Oakland Nursing & Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Oakland Nursing & Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Aug 1, 2025

  Based on record review, interview, facility document review, and facility policy review, the facility failed to ensure an alarm on the fire exit door of the secured unit sounded to prevent elopement for 1 (Resident #7) of 1 resident reviewed for elopement. The failure resulted in Resident #7 exiting the facility on the morning of 07/28/2024 at 6:10 AM and being found by staff approximately one-half mile from the facility at approximately 7:00 AM. It was determined the facility's non-compliance with one or more requirements of participation had caused or was likely to cause serious injury, serious harm, serious impairment, or death to one or more facility residents. […]

• Actual harm, isolatedF692Aug 1, 2025

  Based on interview, record review, and facility document and policy review, the facility failed to monitor and assess a resident's oral fluid intake, notify the physician of changes in intake, and put interventions in place to maintain adequate hydration for 1 (Resident #3) of 3 residents reviewed for dehydration. Specifically, the facility failed to identify and address Resident #3's inadequate fluid intake, which resulted in actual harm to Resident #3 who required hospitalization with diagnoses of encephalopathy and dehydration.The findings include:A facility policy titled, Hydration - Oral, dated 05/05/2023, indicated, 1. Recommend fluids (6-8 glasses per day) to patients/residents during and in-between meals and during periods of physical activity. The policy also specified, 3. […]

• Actual harm, isolatedF689Jul 1, 2022

  Based on complaint and facility reported incident, reviews of a closed medical record, and staff interview, it was determined that the facility staff failed to follow Resident #4's ADL plan of care that specified the need for the extensive assistance of 2 staff persons during bed mobility. This resulted in harm to Resident #4. This was evident for 1 out of 5 residents reviewed for falls during a complaint survey. After the incident, the facility developed initiated, and completed a plan of correction to prevent further injuries to residents during care. Therefore, this deficiency will be cited as past non-compliance. […]

• No harm, potential for more than minimal, widespreadF726Dec 12, 2025

  Based on record review and interview, it was determined that the facility failed to ensure that licensed nurses had specific competencies and skill sets necessary to care for residents' needs. This was evident for 5 (Staff #12, #13, #14, #15, and #16) of 5 randomly selected Licensed Practical Nurses (LPNs) during the Staffing task portion of the annual survey.The findings include:On 12/09/25 skills and competency evaluations were requested for 5 randomly selected LPNs: Staff #12, Staff #13, Staff #14, Staff #15, and Staff #16.On 12/11/25 at approximately 11:00 AM, an interview was conducted with the Director of Nursing (DON) to again request skills and competency evaluations since none had yet been provided. […]

• No harm, potential for more than minimal, widespreadF727Dec 12, 2025

  Based on record review and interview, it was determined that the facility failed to ensure there was a Registered Nurse (RN) for at least 8 consecutive hours every day. This was evident for 2 days (11/23/25, 12/03/25) of 22 days reviewed for federal staffing compliance during the annual survey.The findings include:On 12/08/25 at approximately 8:20 AM, during the entrance conference, nursing staffing schedules were requested for 12/08/25 through 12/21/25. They were provided at 10:59 AM. A review revealed that some days lacked any scheduled RN. […]