Health inspection·February 15, 2024

F 0880 Provide and implement an infection prevention and control program. 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 record review, the facility failed to maintain infection control practices when a Certified Nursing Assistant (CNA) did not wear gloves and a gown before entering a positive COVID room and did not perform hand hygiene after exiting the room. Residents Affected - Few This failure had the potential for the spread of germs and infection. Findings: During an observation on 2/15/24 at 1:12 p.m. in station 1, there was a transparent plastic shield with a zipper at the door of room [ROOM NUMBER]. The door was wide open behind the shield. There was signage on the door indicating transmission-based precautions for COVID. On the left, attached to the door, were Personal Protective Equipment (PPE - disposable protective gowns, gloves, etc.,). room [ROOM NUMBER] had two residents who were in isolation for COVID 19. CNA 1 was entering room [ROOM NUMBER]. CNA 1 unzipped the transparent plastic shield, entered the room, and did not wear gloves and a gown. CNA 1 proceeded to Bed B, delivered a food tray to Resident 1, talked to Resident 1 briefly, and proceeded to exit. CNA 1 picked up a dark cloth from the floor by Resident 1 ' s bed and placed it on the bed. CNA 1 came outside, did not perform hand hygiene, and opened the food cart stationed in the hallway opposite room [ROOM NUMBER]. During an interview on 2/15/24 at 1:15 p.m. with CNA 1, CNA1 stated she just went to drop off the tray. CNA 1 stated she thought those residents were cleared from isolation. CNA 1 later acknowledged she was supposed to follow the infection precautions instructions, wear gloves and a gown before entering the room; and perform hand hygiene after exiting the room before opening the food cart. CNA1 stated, it ' s my mistake. CNA 1 confirmed it was Resident 1 ' s bed cover that she picked up from the floor. CNA 1 stated again it ' s my mistake. During an interview on 2/15/24 at 4:20 p.m. with Director of Nursing (DON), DON stated staff is required to follow the infection precautions protocol including hand hygiene. DON stated, for a COVID positive room, staff must wear PPE including a gown, N95 mask, and gloves before they go in, even if taking in or removing the meal tray. During a review of the facility ' s policy and procedure (P&P) titled, Covid-19 Infection Control Measure, undated, the P&P indicated the company follows infection prevention and control practices . to prevent the transmission of COVID-19 within the facility .standard precautions (hand hygiene and respiratory hygiene); transmission-based precautions, where indicated .appropriate use of PPE . During a review of the P& P titled, Transmission Precautions: Contact, undated, the P&P indicated, (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 555358 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 555358 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fruitvale Healthcare Center 3020 East 15th Street Oakland, CA 94601 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)