Inspection Reports for
Oakland Heights Nursing and Rehabilitation
2361 E 29th St, Oakland, CA 94606, United States, CA, 94606
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
25% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Routine
Deficiencies: 5
Date: Apr 10, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident safety, medication storage, food safety, infection prevention and control, and staff qualifications at Oakland Heights Nursing and Rehabilitation.
Findings
The facility was found deficient in maintaining a safe and homelike environment, proper medication storage practices, food storage labeling and dating, adherence to infection prevention protocols including PPE use, and ensuring the Infection Preventionist had completed required specialized training and certification.
Deficiencies (5)
Resident 18's wall beside the right side of his bed had scattered areas of peeling paint, compromising a homelike environment.
Medications belonging to discharged residents were found stored in the medication refrigerator, risking medication errors.
Unlabeled and undated food was stored in the kitchen refrigerator, freezer, and resident refrigerator, including food beyond its use-by date.
Staff failed to use proper personal protective equipment (PPE) when providing care to residents on enhanced barrier precautions, risking disease transmission.
The designated Infection Preventionist (IP) had not completed or could not provide proof of required specialized infection prevention and control training and certification.
Report Facts
Residents affected: 43
Medication packets found: 8
Medication kits found: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN 1 | Licensed Vocational Nurse | Did not use proper PPE while administering medications via gastrostomy tube to Resident 32 |
| CNA 1 | Certified Nursing Assistant | Did not use proper PPE while providing care and changing bed linen for Resident 44 |
| CNA 2 | Certified Nursing Assistant | Did not use proper PPE while providing care and changing bed linen for Resident 44 |
| Director of Nursing | Director of Nursing | Acknowledged deficiencies in PPE use and medication storage; provided interviews regarding infection preventionist qualifications |
| Infection Preventionist | Infection Preventionist / Nursing Supervisor | Could not provide proof of specialized infection prevention certification |
| Consultant Pharmacist | Consultant Pharmacist | Stated medications of discharged residents should be disposed to prevent medication errors |
| Certified Dietary Manager | Certified Dietary Manager | Stated importance of labeling and dating food to prevent foodborne illness |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: May 6, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to timely report an alleged rape of a resident to the California Department of Public Health within the required 2-hour timeframe.
Complaint Details
The complaint involved an allegation of rape reported by Resident 1 on 4/6/24 at 11:30 p.m. The facility reported the allegation to CDPH on 4/8/24, which was beyond the required 2-hour reporting window. The allegation was substantiated as the report was delayed.
Findings
The facility failed to follow its policy and procedure to immediately report alleged abuse allegations within 2 hours to the appropriate authorities, resulting in a delayed report of an alleged rape of Resident 1. This failure had the potential to delay investigations and affect the physical and psychological well-being of the resident.
Deficiencies (1)
Failure to timely report suspected abuse allegations to the California Department of Public Health within 2 hours as required.
Report Facts
Date of alleged incident: Apr 6, 2024
Date report faxed to CDPH: Apr 8, 2024
Date of interview: Apr 11, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator (APC) | Interviewed regarding the delayed reporting of abuse allegations | |
| Director of Nursing (DON) | Interviewed regarding the importance of timely abuse reporting |
Inspection Report
Routine
Deficiencies: 11
Date: Nov 3, 2023
Visit Reason
The inspection was a routine regulatory survey of Oakland Heights Nursing and Rehabilitation to assess compliance with resident assessment, care, hygiene, dialysis care, dental services, food and nutrition services, sanitation, and equipment maintenance standards.
Findings
The facility was found deficient in completing timely Minimum Data Set (MDS) assessments, providing adequate hygiene and dental care, ensuring proper dialysis medication timing and post-dialysis assessments, maintaining food and nutrition services including menu adherence, food temperature, sanitation, and staff oversight, providing adaptive eating equipment and assistance, and maintaining kitchen equipment and food storage in a sanitary and safe manner.
Deficiencies (11)
Failed to complete Minimum Data Set (MDS) annual comprehensive assessments for two residents and quarterly assessments for eight residents in a timely manner.
Failed to provide regular hygiene services including showers or bed baths for two residents, resulting in poor hygiene conditions.
Failed to ensure dialysis medications were given at appropriate times and post-dialysis assessments were consistently completed for one resident.
Failed to provide routine dental services for one resident, resulting in delayed necessary treatment.
Failed to ensure qualified dietitian and dietary manager oversight of food and nutrition services, resulting in inadequate menu adherence, food safety, and sanitation.
Failed to ensure menus met nutritional needs, were followed, updated, and reviewed by dietitian, with multiple menu deviations noted including inappropriate substitutions and missing sauces.
Failed to provide food at safe and palatable temperatures, with multiple residents reporting cold food and observations confirming lukewarm or cold food temperatures.
Failed to provide special eating equipment and assistance consistently for one resident, with adaptive utensils not readily available and assistance delayed.
Failed to store, prepare, and serve food in accordance with professional standards, including unclean ice machines, unsafe thawing and storage of fish, improper food temperatures, uncalibrated thermometers, expired and unlabeled food items, unclean utensils and equipment, poor kitchen sanitation, and missing ceiling light covers.
Failed to ensure outside garbage dumpster lid was closed, increasing risk of attracting insects and rodents.
Failed to maintain reach-in freezer in working order, resulting in ice buildup and potential food safety issues.
Report Facts
Residents affected by MDS annual assessment deficiency: 2
Residents affected by MDS quarterly assessment deficiency: 8
Residents affected by hygiene deficiency: 2
Residents affected by dialysis care deficiency: 1
Residents affected by dental services deficiency: 1
Residents affected by food and nutrition service deficiencies: 40
Residents affected by food temperature deficiency: 40
Residents affected by adaptive equipment deficiency: 1
Residents affected by food safety and sanitation deficiencies: 40
Residents affected by outside garbage dumpster deficiency: 41
Residents affected by freezer maintenance deficiency: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Vocational Nurse 2 | LVN | Mentioned in relation to adaptive eating equipment for Resident 20 |
| Director of Nursing | DON | Provided statements on MDS assessments, dialysis care, dental services, and adaptive equipment |
| MDS Coordinator | MDSC | Responsible for MDS assessments and provided information on overdue assessments |
| Certified Dietary Manager | CDM | Discussed food and nutrition services, menu adherence, food safety, and sanitation |
| Outside Resource Director of Food Service | ORDFS | Responsible for kitchen operations and food service, discussed food safety and sanitation issues |
| Outside Resource Maintenance Director | ORMD | Discussed ice machine cleaning and freezer maintenance |
| Outside Resource Maintenance Technician | ORMT | Performed ice machine cleaning |
| Director of Staff Development | DSD | Discussed adaptive equipment and dental services |
| Certified Nursing Assistant 3 | CNA 3 | Mentioned in relation to hygiene and oral care for Resident 20 |
| Certified Nursing Assistant 2 | CNA 2 | Discussed shower documentation and hygiene for Resident 40 |
| Administrator | ADM | Discussed oversight of food and nutrition services |
| Social Services Director | SSD | Discussed dental services for Resident 20 |
| Business Office Manager | BOM | Discussed dental services and share of cost for Resident 20 |
| Rehabilitation Director | RD | Discussed occupational therapy and adaptive equipment for Resident 20 |
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Nov 4, 2021
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to dialysis care, food safety, and infection prevention at Oakland Heights Nursing and Rehabilitation.
Findings
The facility failed to manage nutritional needs for a resident on dialysis, improperly stored and labeled food items, and did not disinfect medical equipment between resident use, posing risks for harm and infection transmission.
Deficiencies (3)
Failed to manage nutritional needs for a resident with kidney failure receiving dialysis, including inappropriate diet and potassium intake.
Failed to label and store food properly, including unlabeled mayonnaise, salad dressing, spices, and open soy sauce container with residue and contamination.
Did not disinfect blood pressure cuff, thermometer, and pulse oximeter between resident use, risking transmission of communicable diseases.
Report Facts
Residents affected: 4
Residents affected: 7
Residents affected: 4
Residents affected: Few
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Dietician RD 1 | Registered Dietician | Interviewed regarding nutritional care coordination for Resident 21 |
| Dialysis RD 2 | Dialysis Registered Dietician | Interviewed regarding diet and potassium content for Resident 21 |
| RN 1 | Registered Nurse | Observed failing to disinfect medical equipment between resident use |
| Director of Staff Development | Director of Staff Development | Interviewed regarding infection control practices |
| Diet Services Manager | Diet Services Manager | Interviewed regarding food labeling and storage practices |
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