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 Page 1 of 3 056103 056103 07/23/2024 West Shore Post Acute 508 Westline Drive Alameda, CA 94501

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few facility staff should have notified the doctor right away after the permethrin cream was accidentally washed off two hours after application. CCSR also stated, facility staff should do endorsement to the next shift, so that doctor could give another order. CCSR stated there was no note about the incident in resident records. CCSR stated, she was unable to know if they had a summary of the incident. During a telephone interview on 7/30/24 at 3:24 p.m., with Licensed Vocational Nurse (LVN) 2, LVN 2 stated she could not recall the incident about the permethrin being washed off before 12 hours because it has been a month. LVN 2 stated, she only remembered what she had in her notes about Resident 1 going to dermatology appointment, and she endorsed to evening shift that Resident 1 had gone to dermatology appointment. During a telephone interview on 8/2/24 at 12:24 p.m. with LVN 3, LVN 3 stated, she applied the permethrin cream for Resident 1 on 6/28/24, signed it, wrote it down, and endorsed to the next shift nurse (LVN 2) that they should leave the cream on for 12 hours before they wash it off. LVN 3 stated, they have it written in the 24 hours report for change of condition of residents, but not sure when they washed it off, as she was not working the next day. During a telephone interview on 8/2/24 at 1:03 p.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated, she was the assigned CNA for Resident 1 on 6/28/24. CNA 1 acknowledged that she was the one that gave a shower on the day Resident 1 had the cream for scabies. CNA 1 stated, she later found out the cream was applied on Resident 1 the previous shift between 5 a.m. and 6 a.m. and was supposed to be left on for 12 hours. Nobody told her that they put the cream on. CNA 1 stated, she gave Resident 1 a shower at around 9 a.m. because it was his shower day. CNA 1 stated, the charge nurse (LVN 2) only told her after she had given the Resident1 a shower, that Resident 1 was not supposed to have a shower until 12 hours after the cream was applied. During a review of the facility's policy and procedure (P&P) titled, Medication Administration, undated, the P&P indicated, Purpose: to accurately administer medications to residents .medications shall be administered as ordered by the licensed nurse .the nurse shall notify the physician immediately after a medication error has been noted . During a review of the facility ' s P&P titled, Scabies Identification, Treatment and Environmental Cleaning, revised August 2016, the P&P indicated Treatment with Permethrin .5. leave cream on for at least 8 hours but no more than 12 hours, and then shower or bath the resident . A review of the Daily Med article, Permethrin cream, accessed 8/20/24, for the drug label for permethrin 5% cream indicated, The cream should be removed by washing (shower or bath) after 8 to 14 hours . 056103 Page 2 of 3 056103 07/23/2024 West Shore Post Acute 508 Westline Drive Alameda, CA 94501

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm The facility failed to ensure a Certified Nursing Assistant (CNA) 1 followed infection control protocols for one of one sampled Resident (Resident 1) when CNA 1 did not perform hand hygiene prior to feeding lunch to Resident 1. Residents Affected - Few This failure had the potential for contaminating Resident 1's food with pathogens from a variety of dirty sources. 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 concurrent observation and interview on 7/23/24 at 11:50 a.m. CNA 1 wheeled Resident 1 from the hallway into his room and to his bedside. CNA 1 placed the overbed table with meal tray in front of Resident 1. CNA 1 placed her chair close to Resident 1. CNA 1 looked around for a cloth protector (adult bib), then opened the bathroom door. CNA 1 went into the bathroom, got a long paper towel, and came out of the bathroom without performing hand hygiene, and placed the paper towel over Resident 1's front shirt. CNA 1 sat down, removed the cover, placed the spoon in the food and started to feed Resident 1 without performing hand hygiene. CNA 1 stated she did not wash her hands or use the hand sanitizer before or after wheeling Resident to the room, and prior to setting up Resident 1's tray and feeding him. CNA 1 also stated she was supposed to wash her hands or use the hand sanitizer to prevent the spread of germs. CNA 1 also acknowledged she did not clean Resident 1's hands before assisting him with feeding During an interview on 7/23/24 at 1:45 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated staff are supposed to wash their hands and wash the resident's hands with a towel before feeding the resident. LVN 1 stated it is important to minimize spread of germs and prevent infection. LVN 1 also stated staff are also supposed to sanitize their hands before entering a resident's room. During an interview on 7/23/24 at 4:05 p.m. with Director of Staff Development (DSD), DSD stated staff needed to gel in, gel out of resident ' s room. DSD stated staff are supposed to wash their hands and clean the resident's hands before they feed a resident. DSD also stated they have the wet wipes in the blue packet which they use to clean residents' hands. During a review of the facility's policy and procedure (P&P) titled, Infection Control Handwashing/Hand Hygiene, revised in August 2014, the P&P indicated, Use an alcohol-based hand rub .or alternatively, soap (antimicrobial or non-microbial) and water for the following situations .Before eating or handling food; Before and after assisting a resident with meals . 056103 Page 3 of 3