Inspection·July 28, 2023

F 0550 . Level of Harm - Minimal harm or potential for actual harm A review of the facility's policy and procedure (P&P) titled, Activities of Daily Living (ADLs), Supporting, revised May 2022, the P&P indicated, Privacy will be provided using items such as cubicle curtains and closing room doors if needed . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056479 If continuation sheet Page 2 of 6 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056479 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alameda County Medical Center D/P Snf 15400 Foothill Boulevard San Leandro, CA 94578 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Ensure medication error rates are not 5 percent or greater. 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 document review, the facility failed to ensure the facility had a medication error rate of less than 5 percent when nursing staff failed to follow physician orders for administration of medication for two of eight sampled residents (Resident 89 and Resident 231) during medication pass: Resident 89 did not receive an ordered blood test before meals and Resident 231 did not receive the correct dosage of medication during medication pass. Residents Affected - Some The failure to follow medication administration instructions during two of 28 opportunities of medication administration resulted in an error rate of 7.1 percent. Findings: 1. During a review of Resident 89's Minimum Data Set (MDS-an assessment tool to direct care), dated 7/24/23, the MDS indicated Resident 89 had a diagnosis of diabetes mellitus (the body's inadequate production of the hormone insulin results in high blood sugar levels causing excessive urination and damage to body organs). The MDS also indicated Resident 89 received an injection of insulin on seven of seven days in the assessment look-back period. During a review of Resident 89's July physician orders, the physician order start date 5/15/23, indicated the following sliding scale (dosage to vary by level of blood glucose) dosage of seven units of insulin for a blood glucose reading of 201-250 was to be administered by injection before the meal. The physician order indicated Resident 89 was to have a blood glucose test before each meal. During an observation on 7/26/23 at 12:51 p.m., Licensed Vocational Nurse 1 (LVN 1) took a blood glucose sample for Resident 89 as he began to eat his lunch. LVN 1 stated Resident 89's blood glucose reading was 201. LVN 1 stated Resident 89 was on a sliding scale for insulin administration. LVN 1 stated she did not want to bother the resident with an injection in the middle of his meal and would give his insulin later. 2. During a review of Resident 231's MDS dated [DATE], the MDS indicated Resident 231 had a diagnosis of seizure disorder. (Seizures are the result of abnormal electrical impulses in the brain, and can result in sudden, violent, irregular movements of a limb or the body.) During a review of Resident 231's July physician orders, start date 7/21/23, indicated an order for 1000 milligrams (mg) of oral Keppra (an anti-seizure medication) twice a day. During a medication pass observation and concurrent interview on 7/26/23 at 8:51 a.m., LVN 1 poured five milliliters (mLs) of liquid Keppra into a medication cup for Resident 231 and Resident 89 drank the medication. LVN 1 stated the label on the Keppra bottle indicated a concentration of 500 mg of Keppra for each 5 mLs of liquid. LVN 1 stated the Keppra was to prevent seizures. During a follow-up interview on 7/26/23 at 1:00 p.m., LVN 1 stated she had administered 5 ml of Keppra to Resident 231, which was only a 500 mg dose. LVN 1 stated Resident 231 should have received a 1000 mg dose. During a concurrent interview and observation of Resident 231's physician orders and Keppra bottle label on 7/26/23 at 1:04 p.m., with the Infection Preventionist (IP), the IP stated Resident 231's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056479 If continuation sheet Page 3 of 6 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056479 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alameda County Medical Center D/P Snf 15400 Foothill Boulevard San Leandro, CA 94578 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Keppra medication label indicated a concentration of 500 mg per 5 mLs of liquid. The IP stated Resident 231's order was for 1000 mg of Keppra, which would be 10 mLs of liquid. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056479 If continuation sheet Page 4 of 6 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056479 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alameda County Medical Center D/P Snf 15400 Foothill Boulevard San Leandro, CA 94578 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm 2. A review of Resident 83's Minimum Data Set (MDS, an assessment tool used to guide care), dated 6/15/23, indicated Resident 83 had a diagnosis of dementia (memory loss). Residents Affected - Some A review of Resident 83's Physician Order, dated 7/13/23, indicated, Cleanse Sacral (the spinal area between the lower back and tailbone) wound with normal saline (NS, used to clean wounds), pat dry .Pack loosely with plain packing strip (thin strips of material used to fill deep pockets in wounds), adding wound gel (ointment for the wound). Cover with Mepilex (bordered foam dressing that is moisture-proof and bacteria-proof) dressing . During a concurrent observation and interview on 7/27/23, at 11:15 a.m., with Licensed Vocational Nurse 1 (LVN 1), in Resident 83's room, LVN 1 completed Resident 83's wound care. LVN 1 opened Resident 83's bedside nightstand bottom drawer and placed the newly sanitized scissors inside the drawer. The bottom drawer also contained a box with several sealed gauze dressings, an opened bottle of plain packing strips, and a roll of paper tape. LVN 1 stated she stored Resident 83's wound care supplies, including the sanitized scissors, dated opened bottles of NS, bottle of plain packing strip, and paper tape inside Resident 83's nightstand bottom drawer between treatments. During an interview on 7/28/23, at 9:20 a.m., with the Infection Preventionist (IP), the IP stated wound care treatment supplies were stored in the treatment cart and clean supply room. The IP stated Licensed nurses (LN) were expected to gather sufficient supplies for each individual resident treatment to the resident bedside, and not store supplies inside the resident room due to safety and infection control concerns. The IP stated open bottles of NS brought into a resident's room should be discarded after opening due to risk of infection. A review of the facility's policy and procedure (P&P) titled, Wound Care, revised October 2020, the P&P indicated, .Assemble the equipment and supplies as needed. Date and initial all bottles and jars upon opening .Wipe reusable supplies with alcohol as indicated .Return reusable supplies to resident's drawer in treatment cart. Take only the disposable supplies that are necessary for the treatment into the room. Disposable supplies cannot be returned to the cart . A review of the facility's policy and procedure (P&P) titled, Safety and Supervision of Residents, revised July 2017, the P&P indicated, Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities .Implementing interventions to reduce accident risks and hazards shall include the following .safety items and approaches for sharp items . Based on observations, interviews, and document reviews, the facility failed to ensure staff followed policies and procedures designed to prevent infection and spread of infection when: 1. For two of five unsampled residents (Resident 105, Resident 229), a Licensed Vocational Nurse (LVN 1) failed to clean the blood glucometer (instrument to check the level of sugar in the blood: blood glucose) in between resident use. 2. For one of four sampled residents (Resident 83) with wound care issues, LVN 1 stored clean wound care supplies in a resident room and failed to discard a bottle of normal saline (NS, salt-water solution) used for wound irrigation opened inside the resident room. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056479 If continuation sheet Page 5 of 6 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056479 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alameda County Medical Center D/P Snf 15400 Foothill Boulevard San Leandro, CA 94578 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 These failures had the potential to cause infection or spread infection for Residents 105, 229, and 83. Level of Harm - Minimal harm or potential for actual harm Findings: Residents Affected - Some 1. During an observation and concurrent interview on 7/26/23 at 12:37 P.M., with LVN 1, LVN 1 brought the blood glucometer to Resident 105's bedside. LVN 1 placed the blood glucometer on Resident 105's bed sheet as she collected a blood sample onto a test strip, placed the test strip sample in the blood glucometer, and discarded the test strip sample after obtaining the blood glucose value. LVN 1 picked up the blood glucometer using gloved hands, walked to the exit door, removed her gloves, placed the glucometer in her armpit, sanitized her hands, then carried the glucometer out of the room and placed it on top of the nursing medication cart. After collecting supplies, LVN 1 donned gloves, carried the glucometer, without intervening cleaning of the glucometer, toward Resident 229's room. When asked when the glucometer needed to be cleaned, LVN 1 stated the glucometer needed to be cleaned when it had visible blood on it. LVN 1 stated she did not see visible blood on the blood glucometer now. LVN 1 entered Resident 229's room and placed the glucometer on Resident 229's overbed table, collected a blood sample on the test strip, placed the sample test strip in the glucometer, read the result, picked up and carried the glucometer to a counter by the exit, and directly placed the glucometer on the counter. LVN 1 doffed her gloves, sanitized her hands, donned gloves, and cleaned the glucometer without sanitizing the counter or Resident 229's overbed table. During an interview on 7/26/23 at 1:04 P.M., the Infection Prevention (IP) nurse stated the blood glucose machine should be cleaned before and after each resident's use. During a review of the facility's policy and procedure (PNP) titled, Obtaining a Fingerstick Glucose Level, revised date October 2011, the PNP indicated always ensure that blood glucose meters intended for reuse are cleaned and disinfected between resident uses. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056479 If continuation sheet Page 6 of 6