Health inspection·May 20, 2021

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 the facility failed to inform and provide information for one of three sampled residents (Resident 35) regarding the option to prepare an advance directive (a written statement of a person's wishes regarding medical treatment to ensure those wishes are carried out should the person be unable to communicate them to a doctor). This deficient practice had the potential to result in Resident 35's wishes regarding medical treatment not being followed. Findings: Review of the admission Record dated 5/20/21, indicated Resident 35 was admitted to the facility in 2019 with an included diagnosis of chronic obstructive pulmonary disease (a group of progressive lung disorders characterized by increased difficulty breathing). Review of Resident 35's annual Minimum Data Set (MDS, an assessment tool used to guide care) dated 9/7/20, indicated Resident 35 was able to recall words, repeat words, and knew the correct year and month. The MDS also indicated the advance directive section of the Physicians Orders for Life Sustaining Treatment (POLST, a form that is based on a person's end-of-life care decisions) had not been completed. Review of Resident 35's POLST, dated 9/3/19, indicated the advance directive section, Section D had not been completed. During an interview with Resident 35 on 5/19/21 at 9:15 a.m., Resident 35 stated he did not think anyone from the facility had talked to him about an advance directive, but he would like to learn more about an advance directive. During an interview with the Social Services Director (SSD) on 5/19/21 at 10:35 a.m., SSD stated Resident 35's POLST, Section D should have been completed. SSD stated she did not have any documentation that she had spoken to and/or given any information to Resident 35 or his conservator regarding an advance directive. Review of the facility's policy and procedure titled Advance Directives revised December 2016, indicated 1. 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 . Page 1 of 6 555254 555254 05/20/2021 Medical Hill Healthcare Center 475 29th Street Oakland, CA 94609

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to provide necessary respiratory care and services for one (Resident 217) of three sampled residents when the facility failed to have a physician-ordered bag mask valve (A bag mask valve, commonly called an Ambu bag, is a handheld tool that is used to deliver positive pressure ventilation to a person with insufficient or ineffective breathing.) available at Resident 217's bedside for emergency use. Residents Affected - Few This failure had the potential to result in staff being unable to deliver necessary respiratory support to Resident 217 in the event of a respiratory emergency, potentially resulting in physical injury and/or death. Findings: A review of Resident 217's Minimum Data Set (MDS, an assessment tool used to guide care) dated 5/20/21, indicated Resident 217 had entered the facility in May 2021 with a diagnosis of chronic respiratory disease and respiratory failure. The MDS also indicated Resident 217 had special treatment needs which included oxygen therapy and tracheostomy care. (A tracheostomy is an opening surgically created through the neck into the trachea, commonly called windpipe, to allow direct access to the lungs for breathing .A tube is usually placed through this opening to provide an airway and to remove secretions from the lungs. Breathing is done through the tracheostomy tube rather than through the nose and mouth.) A review of Resident 217's Clinical Physician Orders, start date 5/19/21, indicated, Keep at bedside .ambubag . A review of Resident 217's care plan with the focus of, The resident has a tracheostomy at risk of dislodgement, start date of 5/19/21, reflected an intervention of, Have O2 [oxygen], ambubag .for emergency readily available. During a concurrent observation and interview on 5/19/21 at 9:26 a.m., at Resident 217's bedside, Licensed Vocational Nurse 3 (LVN) 3 was unable to find an Ambu bag. LVN 3 left the room and returned with Registered Nurse 1 (RN 1), and they both searched Resident 217's closet and room but were unable to find an Ambu bag. RN 1 stated an Ambu bag needed to be at Resident 217's bedside for use in case of an emergency. 555254 Page 2 of 6 555254 05/20/2021 Medical Hill Healthcare Center 475 29th Street Oakland, CA 94609

F 0732 Post nurse staffing information every day. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review and interview, the facility failed to post nurse staffing data. Residents Affected - Some This deficient practice prevented residents and visitors from receiving information about the number of nursing personnel available to provide direct care to residents. Findings: During a concurrent observation and interview on 5/17/21 at 11:55 a.m., with the Infection Preventionist (IP), the IP stated the current daily staffing numbers were not posted as she had not completed the calculations for day shift yet. The facility document titled, Posting Direct Care Daily Staffing Numbers, revised 7/16, indicated For each shift, the number of licensed Nurses (RNs [registered nurses], LPNs [licensed practical nurses]. And LVNs [licensed vocational nurses]) and the number of unlicensed nursing personnel (CNAs [certified nurse assistants]) directly responsible for resident care will be posted in a prominent location (accessible to residents and visitors) and in a clear and readable format. 555254 Page 3 of 6 555254 05/20/2021 Medical Hill Healthcare Center 475 29th Street Oakland, CA 94609

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm 3. A review of Resident 4's admission Record dated 5/20/21, indicated he was admitted to the facility in January 2021 with an included diagnosis of chronic obstructive pulmonary disease (a chronic respiratory disease which results in progressive difficulty breathing). Residents Affected - Some During a review of the Minimum Data Set (MDS, an assessment tool used to guide care), dated 2/2/21, the MDS indicated Resident 4 required physical assistance from one person for toilet use and personal hygiene. During an observation on 5/17/21, at 12:17 p.m., Certified Nurse Assistant 2 (CNA 2) donned gloves outside Resident 4's room without performing hand hygiene, and immediately entered Resident 4's room and proceeded to provide direct care to Resident 4. During an interview on 5/17/21, at 12:20 p.m., with CNA 2, CNA 2 stated she had helped Resident 4 change clothes after toilet use. During an interview on 5/19/21, at 9:49 a.m., with the Director of Nursing (DON), the DON stated staff were expected to perform hand hygiene before and after patient care. During an interview on 5/20/21, at 1:15 p.m., with IP, IP stated the expectation was for direct care staff to wash hands or use alcohol-based hand rubs before performing direct resident care like toilet use and dressing. IP stated lack of hand hygiene had the potential to result in outbreak of infection. A review of facility's policy and procedure (P&P) titled, Handwashing/Hand Hygiene, dated August 2019, the P&P indicated, Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: .Before and after direct contact with residents The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. Based on observation, interview, and record review, the facility failed to provide an environment to help prevent the development and transmission of communicable diseases and infections when: 1. Certified nursing assistant 1 (CNA 1), did not don proper personal protective equipment (PPE, protective items or garments worn to protect the body or clothing from hazards that can cause injury) when entering the room of Resident 270, who was on contact precautions (contact precautions are measures intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or the resident's environment). 2. For one of three residents (Resident 268, a resident with open wounds), placement in the same room as Resident 270, a resident with an infection requiring contact precautions, resulted in increased risk of infection. 3. CNA 2 did not perform hand hygiene before performing direct patient care for Resident 4. These failures had the potential to spread infection and cause illness to residents and staff. 555254 Page 4 of 6 555254 05/20/2021 Medical Hill Healthcare Center 475 29th Street Oakland, CA 94609

F 0880 Findings: Level of Harm - Minimal harm or potential for actual harm 1. A review of resident 270's physician progress note dated 5/18/21, reflected Resident 270 was admitted in May 2021, with a diagnosis of Clostridium difficile infection (Cdiff, an infection which can cause severe diarrhea, and inflammation of the digestive tract), open-wound pressure ulcers (one or more layers of skin and tissue are damaged as a result of continuous pressure to an area), and a colostomy (a surgically created opening in the abdomen to allow intestinal contents from the colon to drain into an external collection bag). Residents Affected - Some During an observation on 5/19/21, at 1:02 p.m., Resident 270's door had signage posted which indicated, Contact Precautions. The signage also showed a picture of PPE to be worn before entering the room, which included a gown, gloves, surgical mask, and faceshield. CNA 1 entered resident 270's room without donning a gown or gloves, went to Resident 270's bedside, and removed his meal tray containing the remains of the lunch meal from the overbed table. CNA carried the meal tray to the doorway and handed the tray to a waiting staff member. CNA 1 returned to Resident 268's bedside, removed his meal tray containing the remains of the lunch meal from the overbed table, and passed it to a staff member waiting at the doorway. During an interview on 5/19/21, at 3:10 p.m., with CNA 1, CNA 1 stated she had not worn a gown or gloves when inside the shared room of Resident 270 and 268 because she thought she only needed to wear a gown and gloves when she provided direct care to Resident 270. During an interview on 5/19/21, at 2:59 p.m., with the Infection Preventionist (IP), the IP stated Resident 270 had a Cdiff infection and required contact precautions. IP stated employees should don full PPE which included a surgical mask, faceshield, gown, and gloves, before any contact with a Cdiff infected resident or their belongings, including handling of used food trays. During a review of the facility's policy and procedure (P&P) titled, Transmission-Based Precautions, dated 8/2016, the P&P indicated, For Contact Precautions .Wear gloves when contact [sp] with the resident environment. During a review of the facility's policy and procedure (P&P) titled, Isolation-Categories of Transmission-Based Precautions, dated 10/2018, the P&P indicated, Contact Precautions .staff and visitors will wear gloves (clean, non-sterile) when entering the room Gloves will be removed and hand hygiene performed before leaving the room. Staff will avoid touching potentially contaminated environmental surfaces or items in the resident's room after gloves are removed. Staff and visitors will wear a disposable gown upon entering the room and remove before leaving the room and avoid touching potentially contaminated surfaces with clothing after gown is removed. 2. A review of the facility Resident Listing Report dated 5/17/21 reflected Resident 270, 268, and another resident, all resided in a shared three-bed room. A review of Resident 268's admission Record dated 5/20/21, indicated Resident 268 was admitted in May 2021 with included diagnoses of stage III pressure ulcers (Stage III ulcers are defined as full thickness skin loss) on the left and right buttocks, a non-pressure ulcer on the left lower leg, and infection with methicillinresistant staphylococcus aureus (MRSA, an organism whose treatment is complicated by being resistant to treatment with the antibiotic methicillin, a type of semi-synthetic penicillin). 555254 Page 5 of 6 555254 05/20/2021 Medical Hill Healthcare Center 475 29th Street Oakland, CA 94609

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an observation on 5/17/21, at 10:14 a.m., in the shared room of Resident 268 and 270, Resident 268 was in bed A, Resident 270 was in bed B, and another resident occupied bed C. During an interview on 5/20/21, at 11:19 a.m., with the Infection Preventionist (IP), IP confirmed Resident 270 was the only resident in the shared room with Cdiff. IP stated Resident 270 required contact precautions but had not needed a private room because he was not ambulatory. IP stated she was unaware of any other criteria limitations for shared room placement of Cdiff residents with non-Cdiff residents. IP stated Resident 268 was not ambulatory, but did have wounds. During a review of the facility's policy and procedure (P&P) titled, Transmission-Based Precautions, dated 8/2016, the P&P indicated, For Contact Precautions if resident does not have same infection, may place with resident who has no significant open wounds or significant breaks in skin . 555254 Page 6 of 6