Oakland Rehabilitation and Healthcare Center

In the surveyor’s words

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

• Immediate jeopardy, widespreadF728May 30, 2025

  Refer F 835 Based on interviews and a review of pertinent facility documents, it was determined that the facility failed to ensure that a.) a non-certified Nursing Aide (NA#1) received the required training and competencies needed prior to receiving their own assignment and rendering resident care which included but not limited to; bathing, toileting, transferring, feeding, personal hygiene, and grooming and b.) NAs did not work past 120 days without being certified as a nursing aide. This deficient practice was identified for 2 of 3 NAs reviewed (NA#1 and NA#2) who provided direct care to residents on 4 of 4 nursing units. NA#1 was hired on 9/16/24, to provide care to the residents. […]

• Immediate jeopardy, widespreadF835May 30, 2025

  Refer to F 728 Based on interview and review of pertinent facility documents, it was determined that the facility's Licensed Nursing Home Administrator (LNHA) failed to ensure staff, as well as herself, implemented the facility's policies and procedures including a.) the hiring and utilization of non-certified Nursing Assistants (NAs) to ensure NAs were trained with the appropriate competencies and completed modules prior to receiving their own independent resident care assignment and b.) NAs did not work past 120 days without being certified as a nursing aide. […]

• Actual harm, isolatedF689Mar 3, 2023

  Based on observations, interviews, record review, and facility policy review, the facility failed to ensure staff followed care planned interventions to prevent falls for one of two residents (Resident (R) 10) reviewed for falls out of a total sample of 37 residents. This failure resulted in harm to R10 who was admitted to the hospital with a right femur fracture after sustaining a fall from being turned in bed by staff without assistance. Findings include: Review of R10's undated Admission Record, under the Profile tab in the electronic medical record (EMR), revealed R10 was admitted to the facility on [DATE] with multiple diagnoses to include chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), history of falling, acute respiratory failure with hypoxia, morbid… […]

• No harm, potential for more than minimal, widespreadF838May 30, 2025

  Based on interviews and review of pertinent documentation, it was determined that the facility failed to ensure the facility-wide assessment included a) an assessment with regard to use of non-certified Nursing Aides (NAs) to address the need of those residents under NAs care and b.) revised the facility assessment to address the contingency plan that included staffing guidelines. This failure had the potential to affect all 199 residents who currently live in the facility. This deficient practice was evidenced by the following: On 5/22/25 at 9:49 AM, Surveyor#1 (S#1) met with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) during an entrance conference, the LNHA informed S#1 that the current census was 199 (total number of residents). […]

• No harm, potential for more than minimal, patternF584May 30, 2025

  Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to provide a safe, clean, and comfortable homelike setting. This deficient practice was identified for 1 of 4 units (2E Unit) and 1 of 1 dining room, and was evidenced by the following: 1. During an initial tour of the facility on 5/22/25 at 11:10 AM, in 2E Unit, the surveyor observed upon entry to Resident Room#215 (RR#215), the ceiling tile near the window had brownish discoloration. The surveyor observed the 1st bed with broken basin and wedge for positioning under the resident's bed, and the floor was dusty. The 1st bed overhead light with another wedge for positioning. […]