Health inspection·May 14, 2021

F 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Level of Harm - Potential for minimal harm Based on interview and record review, the facility failed to ensure one (Resident 1) of three sampled residents' comprehensive assessments were transmitted to the Centers for Medicare and Medicaid Services (CMS) within fourteen days after completion. Residents Affected - Some This failure to transmit the comprehensive assessment for 33 days after completion resulted in facility quality measures not being not up-to-date, and potentially inaccurate. Findings: A review of Resident 1's Quarterly Minimum Data Set (MDS, a resident assessment tool used to guide care) showed an assessment reference date (the date established as the reference point for the completed assessments) of 3/18/21, A review of Resident 1's MDS, section Z0500, dated 3/18/21, indicated the MDS assessment was completed and signed by a Registered Nurse on 3/26/21. During a concurrent interview and record review on 5/12/21, at 10:02 AM, with MDS Coordinator 1 (MDS 1), in the conference room, the MDS Report, dated 3/18/2021 was reviewed. MDS 1 stated the MDS Report accurately documented Resident 1's comprehensive assessment was completed but not transmitted. MDS 1 stated the comprehensive assessment was not transmitted because there was a discrepancy with Resident 1's birth date. MDS stated the discrepancy needed correction before the assessment could be transmitted. During a review of the CMS Submission Report - Final Validation Report, dated 5/12/21, the Report indicated the facility transmitted Resident 1's MDS assessment to CMS on 5/12/21 at 13:32. Calculation of the number of days between the due date of 4/9/21, and actual transmission date of 5/12/21 showed a total number of late days to be 33. During a concurrent interview and review of the facility's policy and procedure (P&P) on 5/12/21 at 11:16 AM, with MDS 1, in the conference room, the RAI Omnibus Budget Reconciliation Act-Required Assessment Summary, dated October 2019, was reviewed. MDS 1 confirmed the P&P indicated the Page 1 of 12 056392 056392 05/14/2021 Pleasanton Nursing and Rehabilitation Center 300 Neal Street Pleasanton, CA 94566

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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, for one of 18 sampled residents (Resident 227), the facility failed to develop and implement a care plan (a document that provides direction for provision of resident care) for indwelling urinary catheter use (a tube secured inside the bladder to drain urine into a bag outside the body). This failure had the potential to result in unmet care needs for Resident 227. Findings: A review of Resident 227's admission Record showed an admission date of 4/30/21 with an included diagnosis of acute infection. A review of Resident 227's physician's order dated 5/6/21, indicated an order for a urinary catheter, connected to a bag for urine collection by gravity drainage, to prevent urine retention in the bladder. During a concurrent interview and record review on 5/11/20 at 10:00 a.m., with the Director of Staff Development (DSD), the care plans for Resident 227 were reviewed. The DSD was unable to provide documentation of a care plan for Resident 227's IV therapy or indwelling urinary catheter. Review of Resident 227's Minimum Data Set (MDS, a resident assessment tool used to guide care) Care Area Assessment Summary, dated 3/22/21, indicated Resident 227 had occasional incontinent episodes. The MDS also indicated Resident 227 had triggered the care area titled, Urinary Incontinence and Indwelling Catheter, and the facility had indicated a care plan would be developed on 4/12/21. Review of the facility's policy titled, Comprehensive Care Plans, dated 7/1/20, indicated, It is the policy of this facility that a comprehensive, person-centered care plan that includes, measurable objectives . is developed and implemented for each resident. The care planning process will: .Describe services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .incorporate identified problem areas .incorporate risk factors associated with identified problems .reflect currently recognized standards of practice for problem areas and conditions Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. 056392 Page 2 of 12 056392 05/14/2021 Pleasanton Nursing and Rehabilitation Center 300 Neal Street Pleasanton, CA 94566

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 position one of 18 sampled residents (Resident 26), to facilitate eating. Residents Affected - Few For Resident 26 this failure had the potential to result in food aspiration (inhalation of foreign material into the lungs) with subsequent pneumonia or respiratory arrest. Findings: A review of Resident 26's admission Record, indicated Resident 26 was admitted to the facility in 2016 with diagnoses that included dementia (a decline in mental ability severe enough to interfere with daily life), cerebrovascular accident (CVA, impaired blood flow to the brain, commonly called a stroke), and dysphagia (difficulty swallowing). During a review of Resident 26's Minimum Data Set (MDS, an assessment tool used to direct care) dated 3/9/21, the MDS indicated Resident 26 had a brief interview with mental status (BIMS is a scoring system used to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.) score of six, an indication of severe cognitive impairment. The MDS also indicated Resident 26 required set-up and supervision by one person when eating. During an observation in Resident 26's room, on 5/11/21 at 9:03 a.m., Resident 26 lay in bed with a pillow behind his head, the head of the bed was elevated approximately 30 degrees. Resident 26 had the over bed tray table across his midsection with his breakfast tray on top of the over bed tray table. Resident 26 bent his head forward, his chin toward his chest, while he stirred his oatmeal. Certified Nursing Assistant 1 (CNA 1) entered the room and confirmed Resident 26 should have the elevation of the head of the bed increased so he could swallow more easily with less chance of choking. CNA 1 raised the head of the bed to 90 degrees but lowered it to 45 degrees when Resident 26 objected. Resident 26 stated the increased elevation to 45 degrees was good. During an interview and record review on 5/12/21 at 10:15 a.m. with the Director of Staff Development (DSD), the DSD confirmed the physician order summary dated May 2021 indicated Resident 26 had a history of dysphagia. DSD stated Resident 26 should be positioned upright for meals with HOB at 90 degrees or as close to 90 degrees as Resident 26 could tolerate, to help prevent food aspiration. During a review of the facility's policy and procedure (P & P) titled, Assisting the Resident with In-Room Meals, revised October 2010, the P & P indicated, The purpose of this procedure is to provide appropriate assistance for residents who choose to receive meals in the rooms .Review the resident's care plan and provide for any special needs of the resident .The resident should be positioned so his or her head and upper body are as upright as possible and with the head tipped slightly forward. If the resident is served his or her meal in bed, use wedges and pillows to achieve a nearly upright position . 056392 Page 3 of 12 056392 05/14/2021 Pleasanton Nursing and Rehabilitation Center 300 Neal Street Pleasanton, CA 94566

F 0694 Provide for the safe, appropriate administration of IV fluids 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** 2. A review of Resident 282's admission Record indicated Resident 282 was admitted to the facility with a diagnosis of urinary tract infection. Residents Affected - Few A review of Resident 282's clinical record titled, Midline Insertion Procedure Note, dated [DATE], indicated the physician inserted an IV catheter into Resident 282's upper left arm and threaded it through the vein into a large central body blood vessel (central IV line). The Note reflected the physician dressed the insertion site with a transparent semi-permeable membrane dressing. (TSM, a clear adhesive polyurethane film which allows exchange of oxygen and carbon dioxide but does not allow bacteria or fluids to pass through.) The Note indicated the central IV line was needed to provide IV antibiotic (medication to heal infection) treatment for at least ten days. A review of Resident 282's Medication Administration Record (MAR) dated [DATE], indicated an order with start date [DATE], to change the IV central line dressing every seven days and as needed when soiled. During an observation on [DATE] at 11:40 a.m., with Registered Nurse 2 (RN 2), in Resident 282's room, Resident 282's upper left arm central IV dressing was undated and had blood visible under the TSM dressing. RN 2 stated a central line dressing should be changed when soiled by blood such as was Resident 282's dressing. A review of the facility's policy and procedure titled, Catheter Insertion and Care, Central Venous Catheter Dressing Changes, undated, indicated, Central venous catheter dressings will be changed at specific intervals, or when needed, to prevent catheter-related infections that are associated with contaminated, loosened, soiled, or wet dressings Dressings must stay clean, dry, and intact Change transparent semi-permeable membrane (TSM) dressings at least every 5-7 days and PRN [as needed] (when wet, soiled, or not intact). Based on observation, interview, and record review, for two of 32 sampled residents (Resident 227 and Resident 282), the facility failed to ensure care and services for providing intravenous (IV, a tube/catheter inserted into a vein to administer fluids and medications) fluids and medication were consistent with accepted professional standards of practice and in accordance with physician's orders and comprehensive person-centered plans of care when: 1. For Resident 227, the IV insertion site (the entry point of the catheter into the patient's body) dressing, the IV bag (the container of the infusing fluid), and IV tubing (the connecting tubing between the IV bag and the IV catheter) were not labeled to indicate date of initiation or a date for discontinuation. This failure had the potential to result in infection from lack of timely dressing changes and/or expired product use. 2. For Resident 282, the IV site dressing was not labeled and not dated. This failure had the potential to result in infection from lack of timely dressing changes. Findings: 1. A review of the admission Record on [DATE] at 10:45 a.m., indicated Resident 227 was admitted on [DATE] with an included diagnosis of acute infection. 056392 Page 4 of 12 056392 05/14/2021 Pleasanton Nursing and Rehabilitation Center 300 Neal Street Pleasanton, CA 94566

F 0694 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of Resident 227's physician's order dated [DATE], indicated, Sodium Chloride 0.9% [a dilute salt-water solution] Infuse 50 mL/hr [milliliters per hour] intravenously every shift for hydration for 2 days . During an observation on [DATE] at 11:00 a.m., Resident 227 lay in bed watching television. An IV bag hung from a pole adjacent to his bed. The IV bag contained a solution of sodium chloride 0.9%. The IV bag had tubing which went through an IV pump to regulate the flow of the saline to deliver a continuous rate of 50 mL/hr. The tubing exited the machine and connected to a small catheter positioned inside a vein. The IV catheter insertion site was located on Resident 227's right lower arm. The IV bag, tubing, and insertion site were not labeled or dated. During an interview with Registered Nurse 1 (RN 1) on [DATE] at 11:05 a.m., RN1 stated the IV bag, tubing and site should have been labeled and dated. During a concurrent interview and record review on [DATE] at 10:13 a.m., with the Director of Staff Development (DSD), Resident 227's Medication Administration Record (MAR), Treatment Record, and progress notes were reviewed. DSD was unable to find documentation regarding IV administration or monitoring of the IV and dressing site. A review of the facility policy and procedure titled, Catheter Insertion and Care, Peripheral IV Dressing Changes, revised [DATE], indicated, Peripheral IV dressings will be changed when needed to prevent catheter-related infections associated with contaminated, loosened or soiled catheter-site dressings. Apply and maintain transparent semi-permeable membrane (TSM) dressing or sterile gauze for all peripheral intravenous catheter sites. Change the dressing if it becomes damp, loosened or visibly soiled and at least every 5 to 7 days Label dressing with date, time, and initials. The following should be documented in the resident's medical record: Date, time, type of dressing, and reason for dressing change. A review of the facility policy and procedure titled, Catheter Insertion and Care, Administration Set/Tubing Changes, revised [DATE], indicated, Administration sets and tubing will be changed at specific intervals in order to prevent infections associated with contaminated IV therapy equipment Label all tubing with start and change date and time. Change and then label accordingly any tubing that is observed not to have a label Primary and secondary continuous infusion administration sets: Change no more frequently than every 96 hours, or whenever suspected contamination has occurred Primary and secondary intermittent infusion administration sets: Change every 24 hours . 056392 Page 5 of 12 056392 05/14/2021 Pleasanton Nursing and Rehabilitation Center 300 Neal Street Pleasanton, CA 94566

F 0730 Observe each nurse aide's job performance and give regular training. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure certified nursing assistants completed annual mandatory training when: Residents Affected - Some 1. Four of six sampled certified nursing assistants (CNA 3, 4, 5, and 6) did not complete required annual training for care of residents with dementia (an impairment in memory, communication and thinking). 2. Two of six sampled certified nursing assistants (CNA 3 and CNA 6) did not complete required annual training for prevention of abuse. These failures had the potential for employees to provide improper or inadequate resident care provision. Findings: During an interview with the Director of Staff Development (DSD) on 5/11/21 at 9:15 a.m., DSD stated CNA 3, 4, 5, and 6 had not completed annual dementia training, and CNA 3 and CNA 6 had not completed annual abuse training. DSD stated there was no documentation of training classes offered during 2020. A review of Personnel Records for CNA 3, 4, 5, and 6 on 5/14/21 at 9:00 a.m., indicated the most recent CNA 3: Dementia training on 4/2/2020; abuse training on 3/21/2020. CNA 4: Dementia training on 10/28/2019. CNA 5: Dementia training on 10/29/2018. CNA 6: Dementia training 4/4/19; abuse training on 2/7/19. A review of the facility's policy and procedure titled, Staff Development Program, undated, reflected, All personnel must participate in initial orientation and regularly scheduled in-service training classes . Each program shall include, but not be limited to: .Abuse Program .Dementia. 056392 Page 6 of 12 056392 05/14/2021 Pleasanton Nursing and Rehabilitation Center 300 Neal Street Pleasanton, CA 94566

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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. Based on observation, interview, and record review, the facility failed to ensure that drugs were stored and labeled in accordance with currently accepted professional standards when: 1. Inside the medication room, a bottle of Amantadine (treats parkinson's disease) hydrochloride 50 milligram (mg.)/5 milliliter (ml.) syrup was not stored according to manufacturer's recommendation. This failure had the potential to result in decreasing efficacy of the medication. 2. Inside medication cart, 3 North, multiple medications were either stored beyond the expiration date or not labeled with open-on dates. This failure had the potential to result in medication's decreased therapeutic efficacy. 3. An opened and unlabeled bag of 0.9 % normal saline for injection was left at Resident 48's bedside. This failure had the potential to result in confusion and medication errors. Findings: 1. During an observation of the facility's medication room and concurrent interview with Director of Nursing (DON) on 5/11/21 at 11:15 a.m., there was an unopened bottle of Amantadine hydrochloride 50 mg./5 ml. stored inside the medication refrigerator. The refrigerator's interior temperature was 40 degrees Fahrenheit 40 deg. F. The bottle did not have a sticker refrigerate. DON stated, she was not sure whether the medication was supposed to be stored inside the refrigerator or at room temperature. During a follow-up interview and concurrent review of the manufacturer's drug information with DON on 5/12/21 at 10:49 a.m., DON stated, Amantadine was to be stored at room temperature. The manufacturer's literature indicated, Store at 20 to 25 deg. Centigrade (68 to 78 deg. F). 2. During an observation of medication cart 3 North and concurrent interview with Licensed Vocational Nurse (LVN) 1 on 5/11/21 at 11:55 a.m., the following were observed: - Albuterol HFA (treats asthma or breathing difficulty) 90 microgram (mcg.) inhaler, with expiration date 1/29/21. - Three opened combivent 100-20 mcg (treats asthma) inhalers with no opened-on dates. - Symbicort (treats asthma)160/4.5 inhaler, opened, with no opened-on date. - Latanoprost (lowers eye pressure) eye drops, opened, with no opened-on date. LVN 1 stated she did not know when the medications were opened. LVN 1 also stated, once opened and did not have any date, LVN 1 would not know if medication was still good to use. Review of the manufacturer's information provided by the DON on 5/13/21 at 1:30 p.m., indicated the following: 056392 Page 7 of 12 056392 05/14/2021 Pleasanton Nursing and Rehabilitation Center 300 Neal Street Pleasanton, CA 94566

F 0761 Level of Harm - Minimal harm or potential for actual harm - After assembly, combivent respimat inhaler should be discarded at the latest 3 months after first use or when the locking mechanism is engaged (120 actuations), whichever comes first. -Throw away symbicort when the counter reaches zero (0) or 3 months after you take symbicort out of its foil pouch, whichever comes first. Residents Affected - Some - For latanoprost eye drops, once a bottle is opened for use, latanoprost may be stored at room temperature up to 77 deg. F for 6 weeks. 3. During an observation and concurrent interview with Director of Staff Development on 5/10/21 at 12:35 p.m., there was an an opened, unlabeled bag of Dextrose 5% in Normal Saline that was still attached to an IV pole at Resident 48's bedside. DSD stated, Resident 48 did not have an intravenous line on either arms. DSD also stated, because the IV bag was not labeled, DSD did not know for sure if that was for Resident 48, or when the IV was opened. DSD stated, the bag should have been labeled with Resident 48's name and date of opening. DSD stated Resident 48 was not verbal and not aware of the surroundings. During an interview with DON on 5/10/21 at 1:46 p.m., DON stated Resident 48 had been on intravenous (through the vein) hydration on and off depending on oral fluid intake. DON stated she did not know the last time Resident 48 had an order to get intravenous hydration. 056392 Page 8 of 12 056392 05/14/2021 Pleasanton Nursing and Rehabilitation Center 300 Neal Street Pleasanton, CA 94566

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review the facility failed to ensure expired spices were not used for food preparation. Residents Affected - Some This failure had the potential to decrease food palatability and food intake with resultant weight loss for any of the 98 residents who orally consume food. Findings: During a concurrent observation and interview on 5/10/21 at 10:10 a.m., with the Dietary Manager (DM), in the kitchen, were the following spice containers: one undated Italian seasoning container, one undated whole thyme leaves, one whole bay leaves with an expiration date of 4/4/21, and one rosemary leaves with an expiration date of 8/20/19. DM stated all the spices had been used regularly in meal preparation. DM stated all the spice containers should be labeled with the date of receipt and the item expiration date. A review of the facility's policy and procedure, Food Safety Policies, Food Safety Product Labeling and Dating Guide, dated 1/27/2012, indicated the labels required for storing prepared food included, . date of preparation and/or 'use by' date . A review of the facility policy and procedure, Food Storage, dated 2017, indicated, All food that is past the manufacture's expiration date will be discarded. 056392 Page 9 of 12 056392 05/14/2021 Pleasanton Nursing and Rehabilitation Center 300 Neal Street Pleasanton, CA 94566

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to follow infection control practices to prevent spread of infection when: Residents Affected - Some 1. For one of 18 residents (Resident 26), the resident's over-bed tray table, and the bedside nightstand each had one unlabeled, soiled urinal, containing one-half inch of yellow liquid. 2. The Infection Preventionist (IP) failed to perform hand hygiene after picking up Resident 26's soiled urinals with bare hands, then donning gloves. 3. For two of 18 sampled residents (Resident 438), Housekeeper 1 (HK 1) entered the rooms in the area designated for Persons Under Investigation ((PUI, a resident whose infection status has not been definitely established by laboratory testing) for COVID-19 (a contagious infection that can result in severe breathing problems and death) without donning required Personal Protective Equipment (PPE, protective items or garments worn to protect the body or clothing from hazards that can cause injury/infection). 4. Certified Nursing Assistant 2 (CNA 2) held soiled bed linens from a resident bed against her uniform while transporting the linens to the soiled linen bin. These failures had the potential to result in infection and spread of infection. Findings: 1. During an observation on 5/10/21, at 10:03 a.m., inside Resident 26's room, Resident 26 lay in bed with his eyes closed. On top of Resident 26's over-bed tray table was an unlabeled urinal filled with one-half inch of yellow liquid. On the right side of Resident 26's bed, was a nightstand; the top of the nightstand had another unlabeled urinal which contained one-half inch of yellow liquid. Both urinals had no lids; the rim and neck of each urinal was soiled with a brown substance. During a concurrent observation and interview on 5/10/21, at 11 a.m., at Resident 26's bedside, with the IP, the top of the over-bed tray table still had a urinal with brown substance on the rim and neck, and a half-inch of yellow fluid inside. The nightstand to the right of the bed had an empty urinal with brown substance on the rim and neck. IP stated neither urinal was labeled or dated, and both urinals were soiled. IP stated the soiled urinals should be exchanged for new urinals. During an observation on 5/11/21 at 9:03 a.m., Resident 26 had a breakfast tray with a bowl of oatmeal on top of his over-bed tray table and was eating the oatmeal. During an interview on 5/12/21, at 10:25 a.m., with the Director of Staff Development (DSD), DSD stated urinals were expected to be changed as needed when visibly soiled. The DSD stated the urinals should be labeled to identify the user of the urinal because rooms were shared with other residents. The DSD stated urinals should be stored in the designated urinal holder by the bedrail to help prevent infection. During a review of the facility's policy and procedure (P&P) titled, Cleaning and Disinfecting Non-Critical Resident-Care Items, dated November 2008, the P&P indicated, .Discard resident-care items when damaged or so grossly soiled that a disinfection process is not effective in rendering the item 056392 Page 10 of 12 056392 05/14/2021 Pleasanton Nursing and Rehabilitation Center 300 Neal Street Pleasanton, CA 94566

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some clean .Single resident-use items are cleaned/disinfected between uses by a single resident and disposed of afterwards (e.g., bedpans, urinals) .Replace urinals only when visibly soiled and/or damaged . 2. During a concurrent observation and interview on 5/10/21, at 11 a.m., IP confirmed there were two unclean urinals in Resident 26's room: the one on top of the over-bed tray table was visibly soiled with a brown substance on the neck and rim, and had one-half inch of yellow liquid; the one on top of the left bedside table was empty, but also visibly soiled with a brown substance on the neck and rim. IP picked up the urinal from the left nightstand, stated the urinal was not labeled, and placed the urinal back on top of the nightstand. The IP donned a pair of gloves without performing hand hygiene, picked up the urinal from the over-bed tray table, and stated that urinal was not labeled either. IP carried the urinal to the bathroom and emptied the yellow liquid into the toilet. During a review of the facility's P&P titled, Cleaning and Disinfecting Non-Critical Resident-Care Items, dated November 2008, the P&P indicated, .Steps in the Procedure .Wash and dry hands thoroughly. Put on gloves .Cover the bedpan or urinal before taking it to the bathroom or to the dirty utility room. Empty contents (urine and feces) into the toilet .Remove gloves and discard into designated containers. Wash and dry your hands thoroughly. Return the bedpan or urinal to the resident cabinet. Wash and dry your hands thoroughly . 3. A review of the facility floor map and census dated 5/9/21 showed Residents 438 and 437 had rooms in the area dedicated for PUI residents, (The PUI unit was also known as the yellow zone.) The floor map showed Nursing Station 1 was in the designated PUI area. During an observation on 5/10/21 at 10:15 a.m., a yellow gate blocked the hallway to prevent entry to Nursing Station 1. The gate had signage which indicated, STOP, do not enter. During an interview on 5/12/21 at 10:30 a.m., with Infection Preventionist (IP), IP confirmed Nursing Station 1 was at the start of the area designated for PUI residents; the yellow gate was to ensure staff and visitors observed proper isolation precautions when in the area. IP stated staff were required to don the designated PPE when entering an isolation room for any reason. A review of Resident 438 Order Summary Report, start date 5/4/21, indicated Resident 438 to be on COVID-19 droplet and contact precautions (Contact and droplet precautions are a type of isolation with actions implemented to prevent the spread of infection based upon the transmission mode of direct or indirect contact with respiratory secretions from the resident or environmental surfaces contaminated with respiratory secretions.) with eye protection, for 14 days. A review of Resident 437's Order Summary Report indicated a physician order dated 5/2/21, for Resident 437 to be on COVID-19 droplet and contact precautions with eye protection, for 14 days. During an observation on 5/10/21 at 10:16 a.m., posted on the walls adjacent to the doors of the rooms of Residents 437 and 438 was signage which indicated, STOP, special droplet and contact precautions, every time you enter this room: gown, N95 respirator [a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles], eye protection [goggles or face shield], and gloves. During a continuous observation on 05/10/21 at 10:20 a.m., Housekeeper 1 wore goggles and an N95 respirator for PPE when she entered Resident 437's room carrying a trash basket, and then exited 056392 Page 11 of 12 056392 05/14/2021 Pleasanton Nursing and Rehabilitation Center 300 Neal Street Pleasanton, CA 94566

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident 437's room approximately one minute later without the trash basket. Housekeeper 1 again wore only goggles and an N95 respirator when she picked up another trash basket from the hallway, entered the Resident 438's room and then exited the room approximately one minute later without the trash basket. During an interview on 5/10/21 at 10:23 a.m., with Housekeeper 1, Housekeeper 1 stated she had not worn gown and gloves when she was in the rooms of Residents 437 and 438 because she thought she only needed gown and gloves if she had direct contact with the residents. During a review of the Center for Disease Control article, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, dated 7/15/2020, the article indicated, HCP [healthcare personnel] who enter the room of a patient with suspected or confirmed SARS-CoV-2 [COVID-19] infection should adhere to Standard Precautions and use a NIOSH-approved N95 or equivalent or higher-level respirator (or facemask if a respirator is not available), gown, gloves, and eye protection. 4. During an observation and concurrent interview on 05/10/21 at 10:50 a.m., in Resident 435's room, in the area for residents with no known risk for active COVID-19 infection (green zone), Certified Nursing Assistant 2 (CNA 2) CNA 2 gathered Resident 435's soiled bed linens with her bare hands and held the linens directly against her uniform while she transported the linen to discard into the soiled linen hamper. CNA 2 stated she was unable to recall the facility procedure for handling soiled linens. A review of the facility policy and procedure (P & P) titled, 'Departmental (Environmental Services)-Laundry and Linen, undated, indicated, Consider all soiled linen to be potentially infectious and handle with standard precautions. A review of the facility policy and procedure (P & P) titled, Linen Handling, undated, indicated, Soiled linen shall be carried to the soiled hamper in such a manner as to not to come in contact with the employee's uniform. 056392 Page 12 of 12