit Manager #1 (LPN/UM #1) and observed the following: white debris was present inside of the microwave, a cabinet drawer panel was not intact and slid back and forth, and an aluminum pan containing white debris was found inside the cabinet. […]