Health inspection·January 30, 2025

F 0584 Level of Harm - Minimal harm or potential for actual harm Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observation, interview and record review facility did not promptly investigate and act upon complaints of one of one sampled resident's (Resident 11) missing personal belongings (sweatpants). Residents Affected - Few This failure resulted in the Resident 11 feeling angry. Findings: During a record review of Resident 11's admission record, the admission record indicated, Resident 11 was admitted to the facility in August 2024 and family representative (FR1) was the responsible party. During record review of Resident 11's Inventory of Personal Effects, dated 08/20/24,the record indicated two pair of sweatpants were listed as items acquired. During an interview on 01/28/25 at 09:40 a.m. FR1 stated, Resident 11 had lost around two- three sweatpants over time, since admission. FR1 stated he had made one or two Certified nursing assistants (CNA) aware of missing items at the time items went missing. During an observation on 01/28/25 at 10:04 a.m. FR1 gave CNA1 a verbal description of two missing sweatpants. During an interview on 01/30/25 at 09:31 a.m. CNA1 stated she told the SSD about Resident 11's missing personal belongings, on the week of 01/13/25 when FR1 initially reported loss personal belongings (three sweatpants). CNA1 stated she and SSD looked for pants together on week of 01/13/25 and did not find any. CNA1 also stated when a resident reports missing items, staff was to report that to SSD, and if facility could not locate the missing belongings, the facility needed to replace the item. CNA1 stated she was unaware of where theft and loss reports were located as she typically only made the reports to the SSD verbally. During an interview on 01/30/25 at 09:35 a.m. with CNA1 and SSD, SSD stated she remembered when CNA1 initially reported missing sweatpants for Resident 11 on the week of 01/13/25. SSD stated they searched for Resident 11's sweatpants on both floors but could not find them. SSD stated, they should have documented a loss report to properly and promptly investigated Resident 11's complaint of missing items. During an interview on 01/30/25 at 09:42 a.m. Resident 11 stated she felt upset the facility could Page 1 of 6 056096 056096 01/30/2025 Piedmont Gardens Health Facility 110 41st Street Oakland, CA 94611

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few not locate her personal property sooner. FR1 stated facility makes me angry when Resident 11 does not have sweatpants returned from laundry for dressing and feeling forced to report missing personal property multiple times. FR1 stated Resident 11 was still missing one pair of sweatpants, and he had discussed matter with SSD. During an interview and concurrent record review on 01/29/25 at 10:01 a.m. Social Services Director/Case Manager (SSD) stated when residents reported missing belongings to CNA's, clinical staff, and anyone on the care team, staff were to complete a theft and loss report to initiate further investigation. SSD stated she had no theft and loss reports for Resident 11 from 08/2024 till date. During an interview on 01/30/25 at 10:19 a.m. Director of Nursing (DON) stated if a resident reported missing personal belongings all staff were alerted, including the laundry staff, staff were to search room to room on both floors and a loss report was to be completed by resident and/or family and SSD follows up to replace or reimburse. DON stated,SSD is primarily responsible for investigating loss report once completed. During record review of ' Personal Property ' policy and procedures (P&P) indicated, The facility promptly investigates any complaints of misappropriation or mistreatment of resident property. 056096 Page 2 of 6 056096 01/30/2025 Piedmont Gardens Health Facility 110 41st Street Oakland, CA 94611

F 0656 Level of Harm - Minimal harm or potential for actual harm Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on observation, interview and record review, the facility staff did not have comprehensive care plan for bed alarms and chair alarm as fall prevention for 3 out of 8 sampled residents(Resident 36, 55 and 44.) Residents Affected - Some The failure to not care plan interventions for bed alarm use under fall risk for Resident 36, 55 and 44 has the potential to not provide direct or limited staff supervision for resisdents and also to not accurately monitor, provide care, and reassess the effectiveness of the bed alarms. Findings: During an observation on 1/27/25 at 10:15 a.m. in Resident 44's room, Resident 44 was had a bed alarm strapped to the siderail of her bed while she was asleep in bed. During an observation on 1/27/25 at 10:27 a.m., in Resident 55's room, Resident 55 was up in a wheelchair with family husband and daughter visiting at her bedside. Resident 55 had a white portable position alarm on her wheelchair and a green portable bed alarm strapped to the siderail of Resident 55's bed. During an observation and an interview with Resident 36 on 1/27/25 at 10:43 a.m. in Resident 36's room, Resident 36 was laying in bed resting. Resident 36 had a green portable bed alarm strapped to her bed. Resident 36 stated she gets Physical therapy (PT )in bed in bed for now and she has to be repositioned by staff. During an interview on 1/27/25 on 11:09 a.m. with Licensed Vocational Nurse (LVN 3), LVN 3 stated bed alarms are used on Residents with high risk fall. LVN 3 stated facility should inform the family about the use of bed alarms and document it in the care plan and discuss it in Interdisciplinary Treatment (IDT) together with Social Worker, Case Manager, and Director of Staff Development (DSD). During an interview on 1/27/25 at 11:22 a.m. with Director of Nursing (DON), DON stated bed alarms or position change alarms are only used on residents on high risk falls and falls with injury. During a record review on 01/28/25 of Resident 44's Care Plan, Care plan indicated a fall risk was initiated on 7/2/24 with a targeted date of 1/30/24 and was last revised on 7/2/24. Care Plan also indicated Resident 44 is at moderate risk for falls. The Care plan does not include the use of bed alarms or position alarms. During a record review on 01/28/25 of Resident 55's Care Plan, Care plan indicated a fall risk initiated on 12/27/24 with a targeted date of 3/24/25 and was last revised on 1/16/25. Care Plan also indicated Resident 44 is at moderate risk for falls. The Care plan does not include the use of bed alarms or position alarms. During a record review on 01/28/25 of Resident 36's Care Plan, Care plan indicated a fall risk was initiated on 10/29/24 with a targeted date of 1/29/24 and was last revised on 11/14/24. Care Plan also indicated Resident 36 is at moderate risk for falls. The Care plan does not include the use of bed alarms or position alarms. 056096 Page 3 of 6 056096 01/30/2025 Piedmont Gardens Health Facility 110 41st Street Oakland, CA 94611

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 1/30/25 at 09:30 a.m. with DON DON stated bed alarm should be in the care plan because the care plan is what the facility follow to care for the residents. The DON further stated that the care plan should be updated quarterly, when the residents are due for MDS assessment every three months. During an interview on 1/30/25 at 10:11 a.m. with Minimum Data Set Coordinator (MDSC), MDSC stated it is important for facility to have acre plan for use of bed alarms as it shows the bed alarm is one of the intervention being used and is one of the care plan facility uses for resident safety. During a review of Facility Policy and Procedure (P and P), titled 'Bed and chair Alarm for Fall Prevention, dated 1/29/2025, pg 1, indicated, it is policy of HumanGood to establish guidelines for the appropriate use of bed and chair alarms as part of a comprehensive fall prevention program, ensuring resident safety while adhering to federal and state regulations and promoting dignity and independence. These alarms are to be used as part of a multifacted fall prevention strategy and must not be used as restraints or as substitute for direct supervision and other fall prevention interventions. Procedure: Assessment and indications for Use: Conduct a comprehensive fall risk assessment for each resident upon admission, after any fall, quarterly, and with any significant change in condition. Reassess the necessity of alarms and discontinue use when they are no longer needed, documenting the rationale for continuation or discontinuation. 056096 Page 4 of 6 056096 01/30/2025 Piedmont Gardens Health Facility 110 41st Street Oakland, CA 94611

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm 2.During an observation and an interview on 01/29/25 at 08:44 a.m the glucometer was stored in the med cart with three spots of blood stains on the back of it. LVN 1 stated she was supposed to have cleaned the glucometer for infection control prevention. LVN 1 further stated the glucometer was supposed to be cleaned after every resident use. Residents Affected - Some During an interview on 01/29/25 at 08: 48 a.m. with Infection Preventionist (IP), the IP stated glucometer needs to be disinfected after each use to prevent infection. During an observation on 1/29/25 at 08:51a.m. with LVN 2, LVN 2 came out of Resident 36' s room, and was wiping her hands with two paper towels. LVN 2 placed used paper towels on top of the med cart after wiping her hands with it. LVN 2 did not sanitize the contaminated med cart prior to prepping meds for Resident 42. During an interview on 1/29/25 at 08:53 a.m. with LVN 2, LVN 2 stated the paper towel on top of the med cart was the paper towel she had used to wipe her hands after she had washed her hands. LVN 2 further stated she was supposed to have thrown the used paper towel in the trash instead of placing it on the med cart and sanitize the med cart in between patients for cross contamination. During a review on 01/29/25 of facility ' s Policy and Procedure (P and P) titled Hand Hygiene Program, dated 2010, the P & P indicated, Rationale for hand hygiene: Prevent transmission of infectious agents. Hand hygiene Hand hygiene should be performed in the area where the hands were contaminated (this may be done in the resident ' s bathroom if the resident or the environment/equipment of the resident was handled). Indications for performing hand hygiene before and after contact with resident or their environment, before and after glove use, before handling clean linen, and after disposal of soiled linen. After touching items that are likely to be contaminated (bedpans, urinal), Note: gloves should always be changed between residents and between clean and contaminated sites on the same resident. Gloves use not preclude the need for hand hygiene after removing gloves. Based on observation ,interview record review, facility staff including Certified Nursing Assistant (CNA), Licensed Nurses (LNs), and Maintenance Staff did not perform hand hygiene while providing care to one of five sampled residents (Resident 42) when : 1.CNA 3 did not perform hand hygiene before and after putting in hearing aides in Resident 42 's ears and before donning gloves for incontinence care. 2.LNs did not sanitize/disinfect glucometer and flat surfaces to keep medication tray during medication administration. This failure placed all residents at risk for spread of in infection. 1. Findings: During an observation on 01/29/25 at 09:45 a.m. without performing hand hygiene, CNA 3 entered Resident 42's room, placed Resident 42's hearing aid in both ears with bare hands, without performing hand hygiene, CNA 3 donned gloves and provided incontinence care to Resident 42. During an interview on 01/29/25 at 12:07 p.m. CNA 3 stated hand hygiene includes gel in, gel out 056096 Page 5 of 6 056096 01/30/2025 Piedmont Gardens Health Facility 110 41st Street Oakland, CA 94611

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some and hand washing with soap and water when hands or gloves are visible soiled. CNA 3 stated should have completed hand hygiene before donning gloves to perform incontinence care for Resident 42. CNA 3 stated it is important to perform hand hygiene to reduce transfer of infection. During an interview on 01/29/25 at 12:20 p.m. with Infection Preventionist (IP), IP stated hand hygiene should be done before and after donning gloves when providing direct resident care, and hand washing especially if hands are visibly soiled. IP stated staff should complete proper hand hygiene in before performing incontinence care to prevent spread of germs and infection. During record review of the 'Handwashing/Hand hygiene' policy and procedure (P&P), dated 08/2019, indicated, wash hands with soap and water for the following situations: a. when hands are visibly soiled and use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: b. before and after direct contact with residents; e. after contact with objects (e.g. medical equipment) in the immediate vicinity of the resident. 056096 Page 6 of 6