Health inspection·September 26, 2019

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. 2. Review of Resident 104's Minimum Data Set (MDS - an assessment tool used to guide care, dated 8/20/19, indicated Resident 104 was totally dependent on the assistance of one or two staff persons for Activities of Daily Living (ADLs - e.g. turning in bed, dressing, eating, personal hygiene). Review of Resident 104's Physician Orders, dated 5/24/1,9 indicated an order for condom catheter for related to his diagnoses of Benign Prostatic Hyperplasia (enlarged prostate) and urine retention. During an observation in Resident 104's room on 9/24/19, at 8:22 a.m., Resident 104's urinary catheter drainage bag was hanging on the right side of his bed frame, facing the door, and the contents were visible without a privacy bag to cover it. In an interview immediately following the observation, Certified Nursing Assistant (CNA) 1 stated Resident 104's urinary catheter drainage bag should be placed in a privacy bag due to dignity issues. Review of the facility's policy Quality of Life - Dignity, with revised date August 2009, indicated .Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality .1. Residents shall be treated with dignity and respect at all times .2. 'Treated with dignity' means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth .11. Demeaning practices and standards of care that compromise dignity are prohibited. Staff shall promote dignity and assist residents as needed by .a. Helping the resident to keep urinary catheter bags covered Based on observation, interview, and record review, the facility failed to ensure two of four sampled residents (Residents 36 and Resident 104) were treated with dignity and respect when: 1. Certified Nursing Assistant (CNA) 7 entered Resident 36's room without knocking and/or without permission. This failure resulted in Resident 36 feeling mad that his privacy was not respected. 2. Resident 104's urinary catheter (small flexible tube inserted through the urethra and into the bladder to drain urine) drainage bag was not covered by a urinary catheter drainage bag cover. For Resident 104, this failure had the potential to result in the loss of dignity. Findings: 1. Review of Resident 36's Minimum Data Set (MDS - an assessment tool used to guide care), dated 3/6/19, indicated Resident 36 was totally dependent on the assistance of one or two staff persons for Activities of Daily Living (ADLs - e.g. turning in bed, dressing, eating, personal hygiene). The MDS Page 1 of 16 056479 056479 09/26/2019 Alameda County Medical Center D/P Snf 15400 Foothill Boulevard San Leandro, CA 94578

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few also indicated Resident 36's Brief Interview for mental status was 15 (indicated he was able to recall words, repeat words and knew the correct year, date and month). During an observation and joint interview on 9/23/19, at 10:21 a.m., CNA 7 entered Resident 36's room without knocking and without asking for permission. CNA 7 stated she thought it was okay to enter Resident 36's room without knocking and asking permission because Resident 36's curtain was open, and he could see her standing in the doorway. During an interview with Resident 36 on 9/23/19, at 10:25 a.m., Resident 36 stated he was mad and felt his privacy was not respected when CNA 7 entered his room with knocking and asking permission. During an interview with the Clinical Instructor (CI) on 9/26/19, at 11:34 a.m., CI stated the staff should treat residents with dignity and respect. Review of the facility's policy and procedure titled Quality of Life - Dignity, revised 8/2009, indicated .6. Residents' private space and property shall be respected at all times. a. Staff will knock and request permission before entering resident's room 056479 Page 2 of 16 056479 09/26/2019 Alameda County Medical Center D/P Snf 15400 Foothill Boulevard San Leandro, CA 94578

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. Based on interview and record review, for one of 27 (Resident 51) sampled residents, the facility failed to inquire about Advance Directive (a legal document in which a person specifies what actions should be taken for their health if they are no longer able to make decisions for themselves because of illness or incapacity) from Resident 51 and/or their representative. This failure had the potential to result in Resident 51 not receiving care in accordance with his wishes. Findings: Review of the annual Minimum Data Set (MDS - an assessment tool used to guide care), dated 6/21/19, indicated Resident 51's Brief Interview for mental status was 15 (indicated he was able to recall words, repeat words and knew the correct year, date and month). During a review of the medical record for Resident 51, the Physician Orders for Life-Sustaining Treatment (POLST) form, signed 7/29/19, indicated Section D - Information and Signatures regarding Advance Directives was left unanswered. Review of Resident 51's quarterly Minimum Data Set (MDS - an assessment tool used to direct care), dated 6/21/19, indicated the advance directive section was not completed. Further review of the MDS indicated resident 51 had the ability to clearly think, reason, and remember. During an interview with Resident 51 on 9/26/19 at 11:36 a.m., he stated that no one from the facility had talked to him about an advance directive prior to 9/25/19. He stated he was interested in receiving information about one. Review of Resident 51's Resident Care Conference, dated 7/22/19, indicated the advance directive question had not been answered for Resident 51. During a concurrent interview and record review with the Assistant Director of Nursing (ADON) on 9/24/19 at 9:54 a.m., ADON stated that the advance directive was addressed with residents and their representatives during the initial resident care conferences and when needed. ADON stated Resident 51's advance directive should have been addressed during his initial resident care conference. Review of facility's policy and procedure titled Advance Directives, revised 5/2019, indicated .2. Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so .2. If the resident is incapacitated and unable to receive information about his or her right to formulate an advance directive, the information may be provided to the resident's legal representative .5. Prior to or upon admission of a resident, the Social Services Director or designee will inquire of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives. 6. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record. 056479 Page 3 of 16 056479 09/26/2019 Alameda County Medical Center D/P Snf 15400 Foothill Boulevard San Leandro, CA 94578

F 0636 Level of Harm - Potential for minimal harm Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Review of Resident 9's Face Sheet indicated resident was admitted to the facility on [DATE]. Residents Affected - Some Review of the Minimum Data Set (MDS - an assessment tool used to direct care) indicated the last Annual MDS was done on 7/18/18 and the next Annual MDS was due on 7/18/19. Resident 9's Annual Assessment was still open, was not completed, and was more than 120 days overdue. During a concurrent interview and record review on 9/25/19, at 8:38 a.m., MDSC stated Residnet 9's Annual MDS Assessment was still open and has not been completed. Review of the facility's policy Resident Assessment Instrument, with revised date September 2010 indicated, .1. The Assessment Coordinator is responsible for ensuring that the Interdisciplinary Assessment Team conduct timely resident assessment and reviews according to the following schedule .d. Once every twelve months Based on interview and record review, the facility failed to complete comprehensive Minimum Data Set assessments (MDS - an assessment tool used to guide care) for five of 27 sampled residents (Residents 259, 260, 25, 17, and 9) within the regulatory specified timeframes when: 1. the Minimum Data Set Coordinator (MDSC) did not complete the admission MDS assessment for Resident 259 and 260 within 14 calendar days of their respective admission to the facility. 2. the MDSC did not complete the annual MDS for Resident 25, 17, 21, and 9 within 12 months of their respective previous annual MDSs. This deficient practice had the potential to delay care planning for Residents 259, 260, 25, 17, and 9. Findings: 1. Review of the Resident 259's Face Sheet, printed 9/24/19, indicated Resident 259 was admitted to the facility on [DATE]. Review of Resident 259's MDS record, indicated Resident 259's admission MDS had a reference date of 7/22/19, and the MDS was not completed within 14 calendar days of Resident 259's admission to the facility. 2. Review of the Resident 260's Face Sheet, printed 9/24/19, indicated Resident 260 was admitted to the facility on [DATE]. Review of Resident 260's MDS record, indicated Resident 260's admission MDS had a reference date of 7/30/19, and the MDS was not completed within 14 calendar days of Resident 260's admission to the facility. During an interview on 9/24/19, at 9:55 a.m., MDSC stated Resident 259's and Resident 260's admission MDSs were not completed due to her workload. MDSC stated the work flow process at the facility 056479 Page 4 of 16 056479 09/26/2019 Alameda County Medical Center D/P Snf 15400 Foothill Boulevard San Leandro, CA 94578

F 0636 Level of Harm - Potential for minimal harm Residents Affected - Some was meant for two MDSCs, and she could not keep up with the work flow. MDSC stated the admission MDSs should have been completed by day fourteen of Resident 259's and Resident 260's stay. The facility's policy and procedure titled Resident Assessment Instrument, revised 9/2010, indicated .1. The Assessment Coordinator is responsible for ensuring that the Interdisciplinary Assessment Team conduct timely resident assessments and reviews according to the following schedule: a. Within fourteen (14) days of the resident's admission to the facility; d. once every twelve (12) months 3. Review of Resident 25's Facesheet, printed 9/26/19, indicated Resident 25 was admitted to the facility in 2016. During an interview and concurrent record review on 9/25/19, at 1:35 p.m., Minimum Data Set Coordinator (MDSC) stated she performed the MDS assessments for the facility. MDSC stated Resident 25's MDS annual comprehensive assessment was due on 8/12/19. MDSC stated she completed Resident 25's MDS annual assessment on 8/26/19, which was (14 days) late. 4. Review of Resident 17's Facesheet, printed 9/26/19, indicate Resident 17 was admitted to the facility in 2015. During an interview and concurrent record review on 9/25/19, at 1:35 p.m., MDSC stated Resident 17's MDS annual comprehensive assessment was due on 7/29/19. MDSC stated she completed Resident 17's MDS annual assessment on 9/26/19, which was (59 days) late. 056479 Page 5 of 16 056479 09/26/2019 Alameda County Medical Center D/P Snf 15400 Foothill Boulevard San Leandro, CA 94578

F 0637 Assess the resident when there is a significant change in condition Level of Harm - Potential for minimal harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, for one (Residents 27) of 27 sampled residents the facility failed to ensure a Minimum Data Set (MDS - a resident assessment tool used to guide care) Significant Change in Status Assessment (SCSA - major decline or improvement in a resident's status) was done within 14 days after it was determined. Minimum Data Set Coordinator (MDSC) completed Resident 27's SCSA 64 days after it was due. Residents Affected - Some This deficient practice had the potential to result in Resident 27 not receiving care based on their current health status. Findings: Review of Resident 27's Face Sheet, printed 9/20/19, indicated Resident 27 was admitted to the facility on [DATE]. During an interview on 9/26/19, at 8:30 a.m., MDSC stated Resident 27's SCSA was completed late because she had to facilitate care conferences and review charts before care conferences occurred. MDSC stated Resident 27's SCSA could not be completed until after the care conference had occurred. MDSC stated it was too much work, not enough time and help to complete the assessment on time. Review of Resident 27's Minimum Data Set (MDS - an assessment tool to direct resident care) records, indicated Resident 27 had a SCSA comprehensive assessment reference date of 7/22/19 and was completed on 9/24/19 (64 days late). The facility's policy and procedure titled Change in a Resident's Condition or Status, revised 5/2017, indicated .9. If a significant change in the resident's physical or mental condition occurs, a comprehensive assessment of the resident's condition will be conducted as required by current OBRA regulations governing resident assessments and as outlined in the MDS RAI Instruction Manual The facility's policy and procedure titled Resident Assessment Instrument, revised 9/2010, indicated .1. The Assessment Coordinator is responsible for ensuring that the Interdisciplinary Assessment Team conduct timely resident assessments and reviews according to the following schedule: b. When there has been a significant change in the resident's condition 056479 Page 6 of 16 056479 09/26/2019 Alameda County Medical Center D/P Snf 15400 Foothill Boulevard San Leandro, CA 94578

F 0638 Assure that each resident’s assessment is updated at least once every 3 months. Level of Harm - Potential for minimal harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 9. Review of Residents 1, 12, 15, 18 and 77's record on 9/26/19, at 12 p.m., indicated the following: Residents Affected - Some a. Resident 1's quarterly MDS dated [DATE] was completed 9/24/19 (85 days late); b. Resident 12's quarterly MDS dated [DATE] was completed 9/24/19 (82 days late); c. Resident 15's quarterly MDS dated [DATE] was completed 9/25/19, (83 days late); d. Resident 18's quarterly MDS dated [DATE] was completed 8/15/19, (17 days late), and; e. Resident 77's quarterly MDS dated [DATE] was completed 9/26/19, (67 days late). Review of the facility's policy and procedure titled Resident Assessment Instrument, revised 9/2010, indicated .1. The Assessment Coordinator is responsible for ensuring that the Interdisciplinary Assessment Team conduct timely resident assessments and reviews according to the following schedule: c. At least quarterly Based on interview and record review, for 13 of 27 (Resident 2, 4, 7, 10, 8, 14, 6, 22, 1, 12, 18, 15, and 77) sampled residents, the facility failed to complete Quarterly Minimum Data Set (MDS, an assessment too used to direct care) Assessments in the regulatory specified manner. This failure had the potential for Residents 2, 4, 7, 10, 8, 14, 6, 22, 1, 12, 18, 15, and 77 to not receive care and services needed based on their current health status. Findings: 1. Review of Resident 2's the Face Sheet, printed 9/26/19, indicated Resident 2 was admitted to the facility on [DATE]. Review of Resident 2's Quarterly MDS assessment indicated it was due on 7/2/19 and completed on 9/24/19 (84 days late). 2. Review of Resident 4's the Face Sheet, printed 9/26/19, indicated Resident 4 was admitted to the facility on [DATE]. Review of Resident 4's Quarterly MDS assessment indicated it was due on 7/10/19 and completed on 9/24/19 (76 days late). 3. Review of Resident 7's Face Sheet, printed 9/26/19, indicated Resident 7 was admitted to the facility on [DATE]. Review of Resident 7's MDS Quarterly MDS Assessment indicated it was due on 7/3/19 and completed on 9/24/19 (84 days late). 4. Review of Resident 10's Face Sheet, printed 9/26/19, indicated Resident 10 was admitted to the facility on [DATE]. 056479 Page 7 of 16 056479 09/26/2019 Alameda County Medical Center D/P Snf 15400 Foothill Boulevard San Leandro, CA 94578

F 0638 Level of Harm - Potential for minimal harm Residents Affected - Some Review of Resident 10's Quarterly MDS assessment indicated it was due on 7/11/19 and completed on 9/24/19 (76 days late). During an interview and concurrent record review of Residents 2, 4, 7, 10's last MDS Assessments on 9/25/19 at 8:38 a.m., the MDSC was unable to show completed MDS quarterly reviews, based on each of the residents' assessment reference dates. MDSC stated all MDSs for the (Quarterly) MDS assessments for Residents 2, 4, 7, 10's were either still open, completed late, and/or transmitted late. 7. Review of Resident 6's Face Sheet, printed 9/20/19, indicated Resident 6 was admitted to the facility on [DATE]. Review of Resident 6's Quarterly MDS assessment indicated it was due on 7/2/19 and completed on 9/24/19 (85 days late). 8. Review of the Resident 22's Face Sheet, printed 9/20/19, indicated Resident 22 was admitted to the facility on [DATE]. Review of Resident 22's Quarterly MDS assessment indicated it was due on 7/31/19 and completed on 9/24/19 (56 days late). During an interview on 9/26/19 at 8:30 a.m., MDSC stated Resident 6's and Resident 22's Quarterly MDSs were completed late. 5. Review of Resident 8's Facesheet, printed 9/26/19, indicated Resident 8 was admitted to the facility in 2015. During an interview and concurrent record review on 9/26/19, at 1:35 p.m., Resident 8's Quarterly MDS indicated it was due on 7/9/19 and completed on 9/26/19. MDSC stated she completed the Quarterly MDS assessment on 9/26/19, which was (80 days) late. 6. Review of Resident 14's Facesheet, printed 9/26/19, indicated Resident 14 was admitted to the facility in 2018. During an interview and concurrent record review on 9/26/19, at 1:35 p.m., Resident 8's Quarterly MDS indicated it was due on 7/16/19 and completed on 9/26/19. MDSC stated she completed the Quarterly MDS assessment on 9/26/19, which was (73 days) late. 056479 Page 8 of 16 056479 09/26/2019 Alameda County Medical Center D/P Snf 15400 Foothill Boulevard San Leandro, CA 94578

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, for one (Resident 94) of 27 sampled residents, the facility failed to develop and implement comprehensive care plans to address medical and nursing needs of the residents when there was no comprehensive care plan to address indwelling catheter. This failure had the potential to result in delayed or unrecognized catheter related adverse affects. Findings: Review of the Resident Face Sheet, not dated, indicated Resident 94 was admitted to the facility on [DATE]. Review of the annual Minimum Data Set (MDS-an assessment tool used to guide care), dated 5/18/19, indicated Resident 94 had an indwelling urinary catheter (a flexible tube that is inserted into the bladder to drain urine). Review of Resident 94's physician's orders, dated 9/26/19, indicated Resident 94 had an order for a suprapubic catheter. During a concurrent interview and record review with the Assistant Director of Nursing (ADON) on 9/25/19 at 12:08 p.m., ADON stated she could not find in Resident 94's medical record a care plan that addressed his indwelling urinary catheter. ADON stated Resident 94 needed a care plan that addressed the indwelling urinary catheter. Review of the facility's policy and procedure titled Care Plans, Comprehensive Person-Centered, revised 12/2016, indicated .12. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required comprehensive assessment (MDS) 056479 Page 9 of 16 056479 09/26/2019 Alameda County Medical Center D/P Snf 15400 Foothill Boulevard San Leandro, CA 94578

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 did not provide competency training to provide services for dialysis-dependent (dialysis - a process where a machine filters the blood of wastes when the kidneys are not healthy enough to do it) residents in accordance with the facility assessment. This failure had the potential to result in dialysis-dependent residents receiving inappropriate care and services. Findings: Review of the Facility Assessment last reviewed 7/12/19 indicated the average number of residents on special treatments and conditions included 6-10 residents who were on hemodialysis (also known as dialysis). Staff training/education and competencies needed to provide level of requirements were also included in the facility assessment. The nursing staff skill sets that were evaluated annually included specialized care such as dialysis. During an interview and concurrent review of competency trainings with Clinical Instructor (CI) on 9/26/19 at 10:36 a.m., CI stated she had just started work in June 2019 and has not given competency training on dialysis care and management to licensed nurses. During an interview with Director of Nursing (DON) on 9/26/19 at 11:57 a.m., DON stated there was no competency training provided to licensed nurses recently. DON stated the last training provided was in 2017. DON stated training should be provided every year because of the resident population and characteristics that the facility had. (Refer to F760 for additional information regarding Residents 49 and 76) 056479 Page 10 of 16 056479 09/26/2019 Alameda County Medical Center D/P Snf 15400 Foothill Boulevard San Leandro, CA 94578

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on interview and record review, for one of 24 (Resident 65) sampled residents, the facility failed to consistently monitor Resident 65's behaviors and side effects related to the use of psychotropic (capable of affecting the mind, emotions, and behaviors) medications during the months of July 2019, August 2019, and September 2019. For Resident 65, this deficient practice had the potential to result in the physician receiving and using inaccurate information to make decisions regarding the need to continue, increase, or decrease of the use of psychotropic medications. Findings: Review of Resident 65's Face Sheet indicated Resident 65 was admitted to the facility with diagnoses that included Traumatic Brain Injury Assault (an injury to the brain caused by an impact such as a road traffic incident, assault, or fall). Review of Resident 65's Minimum Data Set (MDS - an assessment tool used to direct care), dated 7/16/19, indicated Resident 65 had diagnoses that included a severe chronic mental disorder and depression. Review of Resident 65's Physician Orders (PO) indicated Resident 65 was to receive the following: a. Haldol, order dated 5/30/19, for a severe chronic mental disorder manifested (m/b) by auditory hallucination and talking to self; b. Trazadone (Desyrel), order dated 5/27/19, for insomnia associated with depression m/b sleeplessness, and; c. Sertraline (Zoloft), order dated 5/30/19, for depression. Review of Resident 65's Medication Administration Records (MARs), dated July 2019, August 2019, and September 2019, indicated that there was inconsistent monitoring of Resident 65's behaviors for the use of Haldol and Sertraline, and inconsistent monitoring of Resident 65's time spent sleeping related to the use of Trazadone on multiple days and across multiple shifts (days, afternoon, and night shifts). The MARs also indicated there was inconsistent monitoring of side effects related to Resident 65's use of Sertraline on multiple days and across multiple shifts (days, afternoon, and night shifts). During an interview and concurrent record on 9/26/19, at 8 a.m., Registered Nurse (RN) 4 stated Resident 65's behavior and side effect monitoring was not consistent for multiple days and across multiple shifts from July to September 2019. RN 4 stated it was important to monitor the (Resident 65's) behaviors and presence of side effects during psychotropic drug use in order (for the physician) to know the need for continued use, increase, or decrease of the psychotropic medications. In an interview with the Director of Nursing (DON) on 9/26/19 at 12:20 p.m., and concurrent record review of Resident 65's MAR from July to September 2019, DON stated some of the licensed nurses were 056479 Page 11 of 16 056479 09/26/2019 Alameda County Medical Center D/P Snf 15400 Foothill Boulevard San Leandro, CA 94578

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some noncompliant with the behavior and side effects monitoring documentation for resident's psychotropic drug use from July to September 2019. DON stated the Interdisciplinary Team's (IDT's) recommendations for the psychotropic drugs' Gradual Dose Reduction (GDR) were based on the identified number of incidents of behavior manifestations and medication side effects monitored. Review of the facility's policy and procedure titled, Antipsychotic Medication Use, with revised date December 2018, indicated .Antipsychotic medications may be considered for residents with dementia but only after medical, physical, functional, psychological, emotional, psychiatric, social and environmental cause of behavioral symptoms have been identified and addressed. Antipsychotic medications will be prescribed at the lowest possible dosage for the shortest period of time and are subject to gradual dose reduction and re-review 056479 Page 12 of 16 056479 09/26/2019 Alameda County Medical Center D/P Snf 15400 Foothill Boulevard San Leandro, CA 94578

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, for two of 27 sampled residents (Residents 49 and 76 and 94), the facility failed to ensure Residents 49 and 76 were free of significant medication errors when: Residents Affected - Some 1. Resident 49 did not receive Renvela (a phosphate binder medication that prevents the absorption of phosphorus in the blood) as ordered by the physician, and; 2. Resident 76 did not receive Renagel (a type of phosphate binder) and Lomotil (medication to treat diarrhea) as ordered by the physician. For Residents 49 and 76, this failure had the potential to result in increased phosphorus levels adverse effects (e.g. body changes that pull calcium out of your bones, making them weak). For Resident 76, this failure had the potential to result in dehydration. Findings: 1. Review of Resident 49's nutrition care plan, last reviewed 9/12/19, indicated the goal was for Resident 49 to have blood phosphorus (a mineral) level between 3 - 5.5 milligrams/deciliter (mg/dL). One of the approaches was for licensed nurses to give medications as ordered. Review of Resident 49's physician's orders indicated Resident 49 went to dialysis every Monday, Wednesday, and Friday around lunch time. The physician's orders indicated for Resident 49 to receive one 0.8-gram packet of Renvela by mouth three times daily with meals. During an interview and concurrent review on 9/25/19, at 10:08 a.m., Director of Nursing (DON) stated Resident 49's MAR Medication Administration Record (MAR) for September 2019 did not indicate that Resident 49 receive Renvela as an as needed (PRN) medication. The MAR indicated from 9/3/19 until 9/9/19, there was no information whether Resident 49 received Renvela. The MAR also indicated there were seven out of 48 possible doses that Resident 49 did not receive in September 2019. 2. Review of Resident 76's facesheet, printed 9/24/19, indicated Resident 76 was admitted to the facility with diagnoses that included kidney failure. Review of Resident 76's Minimum Data Set (MDS - an assessment tool used to guide care), dated 5/24/19, indicated Resident 76 had the ability to clearly think, reason, and remember. Review of Resident 76's physician's orders indicated Resident 76 was to receive 1600 milligrams (mg) of Renagel three times daily with meals. Review of Resident 76's chronic kidney disease care plan last reviewed 7/30/19 indicated for licensed staff to administer phosphate binder per physician's order. During an interview and concurrent review on 9/25/19, at 12:06 p.m., Infection Preventionist (IP) stated there was no documentation in Resident 76's MAR that a breakfast dose of Renagel was administered to Resident 76. Resident 76's MAR indicated on days that Resident 76 went to dialysis, the breakfast dose for Renagel indicated not administered, patient off the floor. The MAR indicated Resident 056479 Page 13 of 16 056479 09/26/2019 Alameda County Medical Center D/P Snf 15400 Foothill Boulevard San Leandro, CA 94578

F 0760 76 did not receive 11 out of 76 possible doses of Renagel. Level of Harm - Minimal harm or potential for actual harm During an interview on 9/23/19, at 11:12 a.m., Resident 76 stated she had not been able to eat well because of diarrhea. Residents Affected - Some During an interview on 9/23/19 at 11:12 a.m., Certified Nursing Assistant (CNA) 5 stated Resident 76 had been having diarrhea, which was known by licensed staff. CNA 5 stated when Resident 76 had two episodes of loose stools in one shift, the licensed nurses were notified so they could give Resident 76 anti-diarrhea medication. Review of Resident 76's Medication Administration Record (MAR), printed 9/24/19, indication Resident 76 was to receive 2.5 milligrams (mg) of Lomotil two times per day as needed for diarrhea. The MAR In an interview and concurrent record review on 9/24/19, at 1:23 p.m., Resident 76's bowel movement record indicated she had large, thin bowel movements on 9/2/19, 9/16/19, 9/17/19, 9/19/19, 9/20/19 and 9/22/19. Registered Nurse (RN) 3 stated Resident 76's bowel movement record indicated Resident 76 had (multiple) episodes of diarrhea. RN 3 stated large, thin bowel movement meant large, watery or loose bowel movement. Review of Resident 76's MAR, printed 9/24/19, indicated that Resident 76 did not receive Lomotil when she had large, thin bowel movements (diarrhea) on 9/2/19, 9/16/19, 9/17/19, 9/19/19, 9/20/19, and 9/22/19. (Refer to F726 for additional information regarding dialysis dependent residents) 056479 Page 14 of 16 056479 09/26/2019 Alameda County Medical Center D/P Snf 15400 Foothill Boulevard San Leandro, CA 94578

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, for two of four sampled residents (Residents 104 and 107) the facility failed to implement their infection prevention and control policy and procedures when: Residents Affected - Some 1. Resident 104's indwelling catheter uncovered drainage bag was touching the floor, and; 2. Registered Nurse (RN) 3 did not perform hand hygiene (general term that applies to hand washing, antiseptic hand wash, and alcohol-based hand rub) hands between glove changes and touched clean gauze with bloody gloves. For Residents 104 and 107, these deficient practices had the potential to result in the spread of infection. Findings: 1. Review of Resident 104's Physician Orders, dated 5/24/19, indicated Resident 104 had a condom catheter related to his diagnoses of Benign Prostatic Hyperplasia (enlarged prostate) and urine retention. During an observation on 9/24/19, at 8:22 a.m., Resident 104's uncovered urinary catheter drainage bag was touching the floor. In an interview on 9/24/19, at 8:22 a.m., Certified Nursing Assistant (CNA) 1 stated urinary catheter drainage bag should not be touching the floor to prevent cross-contamination. Review of the facility's policy and procedure titled, Catheter Associated Urinary Tract Infection (CAUTI) Prevention Policy, revised 8/2015, indicated .Patients with indwelling catheters will receive care compliant with recommended strategies to prevent Catheter Associated Urinary Tract Infection (CAUTI) under the professional medical judgement of the provider .Proper techniques for Urinary Catheter Maintenance .Do not rest the bag on the floor 2. Review of Resident 107's Minimum Data Set (MDS - an assessment tool used to guide care), dated 8/28/19, indicated Resident 107 had multiple diagnoses that included left and right hip pressure ulcers (opening over the bony area caused by pressured) at Stage 4 (an advance level). Review of Resident 107's physician's orders, not dated, indicated directions to cleanse the left and right ischial tuberosity (hip) wounds daily with Theraworx (a cleaning solution), place Theraworx to moisten Drawtex (gauze), apply on wound bed and cover with Optifoam (foam) dressing until healed. During an observation of Resident 107's left and right hip pressure ulcers wound treatment with RN 3 on 9/25/19 at 10:44 a.m., RN 3 cleaned Resident 107's bloody wound beds with Theraworx. After RN 3 cleaned the bloody wound beds, without changing gloves, she pat the wounds dry with clean gauze. Then RN 3, with bloody gloves, applied clean gauze and foam dressing over the wounds. After applying the clean dressings, RN 3 removed her gloves and sanitized her hands. 056479 Page 15 of 16 056479 09/26/2019 Alameda County Medical Center D/P Snf 15400 Foothill Boulevard San Leandro, CA 94578

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview with RN 3 on 9/25/19, at 11:13 a.m., RN 3 stated she should have changed her soiled gloves before touching clean gauze during wound care. During an interview with the Infection Prevention and Control Nurse (IPCN) on 9/25/19, at 11:04 a.m., she stated during wound care after cleaning a wound and gloves are soiled, the gloves should be changed before touching clean supplies. IPCN stated hands should be sanitized after removing gloves. 056479 Page 16 of 16