Alameda Oaks Nursing Center

In the surveyor’s words

From the most serious findings on record at Alameda Oaks Nursing Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684Mar 6, 2025

  Based on interviews and record reviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 (Resident #1) of 5 residents reviewed for quality of care. The facility failed to have a nurse evaluate Resident #1 after an unwitnessed fall. Resident #1 sustained a left distal femoral shaft fracture and a right tibia and fibula fracture. The noncompliance was identified as PNC. The PNC began on 08/29/24 and ended on 09/05/24. The facility had corrected the noncompliance before the investigation began. The failure could affect residents, resulting in not receiving needed care to maintain optimal health and placing them at risk for injury or deterioration in their condition. […]

• Actual harm, isolatedF689Sep 29, 2022

  Based on record review and interview, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents, for one Resident (R #1) of 4 residents reviewed for falls and accident hazards. R #1 had an unwitnessed fall and sustained a fractured left leg (tibia), and displaced fractured right leg (femur) which led to hospitalization . The facility did not provide the amount of supervision necessary to prevent R #1 from falling and sustaining multiple fractures which lead to hospitalization . This failure could place residents with high risk for falls at risk for additional falls and injuries. […]

• No harm, potential for more than minimal, widespreadF812Jul 3, 2024

  Based on observation, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for sanitation. 1. The facility failed to ensure the ice machine was clean. 2. The facility failed to ensure drinking glasses were clean. 3. The facility failed to ensure non-stick pans were not eroded. 4. The facility failed to ensure pots and pans were not dented. 5. The facility failed to ensure pest control was effective. 6. The facility failed to ensure personal items were not on prep carts or in walk-ins. 7. The facility failed to ensure proper cleaning was done according to their daily kitchen cleaning log. 8. […]

• No harm, potential for more than minimal, widespreadF908Jul 3, 2024

  Based on observation, interview and record review, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 1 walk-in freezers, 1 of 1 walk-in refrigerators, 1 of 1 air intake vent, and 1 vent hood reviewed for essential equipment in the kitchen. The facility failed to ensure the walk-in freezer was free of ice build-up, the door properly closed, and the inside light was bright enough. The facility failed to ensure the light in the walk-in refrigerator was bright enough. The facility failed to ensure the air intake and return air vent was clean. […]

• No harm, potential for more than minimal, patternF812Sep 10, 2026

  Based on observation, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, 1 of 1 nutrition room, and 1 of 1 dining room reviewed for storage, preparation, and sanitation. 1. The facility failed to ensure all spice containers were not open to air. 2. The facility failed to ensure the shelf above the stove was clean. 3. The facility failed to ensure plastic cups were clean. 4. The facility failed to ensure all items in the refrigerator were labeled and dated. 7. The facility failed to ensure boxes of products were not stacked to the ceiling in the walk-in freezer. 8. The facility failed to ensure items in the nutrition room refrigerators were labeled and dated. […]