Health inspection·February 20, 2026

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure resident care item was cleaned and disinfected (objects treated with chemicals to kill germs, bacteria, and viruses, reducing the risk of infection) according to manufacturer's instructions for one of one sampled resident (Resident 1) when Resident 1's urine collection canister was not fully submerged in a dish soapy solution for cleaning and in 70% isopropyl alcohol (IPA) for disinfection for a minimum of ten minutes.This failure had the potential for Resident 1 to be exposed to infections.During a review of Resident 1's admission Record, dated 2/20/26, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with an admission diagnoses of chronic (a condition or disease that is persistent or otherwise long-lasting in its effects) systolic heart failure (a serious condition that occurs when the left chamber of the heart is unable to pump blood efficiently), acute myocardial infarction (a medical emergency that occurs when blood supply to the heart is blocked), type 2 diabetes mellitus (a chronic condition where the body develops resistance to insulin, a vital hormone produced by the pancreas that regulates blood sugar, causing high blood sugar levels because cells fail to respond to insulin properly).During a record review of Resident 1's Minimum Data Set (MDS, an assessment used to guide plan of care) dated 1/5/26, the MDS indicated Resident 1's Brief Interview for Mental Status (BIMS, is a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information) score was 15 out of 15, indicating intact cognitive response.During a concurrent observation and interview on 2/20/26 at 10:59 a.m. with Resident 1, in Resident 1's room, Resident 1 was pointing at a clear tubing at the right side of his yellow adult briefs connected into a clear canister with a blue cover on a urine collection system machine. Resident 1 stated, the canister was never once disinfected. Resident 1 stated, the canister had been rinsed with only soap and water.During an interview on 2/20/26 at 11:08 a.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 1's urine canister was cleaned with soap and water once or twice a day. CNA 1 stated there was no documentation for the canister cleaning.During a concurrent observation and interview on 2/20/26 at 11:21 a.m. with the Infection Preventionist (IP), in Resident 1's bathroom, an undated document titled, Cleaning Procedure for Purewick Cannister, Tubing, and External Catheter was posted on the wall. The IP stated staff were educated to clean and disinfect the canister with soap and water and to wipe off sediments with a brush. The IP stated there was no documentation for the canister cleaning.During a review of facility provided document titled, Cleaning Procedure for Purewick Cannister, Tubing, and External Catheter, undated, indicated, Disinfecting the Cannister: Will be done daily every shift. 1. Empty urine in the toilet. 2. Clean the canister by scrubbing with soap and water using a brush to remove debris. 3. Dry with a paper towel.During a concurrent interview and record review on 2/20/26 at 12:41 p.m. with the IP, the facility's policy and procedure (P&P) titled, External Catheter for Female Urinary Incontinence Management, dated 3/1/23 was reviewed. The (P&P) indicated, An Residents Affected - Few Page 1 of 2 056052 056052 02/20/2026 Eden Healthcare Center 27350 Tampa Avenue Hayward, CA 94544

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few external female catheter is a noninvasive (not requiring the introduction of instruments into the body) option to manage female urinary incontinence (involuntary loss of bladder control, causing urine leakage that ranges from minor leaks to sudden, uncontrollable accidents) by drawing urine away from the resident and into a collection cannister. Compliance Guidelines: . 7. The female external catheter urine collection system and accessories should be cleaned and disinfected at the time of each use or at a minimum, daily as per manufacturer's instruction. The IP stated creating the Cleaning Procedure for Purewick Cannister, Tubing, and External Catheter document by summarizing the manufacturer's instruction.During a follow up interview and record review on 2/20/26 at 1:25 a.m. with the IP, the manufacturer's instruction titled, Cleaning the Collection Canister, undated, was reviewed. The Cleaning the Collection Canister indicated, Initial Rinse: Rinse the canister and lid thoroughly with cool tap water. While rinsing, remove any excess dirt by wiping the canister and lid with disposable low lint wipes. Cleaning: Prepare a soapy solution by mixing 1 teaspoon (approximately 5 mL) of dish soap with approximately 4 L of cool tap water. Fully submerge canister and lid in the solution. Allow it to sit for a minimum of ten (10) minutes. While submerged, use a soft brush (e.g., toothbrush) to brush all accessible areas of the canister and lid for a minimum of one (1) minute to remove any visible signs of debris or dirt. Rinse: Rinse the canister and the lid thoroughly with cool tap water until there is no visible sign of the cleaning solution. Visual inspection: Inspect the canister and the lid to ensure that all debris and dirt have been removed. If there is any sign of debris or dirt, repeat steps above until there is no sign of debris or dirt remaining on the canister and lid. Disinfection: Fully submerge the canister and lid in 70% isopropyl alcohol (IPA). Allow it to sit for a minimum of ten (10) minutes. Rinse: Rinse the canister and the lid thoroughly with cool tap water. Drying: Dry the canister and lid with a clean low lint towel or cloth. The IP stated, following the manufacturer's instruction in cleaning and disinfecting the canister could prevent the growth of bacteria and fungus and prevent resident exposure to infection. The IP stated the canister would be considered a non-critical care item.During a concurrent interview and record review on 2/20/26 at 1:56 p.m. with the Director of Nursing (DON), Resident 1's Order Summary Report dated 11/11/25 was reviewed. The Order Summary Report indicated, Resident 1 was to use Purewick urine collection system every shift for urine incontinence management. The DON stated, Resident 1 preferred to use external female catheter (a soft, flexible wick that sits outside the body).During a review of the facility's policy and procedure titled, Cleaning and Disinfection of Resident-Care Items and Equipment, undated, indicated, c. Non-critical items are those that come in contact with intact skin but not mucous membranes (the moist, inner lining of some organs and body cavities) . 2. Intermediate and low-level disinfectants for non-critical items include: a. ethyl or isopropyl alcohol. 056052 Page 2 of 2