Health inspection·July 23, 2024

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on interview and record review, the facility failed to ensure the treatment for scabies (a contagious, itchy skin rash caused by a tiny burrowing mite called Sarcoptes scabiei.) for one of two sampled residents (Resident 1) was carried out according to the physician order and instructions when Permethrin topical cream (used to treat scabies) was washed off two hours after application. There was no evidence the medication error was reported to the physician. This failure had the potential for Resident 1's scabies treatment to be ineffective and could lead to spread of Scabies to other residents and staff at the facility. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted in April 2024 and readmitted in July 2024, with multiple diagnoses including dementia (a loss of brain function that occurs with certain diseases, affecting one or more brain functions such as memory, thinking, language, judgment, or behavior). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan), dated 5/23/24, the MDS Section C indicated Resident 1 had severe cognitive impairment. During a review of MDS Section GG, the MDS indicated Resident 1 required substantial/maximal assistance for showers/bath. During a review of Resident 1's, Physician Orders, dated 6/28/24, the Physician Orders indicated, Permethrin 5%. Apply from scalp to toe including soles of the feet. Wash off after 12 hrs. Repeat in 1 week . During a review of Resident 1's, Treatment Administration Record (TAR), dated June 2024, the TAR indicated permethrin 5% topical cream one time daily for one day starting 6/28/24, order date 6/27/24. Discontinued 6/28/24 Notes: apply to entire body from head to toe and under fingernails. Refer to manufacturer ' s instructions. Apply one time .leave on 12 hrs. and wash off after 12 hours. for: skin rash. A review of the TAR indicated Resident 1 had received the one-time permethrin treatment that was scheduled for 5 a.m. on 6/28/24 as it showed initials of the nurse. During a telephone interview on 7/30/24 at 1:24 p.m., the Corporate Clinical Services Resource (CCSR) acknowledged that the permethrin cream was supposed to be left on for 8-12 hours before they wash it off, but the facility staff washed it off two hours after the application. CCSR also stated, the (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 056103 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056103 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Shore Post Acute 508 Westline Drive Alameda, CA 94501 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)