Health inspection·August 11, 2022

F 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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** Based on interview and record review, the facility failed to ensure four of nine sampled residents' (Resident 112, 107, 1, and 157) admission (an assessment within 14 calendar days after admission) or Annual Minimum Data Set (MDS, a comprehensive assessment of each residents' functional capabilities and helps nursing home staff identify health problems) assessments were completed when: 1. Resident 112's admission MDS assessment was not completed, 2 Resident 107's Annual MDS assessment was not completed, 3. Resident 1's MDS Section C (Cognitive Patterns) was not completed, and 4. Resident 157's admission MDS assessment was not completed. These failures had the potential for Residents 112, 107, 1, and 157 to not receive individualized plan of care based on their physical, mental, and emotional needs. Findings: 1. A review of the Resident 112's Admission MDS assessment, dated 7/18/22, with an observation end date of 7/25/22, indicated the following sections were not filled and fully completed: Section C-Cognitive Patterns, Section D-Mood, Section F-Preferences for Customary Routine and Activities, Section G-Functional Status, Section H-Bladder and Bowel, Section I-Active Diagnoses, Section J-Health Conditions, Section L-Oral/Dental Status, Section M- Skin Conditions, Section N-Medications, Section O-Special Treatments, Procedures, and Programs, Section P-Restraints and Alarms, and Section S-California [Physician Orders for Life-Sustaining Treatments--POLST]. During an interview on 8/11/22, at 9:47 a.m., with the MDS Coordinator, MDS Coordinator stated Resident 112's admission assessment should have been completed on 7/24/22, which was 14 days after Resident 112's admission to the facility. MDS Coordinator stated Resident 112's MDS is still open. The MDS Coordinator stated MDS assessments needed to be completed timely, to help develop the care plan for the resident and for also CMS (Centers for Medicare and Medicaid Services) to have access to residents' data. 2. A review of Resident 107's Annual MDS assessment, with an observation end date of 7/25/22, indicated the following sections were not filled and fully completed: Section C- Cognitive Patterns- C1310 Signs and Symptoms of Delirium, Section E- Behaviors- E0100 Potential Indicators of Psychosis, Page 1 of 8 555113 555113 08/11/2022 Lake Park Healthcare Center 1850 Alice Street Oakland, CA 94612

F 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Section F-Preferences for Customary Routine and Activities, Section G- Functional Status, Section HBladder and Bowel, Section J- Health Conditions, Section L- Oral/Dental Status, Section M- Skin Conditions, Section N- Medications, Section O- Special Treatments, Procedures, and Programs, Section PRestraints and Alarms, and Section S-California [Physician Orders for Life-Sustaining Treatments--POLST]. During an interview on 8/11/22 at 9:47 a.m., the MDS Coordinator stated Resident 107's Annual assessment was not completed, and it was overdue. During a review of Resident 1's MDS Section C, dated 7/21/22, the MDS Section C indicated, a Brief Interview for Mental Status needed to be conducted. MDS Section C indicated Repetition of Three Words, Temporal Orientation, and Recall was coded with a dash line and the Brief Interview for Mental Status (BIMS-screening used to assist with identifying a resident's current cognition) Score was coded with a zero and a dash. During a phone interview on 8/11/22, at 9:41 a.m., with MDS Coordinator, MDS Coordinator stated, when a dash is coded for Section C, it means the interview with the resident has been scheduled but it was not done and a coding of a zero and a dash in the BIMS score means that the interview was not done. 4. During a review of Resident 157's MDS Section A, dated 7/21/22, the MDS Section A indicated, Resident 157's type of assessment was an admission Assessment and Resident 157 was admitted on [DATE]. During a review of Resident 157's MDS, undated, the MDS indicated, that the following sections were blank: Sections B, C, D, E, F, G, GG, H, I, J, M, N, O, P, Q, S, and V. During a phone interview on 8/11/22, at 9:41 a.m., with MDS Coordinator, MDS Coordinator stated the MDS was not done for Resident 157 in July 2022. MDS Coordinator stated, if the coding is blank, it means the assessment was not done. MDS Coordinator further stated Section Z reflected what assessments were done and who completed the assessment. During a review of Resident 157's Section Z (Assessment Administration), undated, MDS Section Z indicated sections A and K were completed. During a review of the facility's policy and procedure (P&P) titled, Resident Assessments, dated November 2019, the P&P indicated, A comprehensive assessment of every resident's needs is made at intervals designated by OBRA [Omnibus Budget Reconciliation Act, also known as the Nursing Home Reform Act of 1987] and PPS [Prospective Payment System] requirements. The P&P also indicated, a. OBRA required assessments=conducted for all residents in the facility: (1) Initial Assessment (Comprehensive)- Conducted within fourteen (14) days of the resident's admission to the facility. 555113 Page 2 of 8 555113 08/11/2022 Lake Park Healthcare Center 1850 Alice Street Oakland, CA 94612

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and document reviews, the facility failed to be free of medication error rate of five percent or greater for two medication errors observed out of 27 opportunities when gloves were not worn during the administration of a Lidocaine patch (medication used for pain) and eye drop medication administration policies and procedures were not followed. The medication error rate was calculated as followed: two divided by 27 then multiplied by 100, which was equal to 7.4 percent. Residents Affected - Few This failure had the potential for the spread of infection and a decreased medication therapeutic effect for the affected residents. Findings: A review on the facility's the policy and procedure, dated 5/16, titled, Medication Administration Transdermal Delivery Systems (Patches) indicated, the patch is in place and maintaining proper placement of the patch and care of the application sites .PROCEDURES .Perform hand hygiene .Put on gloves . During an observation on 08/09/22, at 8:30 a.m., Licensed Vocation Nurse (LVN) 1 was observed not putting on gloves prior to the administration of a Lidocaine 4% patch. LVN 1 applied the Lidocaine patch to Resident 1 without having gloves on her hands. During an interview on 08/09/22, at 10:00 a.m., LVN 1 was asked why she had not put on gloves prior to applying the Lidocaine 4% patch. LVN 1 stated she did not know it was required per policy. LVN 1 stated it makes sense since you do not want the medication absorbed through the hands. LVN 1 also acknowledged it could also be an infection control issue. If her hands are not cleaned properly and gloved, she could spread infection. A review of the facility's policy and procedure, dated 5/16, titled, Medication Administration Eye Drops, indicated, To administer ophthalmic solution into the eye in a safe and accurate manner . Shake the eye drops container .Do NOT let tip of dropper touch the eye or any other surface .Instruct resident to close eyes slowly to allow for even distribution over surface of the eye .While the eye is closed, use one finger to compress the duct in the inner corner of the eye for 1-2 minutes. This reduces systemic absorption of the medication. Alternatively, the resident may keep his/her eyes closed for approximately three minutes . During an observation on 08/09/22, at 9:00 a.m., LVN 1 administered one eye drop of Brimonidine (medication used to lower pressure in the eye) to each of Resident 2's eyes. LVN 1 did not shake the eye drop container prior to administration. LVN 1 touched the tip of the dropper to Resident 2's eyelashes. LVN 1 did not compress the duct in the inner corner of the eyes for one to two minutes or ask Resident 2 to keep their eyes closed for approximately three minutes. During an interview on 08/09/22, at 10:05 a.m., with LVN 1, LVN 1 stated she did not shake the eye drop container prior to administration. LVN 1 stated she might have touched the tip of the dropper to Resident 2's eyelashes; however, LVN 1 stated she was trying to give the drop quickly because of Resident 2's history of non-compliance. LVN 1 further said she had forgotten to compress the duct in the inner corner of the eyes or ask Resident 2 to close their eyes for approximately three minutes. 555113 Page 3 of 8 555113 08/11/2022 Lake Park Healthcare Center 1850 Alice Street Oakland, CA 94612

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 store and label food safely when Refrigerator #1 (Ref #1) had two boxes of lactose free milk and one soy original milk with no labeled open dates and times. This deficient practice placed the residents at risk for food borne illnesses. Findings: During a concurrent observation and interview on 8/8/22, at 9:25 a.m., with Director of Dining Services (DSS), in the kitchen, it was observed that in Ref #1, there were two opened boxes of lactose free milk and one opened box of original soy milk that did not have the open date and time on it. DSS stated they put the date received on the boxes but do not put the open date and time on the milk. DSS stated they follow the manufacturer's best by date indicated in the box to determine when it would be discarded. During a concurrent interview and policy review, on 8/9/22, at 10:37 a.m., with DSS, the facility's document titled, Food Safety Management System: PQA-Food Product Shelf-Life Guidelines, dated 01/28/2022 was reviewed. The Food Safety Management System: PQA-Food Product Shelf-Life Guidelines indicated, Milk Substitutes can be stored in the refrigerator for seven to ten days days, if opened. DSS confirmed to determine the seven to ten day time period, there should be an open date placed on the milk boxes. 555113 Page 4 of 8 555113 08/11/2022 Lake Park Healthcare Center 1850 Alice Street Oakland, CA 94612

F 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm Based on interview and document review, for one of nine sampled residents (Resident 1), the facility failed to ensure a resident was monitored during the use of antibiotic (medication used to treat bacterial infections) when Resident 1 was prescribed amoxicillin (antibiotic medication) and was not monitored. Residents Affected - Few This failure resulted in the potential for prolonged and unnecessary use of the antibiotic for Resident 1. Findings: During an interview on 8/9/22, at 1:08 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated there were two residents currently on antibiotics LVN 1 was aware of, a resident who had surgery and the other resident had a tooth procedure. LVN 1 stated she received the antibiotic order from the doctor, and the doctor tells her when to start and stop the medication. LVN 1 stated she was not responsible to do a review of infections treated with antibiotics. LVN 1 stated there were two residents currently on antibiotics, one resident received antibiotic for surgery and the other for a tooth procedure. During an interview on 8/9/22, at 2:43 p.m., with the Infection Preventionist (IP), the IP stated she was the Antibiotic Steward, hired a month ago. The IP stated the Antibiotic Stewardship binder was not in order and the facility did not track the necessary information. IP stated, they are not following McGreer's (a criteria that evaluates for infection). The IP stated antibiotics should have a system to monitor for the name of antibiotic, what is used for, when it was started, and when the medication should end. The IP stated everyone on an antibiotic should be tracked, even those who used it to preserve health and prevent the spread of an infection. Review of the physician's order, dated 6/22/22, for Resident 1, it indicated the order, AMOXICILLIN 500 MG CAPSULE NOTES: [None], Instructions: [None], Therapeutic Range: [None], Quantity: 1, Route: Oral, Frequency: two times daily starting 06/22/22, Status: Active (current); DC [discontinue] date: [no end date], Class: [None]. Review of the facility's policy and procedure, titled, Antibiotic Stewardship - Review and Surveillance of Antibiotic Use and Outcomes, revised on December 2016, indicated, Antibiotic usage and outcome data will be collected and documented using a facility-approved antibiotic surveillance tracking form. The data will be used to guide decisions for improvement of individual resident antibiotic prescribing practices and facility-wide antibiotic stewardship . 1. As part of the facility antibiotic stewardship program, all clinical infections treated with antibiotics will undergo review by the infection preventionist, or designee. 2. The IP or designee, will review antibiotic utilization as part of the antibiotic stewardship program and identify specific situations that are not consistent with the appropriate use of antibiotics. a. Therapy may require further review and possible changes if: (1) the organism is not susceptible to antibiotic chosen; (2) the organism is susceptible to narrower spectrum antibiotic; (3) therapy was ordered for prolonged surgical prophylaxis; or (4) therapy was started awaiting culture, but culture results and clinical findings do not indicate continued need for antibiotics. 3. At the conclusion of the review, the provider will be notified of the review findings. 4. All resident antibiotic regimens will be documented on the facility-approved antibiotic surveillance tracking form. The information gathered will include: a. resident name and medical record number; b. Unit and room number; c. date symptoms appeared; d. name of antibiotic; e. start date 555113 Page 5 of 8 555113 08/11/2022 Lake Park Healthcare Center 1850 Alice Street Oakland, CA 94612

F 0881 of antibiotic; f. pathogen identified; g. site of infection; h. date of culture; i. stop date; j. total days of therapy; k. outcome; and l. adverse events. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 555113 Page 6 of 8 555113 08/11/2022 Lake Park Healthcare Center 1850 Alice Street Oakland, CA 94612

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to follow its pneumonia vaccine policy and procedure for four of nine sampled residents (Resident 109, 110, 112, 113) when Residents 109, 110, 112, and 113 were not offered the pneumonia vaccination and their immunization records were not updated. This failure had the potential for vulnerable residents in the facility to become exposed to bacteria that causes serious infections in the lungs, ears, sinuses, brain/spinal cord tissue, and blood. Residents Affected - Some Findings: Review of the facility's Resident Immunization Record, indicated Resident 113 received a pneumococcal vaccine on 7/13/2016 at the acute care hospital, Resident 109 received the pneumococcal vaccine on 11/24/14 at the acute care hospital, Resident 112 received the pneumococcal vaccine on 1/15/15 at the acute care hospital, and Resident 110 received the pneumococcal vaccine on 3/28/16 at the acute care hospital. During an interview on 8/10/22, at 11:15 a.m., with the Infection Preventionist (IP), the IP stated she looked in all the areas where updated pneumonia vaccine records could be kept with no success. IP stated Residents 109,110, 112 and 113 were not updated with their pneumonia vaccines and Residents 109, 110, 112, and 113 were overdue for their next pneumococcal vaccine. Review of the facility's policy, titled Pneumococcal Vaccine, revised on October 2019, it indicated, All residents will be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. 1. Prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, will be offered the vaccine series within thirty days of admission to the facility unless medically contraindicated or the resident has already been vaccinated. 2. Assessments of pneumococcal vaccination status will be conducted within five working days of the resident's admission if not conducted prior to admission. 3. Before receiving a pneumococcal vaccine, the resident or legal representative shall receive information and education regarding the benefits and potential side effects of the pneumococcal vaccine. Provision of such education shall be documented in the resident's medical record. 4. Pneumococcal vaccines will be administered to resident (unless medically contraindicated, already given, or refuse: per facility's physician-approved pneumococcal vaccination protocol. 5. Residents/representatives have the right to refuse vaccination, If refused, appropriate entries will be documented in each resident's medical record . Review of the undated facility document, titled, Administering Pneumococcal Vaccines (PCV13 and PPSV23) to Adults, indicated to assess adults age [AGE] years or older for the need of the pneumococcal vaccination. 555113 Page 7 of 8 555113 08/11/2022 Lake Park Healthcare Center 1850 Alice Street Oakland, CA 94612

F 0888 Ensure staff are vaccinated for COVID-19 Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and document review, the facility failed to develop policies and procedures to address COVID-19 (an infectious disease spread by person to person through respiratory droplets) vaccinations for their nursing registry staff. This failure had the potential for registry staff to spread COVID-19 infection to the residents and the facility's regular staff. Residents Affected - Few Findings: During an interview on 8/8/22, at 10:30 a.m., with Licensed Vocational Nurse (LVN) 2, LVN 2 stated she was from the registry and worked on-call at the facility to work eight or 12 hour shifts. During an interview 8/10/22, at 11:00 a.m., with the Administrator (ADM), the ADM stated the facility used a lot of registry personnel (licensed nurses and certified nurse assistants) and did not keep a log or verify their COVID-19 vaccination statuses. ADM stated the registry agency checked vaccination statuses of the registry personnel beforehand and sent them to work at the facility. During an interview on 8/9/22, at 10:30 a.m., with the Infection Preventionist (IP), IP stated she was new and started a month ago. The IP provided the document, titled, COVID-19 Staff Vaccination Status for Providers. The IP stated COVID-19 vaccinations for registry staff was not included on the document because the registry agency verified their vaccination statuses. IP stated the Executive Director (ED) kept track of the vaccination statuses because the building was being sold. IP further stated it was the facility and IP's responsibility that registry staffs' COVID-19 vaccinations statuses were verified. During an interview and concurrent record review on 8/10/22, at 11:00 a.m., with the ED, the ED stated the building was in the process of being sold and she kept track of all the facility's paperwork. A review of the ED's untitled and undated document, indicated a list of staff names of COVID-19 vaccinations tracked. The list was organized according to departments: Admin, Health Unit, Assisted Living, Facility Operations, and Dining Services. The list did not include registry staff names or any titles. The ED provided the COVID-19 Mitigation Plan and stated the facility follows this as their policy and procedure for staff vaccinations. Review of the facility's policy and procedures titled, Mitigation Plan and Plan for Epidemic Outbreak Specific to COVID-19 Mitigation Plan Report, dated 3/8/22, indicated it did not include a system to track and securely document COVID-19 vaccination status for all staff. Another document, titled, Lake Park SNF [Skilled Nursing Facility] Facility Assessment Plan, 2022, dated 8/18/22, indicated, Infection Control-Infection prevention and control program. The facility must establish an infection prevention and control program that must include, at a minimum, the following elements: (a) A system for reviewing, identifying, reporting, investigating and controlling infections .to all residents, staff, volunteers, visitors and other individuals providing services under a contractual arrangement based upon facility assessment conducted according to accepted national standards. 555113 Page 8 of 8