Health inspection·December 5, 2019

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to provide personal hygiene assistance (combing hair, brushing, teeth, shaving, washing, and drying the face and hands) to one of 18 sampled residents (Resident 36) when Resident 36's facial hair was not shaved. Residents Affected - Few This failure resulted in Resident 36, a female, having overgrown facial hair resembling a mustache and beard. Findings: During a review of Resident 36's Minimum Data Set (MDS, an assessment tool used to guide care) dated 10/2/19, indicated Resident 36 had a Brief Interview for Mental Status (BIMS, a tool used to assess mental function) score of 03, indicating Resident 36 was severely cognitive impaired. The MDS also indicated Resident 36 needed extensive assistance of one person with her Activities of Daily Living (ADLs). During a concurrent observation and interview on 12/2/19 at 12:20 p.m., with Resident 36 and the Director of Staff Development (DSD), in the main dining room, Resident 36 was observed to have overgrown facial hair (beard and mustache). Resident 36 stated, I don't like it but no one does it for me. The DSD stated, She used to refuse to be shaved, but they will do it today. When the DSD asked Resident 36 if she wanted to be shaved, Resident 36 indicated she did want to be shaved. During an interview on 12/4/19 at 1:31 p.m., with Certified Nursing Assistant 1 (CNA 1), CNA 1 indicated Resident 36 sometimes refused to be shaved, but not all the time. CNA 1 also indicated she was aware Resident 36 was not shaved on 12/2/19. During a review of the facility's policy and procedure (P&P) titled, Routine Resident Care, dated September 2011, the P&P indicated, Residents receive the necessary assistance to maintain good grooming and personal hygiene . Page 1 of 8 056170 056170 12/05/2019 Excell Health Care Center 3025 High Street Oakland, CA 94619

F 0695 Provide safe and appropriate respiratory care for a resident when needed. 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 follow the physician's order for oxygen administration for one of 18 sampled residents (Resident 29), when Resident 29's oxygen flow rate was not at the specific ordered rate. Residents Affected - Few This failure had the potential to result in life threatening adverse effects for Resident 29, who had a medical history of Chronic Obstructive Pulmonary Disease (COPD, a term used to describe progressive lung diseases including emphysema, chronic bronchitis, and non-reversible asthma) due to oxygen toxicity. Findings: During a review of Resident 29's face sheet dated 12/4/19, the face sheet showed Resident 29 was admitted with multiple diagnoses, including COPD and lung cancer. During a review of the Brief Interview for Mental Status (BIMS, a tool used to assess mental function) in Resident 29's Annual Minimum Data Set (MDS, an assessment tool used to guide care), dated 6/25/19, Resident 29's BIMS score was 15, meaning Resident 29 was cognitively intact. The MDS also indicated Resident 29 required oxygen therapy. During a concurrent observation and interview on 12/2/19, at 10:19 a.m., with Resident 29, in room [ROOM NUMBER]-2, Resident 29 was receiving oxygen via a nasal cannula (NC, a tube used to deliver supplemental oxygen) and set at a flow rate of 3.5 Liters (L, a unit of measurement). Resident 29 stated the flow rate is supposed to be 2 L NC. Resident 29 indicated that due to his medical conditions, he needs oxygen all the time. During a concurrent observation and interview on 12/2/19, at 11:58 a.m., with Licensed Vocational Nurse 2 (LVN 2), in room [ROOM NUMBER]-2, LVN 2 confirmed the oxygen administration rate was set at 3.5 L NC. LVN 2 stated Resident 29's flow rate was supposed to be at 2 L NC. LVN 2 indicated if Resident 29 felt short of breath and notified the licensed nurse, LVN 2 would assess the resident and provide the 'as needed' (PRN) inhaler or nebulizer as ordered. LVN 2 would then notify the physician. LVN 2 stated there is no order for the oxygen flow rate to be titrated (adjusting the concentration). During a review of Resident 29's Medication Administration Record (MAR) for December, the MAR indicated a physician's order was placed on 2/28/18 at 6:01 p.m. for oxygen to be administered at 2 L/NC, continously. During a subsequent interview with LVN 2, on 12/4/19, at 1:53 p.m., LVN 2 stated that with Resident 29's medical history of COPD and lung cancer, the oxygen flow rate for Resident 29 needed to be monitored and not increased without an order. LVN 2 indicated Resident 29 should not be given more oxygen than what was ordered because it could cause a build up of carbon dioxide (CO2) in the blood, and Resident 29 would not be able to expel CO2 properly from his lungs when feeling short of breath. 056170 Page 2 of 8 056170 12/05/2019 Excell Health Care Center 3025 High Street Oakland, CA 94619

F 0726 Level of Harm - Minimal harm or potential for actual harm Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Based on interview and record review, the facility failed to ensure competency skills checks for three of five licensed nursing staff were completed. Residents Affected - Some This failure had the potential for care to be provided by licensed nurses in an unsafe and incompetent manner. Findings: During an interview on 12/4/19, at 12:04 p.m., with the Director of Nursing (DON), DON acknowledged her role as the nursing supervisor included conducting competency skills checks for all licensed nurses. During an interview on 12/4/19, at 12:33 p.m., with Registered Nurse 1 (RN 1), RN 1 stated DON had never done a competency skills checklist with her. During a review of employee personnel files, the files indicated RN 1 was hired on 10/24/11, LVN 1 was hired on 8/21/17, and LVN 4 was re-hired on 10/3/18. No competency skills checklists for RN 1, LVN 1, and LVN 4 could be found in their employee personnel files. During a concurrent interview and record review on 12/4/19, at 12:49 p.m., with DON, DON could not show current and previous years' competency skills checklists for three licensed nurses. 056170 Page 3 of 8 056170 12/05/2019 Excell Health Care Center 3025 High Street Oakland, CA 94619

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure the medication error rate was less than five percent (5%) when, during a medication pass observation, three medication errors out of 32 opportunities resulted in a 9.3% error rate because: Residents Affected - Some 1. Licensed Vocational Nurse 2 (LVN 2) did not follow the manufacturer's specifications when administering a potassium chloride tablet without food to Resident 32. 2. Licensed Vocational Nurse 3 (LVN 3) incorrectly crushed and administered an enteric-coated aspirin to Resident 83 and also administered a potassium chloride tablet without food to Resident 83. These failures had the potential to result in undesired health outcomes for Residents 32 and 83, such as stomach irritation, gastric ulcer, and gastric bleeding. Findings: 1. During a medication pass observation on 12/4/19 at 9 a.m., LVN 2 prepared and administered 13 medications to Resident 32, including potassium chloride (Klor-con). During a review of the Order Summary Report for Resident 32, the physician's order, dated 9/2/14, stated, Klor-con M20 ER [ER, extended release] 20 MeQ [MeQ, a unit of measurement] tab--give one tablet a day for supplement. Administer with meals. During a review of the Klor-con M20 medication label, the label stated, Give with food/meals. Take with plenty of water. During an interview on 12/4/19 at 1:16 p.m., with LVN 2, LVN 2 indicated she should have given the Klor-con with food, according to the physician's orders. LVN 2 stated, This medication interacts in the stomach. It has something to do with binding . LVN 2 also indicated the pharmacist told the licensed nurses to give the medications as instructed on the label. 2. During a medication pass observation on 12/4/19 at 9:50 a.m., LVN 3 prepared and administered seven tablets to Resident 83, including enteric-coated (EC) aspirin and Klor-con to Resident 83. (Enteric coating is a delayed-release safety coating designed to allow the aspirin tablet to pass through the stomach to the small intestine before dissolving, thereby providing added stomach protection.) LVN 3 crushed all the tablets, including the enteric-coated aspirin, and mixed them in applesauce in a medicine cup. LVN 3 placed the Klor-con tablet in a separate medicine cup and administered it separately with apple sauce. During a review of the Order Summary Report for Resident 83, a physician's order, dated 12/3/19, indicated, Potassium Chloride (KCL) ER tab 10 MeQ, give one tablet by mouth one time a day for supplement. Give with food. During a review of the KCL ER medication label, the label stated, Take this medication with a meal. Take with plenty of water. During a review of the Order Summary Report for Resident 83, a physician's order, dated 11/3/19, indicated, Aspirin EC Tablet Delayed Release, 81 mg [milligrams, a unit of measurement] 056170 Page 4 of 8 056170 12/05/2019 Excell Health Care Center 3025 High Street Oakland, CA 94619

F 0759 (Aspirin)--give 1 tablet by mouth, one time a day for A. Fib [atrial fibrilation, a heart condition]. Level of Harm - Minimal harm or potential for actual harm During an interview on 12/4/19 at 1 p.m. with LVN 3, LVN 3 admitted crushing the enteric-coated aspirin, and stated, Coated medications should not be crushed. LVN 3 also indicated Resident 83 had eaten breakfast at 7:30 a.m., and the KCL tab should have been given with food. LVN 3 stated, It is for better absorption, with food. Residents Affected - Some During a telephone interview on 12/4/19 at 1:26 p.m. with the facility's Registered Pharmacist (RPh), RPh stated, Enteric-coated medications should not be crushed. It may be harmful to the patients. The crushed enteric-coated medications also loses the protective coating which could be harsh on the stomach. During a review of the manufacturer's instructions for the administration of potassium chloride, the instructions indicated Klor-Con M tablets should be taken with meals and with a glass of water or other liquid. This product should not be taken on an empty stomach because of its potential for gastric irritation. During a review of the Institute for Safe Medication Practices (ISMP) guidelines titled, Oral Dosage Forms That Should Not Be Crushed, commonly referred to as the Do No Crush list, enteric-coated aspirin is listed as a medication that should not be crushed because it is coated and designed to be released slowly. During a review of the facility's policy and procedure (P&P) titled, Medication Administration, dated 06/08, the P&P indicated, Medications are administered in accordance with the written orders of the attending physician .The nurse is responsible to read and follow precautionary or instructions on prescription labels .Check the Do Not Crush list before crushing medications. 056170 Page 5 of 8 056170 12/05/2019 Excell Health Care Center 3025 High Street Oakland, CA 94619

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure safe storage of medications when a bottle of Timolol Maleate eye drops (a medication used to lower pressure in the eyes) was stored in the medication refrigerator instead of at room temperature, as per the manufacturer's specifications. This failure had the potential for the effectiveness of the medication to be reduced and residents receiving the medication to not receive the full therapeutic benefit of the drug. Findings: During a concurrent observation and interview on 12/3/19, at 8 a.m., with Registered Nurse 1 (RN 1), in Medication Storage room [ROOM NUMBER], a bottle of Timolol Maleate eye drops was seen in the medication refrigerator and the refrigerator's temperature was 40 degrees Fahrenheit. The medication instructions printed on the Timolol Maleate box indicated Store at 25 degrees Celsius (77 degrees Fahrenheit). RN 1 stated, I don't know why this is here but it should not be stored in the refrigerator. We missed it. RN 1 indicated inappropriate storage of medications causes the medication to lose its efficacy. During a review of the facility's policy and procedure (P&P) titled, Storage of Medication, dated 05/12, the P&P indicated, Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier .Medications and biologicals are stored at their appropriate temperatures and humidity according to the United States Pharmacopeia guidelines for temperature ranges. Medications requiring storage at 'room temperature' are kept at temperatures ranging from 15 degrees Celsius (59 degrees Fahrenheit) to 25 degrees Celsius (77 degrees Fahrenheit). 056170 Page 6 of 8 056170 12/05/2019 Excell Health Care Center 3025 High Street Oakland, CA 94619

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 their infection control and prevention program was followed for two of 18 sampled residents when: Residents Affected - Few 1. Licensed Vocational Nurse 1 (LVN 1) did not wash his hands between glove changes and after providing wound care to Resident 10. 2. The urinary drainage bag for Resident 58 was on the floor. These failures had the potential to spread infection to Resident 10 and Resident 58. Findings: 1. During a wound dressing change observation on 12/2/19 at 9:45 a.m. with LVN 1, LVN 1 donned gloves, removed the soiled dressing, removed the gloves, put a new pair of gloves on without washing his hands, cleansed the wound, applied an ordered medical treatment to the wound, and covered the wound wearing the same pair of gloves. LVN 1 gathered the soiled dressing materials, discarded them, then removed his gloves. LVN 1 used hand sanitizer, and then exited Resident 10's room without washing his hands During an interview on 12/2/19 at 9:55 a.m. with LVN 1, LVN 1 admitted he did not wash or sanitize his hands between glove changes, and after cleansing the wound but prior to applying treatment to the wound. LVN 1 indicated he was supposed to wash his hands after every glove change and stated, I am supposed to wash with soap and water after doing [the wound care] treatment. During an interview on 12/2/19 at 11:20 a.m. with the Director of Staff Development (DSD), DSD stated, Staff must wash their hands before and after a procedure and after use of gloves before donning a new pair. During a review of the facility's policy and procedure (P&P) titled, Clean Dressing Change, dated 12/09, the P&P indicated, Put on gloves Remove soiled dressing, place in bag for disposal. Remove/dispose of gloves, wash hands, don clean gloves. Clean wound as ordered Remove/dispose of gloves, wash hands, don clean gloves. Apply dressing and secure as ordered Remove gloves; place in bag for disposal. Wash hands. 2. During a review of Resident 58's admission Record, dated 10/19/19, the admission Record indicated Resident 58 was admitted with multiple diagnoses, including obstructive and reflux uropathy (occurring when urine cannot drain through the urinary tract; urine then backs up into the kidneys and causes the kidneys to swell) and urinary retention. During an observation on 12/2/19 at 9:10 a.m. of room [ROOM NUMBER], Bed 2, Resident 58 was in bed with his urinary drainage bag hanging on the right side of his bed and touching the floor. During an interview on 12/2/19 at 9:15 a.m. with LVN 1, after LVN 1 checked the urinary drainage bag, LVN 1 stated, Yes, the catheter bag is touching the floor. How many inches should the catheter bag be off the floor? 056170 Page 7 of 8 056170 12/05/2019 Excell Health Care Center 3025 High Street Oakland, CA 94619

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of the facility's policy and procedure titled, Infection Prevention Program Overview, dated 2/18, did not reveal any specific information regarding catheter maintenance for the prevention of catheter-associated urinary tract infections. During a review of the professional guidelines the facility indicated they followed, Lippincott procedures on indwelling urinary catheter (Foley) care and management, dated 11/15/19, the Lippincott procedures indicated, .don't place the drainage bag on the floor to reduce the risk of contamination and subsequent CAUTI [catheter associated urinary tract infections]. During a review of the Centers for Disease Control's (CDC), Guideline for Prevention of Catheter-Associated Urinary Tract Infections, 2009, the CDC guidelines indicated at Proper Techniques for Urinary Catheter Maintenance, that the urine collection bag should not rest on the floor. 056170 Page 8 of 8