The Rehabilitation Center of Oakland

In the surveyor’s words

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

• Immediate jeopardy, widespreadF812Sep 13, 2024

  Based on observation, interview, and document review, the facility failed to store, prepare, and distribute food in a safe and sanitary manner when: 1. Fish being prepared to be served for lunch, which included time/temperature controlled for safety (TCS) foods (foods such as meat, including fish, are high potential for bacteria growth), was stored in the freezer with a temperature of 30 degrees (*) Fahrenheit (F), above 0 *F the food inside a freezer number (#) 2 will not be safe temperature for storage and may be at risk for bacterial growth, spoilage and food borne illness; facility did not ensure staff followed procedures in proper thawing of fish, creating an Immediate Jeopardy [IJ - a situation in which recipient(s) of care has suffered or is likely to suffer from gastrointestinal… […]

• Actual harm, isolatedF689Feb 6, 2025

  Based on observation, interview and record review, the facility failed to assist one of five sampled residents (Resident 1) to push the wheelchair safely, while she was sitting in her unlocked wheelchair, sliding down the slope of the ramp (ramp is a slope or an incline, a surface that tilts from one level to another) to enter the smoking patio on the left side of the facility. This failure resulted in Resident 1 falling out of wheelchair facing downwards, sustaining a contusion (bruise caused by direct blow to the body that can cause damage to the surface of the skin and to deeper tissues as well) of nose, closed fracture (broken bone) of nasal bone and feeling embarrassed. […]

• No harm, potential for more than minimal, widespreadF802Sep 13, 2024

  Based on observation, interview and document review, the facility failed to ensure kitchen staff were routinely trained and evaluated for competency skills when: 1. [NAME] failed to thaw fish safely in a sink. 2. [NAME] failed to report out of range temperatures on 9/9/24. 3. Dietary Manager was not able to state appropriate thawing procedures. 4. Dietary Manager was not able to state the importance of keeping freezer at proper temperature. These failures had the potential to result in food borne illness. Findings: During an interview on 9/9/24, at 10:26 a.m., with Dietary Manager (DM) and [NAME] (CK) 1, DM stated, the fish fillet inside 3-compartment dishwashing sink was going to be served for lunch. CK 1, then stated the fish fillet was taken out of the freezer at around 8:00 a.m. […]

• No harm, potential for more than minimal, widespreadF801Jul 29, 2022

  Based of observation, interview, and facility document review, the facility failed to ensure: 1. There was adequate supervisory oversight for the Food and Nutrition Department; 2. Food was ordered in the right quantity for the planned menu; and 3. The RD inspected the resident food refrigerator located in the nursing station. These failures had the potential to result in unsafe and unsanitary practices in regard to food storage, food preparation, and food service, as well as result in an inadequate supply of food for the planned menu to meet the nutritional needs of the residents all of which could in turn affect the safety and wellbeing of 52 residents who ate food by mouth out of a facility census of 54. […]

• No harm, potential for more than minimal, widespreadF802Jul 29, 2022

  Based on observation, interview, and facility record, the facility failed to ensure kitchen staff were competent for job duties performed when Certified Nursing Assistant/Diet Aide 1 (CNA 1) washed dishes in the kitchen and did not know the appropriate sanitizer strength and did not ensure appropriate wash water temperature for the dish machine (Cross-reference F812). This failure had the potential to result in contamination of dishware, utensils, and food leading to illness for 52 residents who received food from the kitchen out of a facility census of 54. […]