Health inspection·June 19, 2019

F 0802 Level of Harm - Minimal harm or potential for actual harm Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Based on observation, interview, and record review, the facility failed to ensure staff competency when Dietary Aide 1: Residents Affected - Few a. used a sanitizing agent test strip not intended for use with the Quat sanitizer (anti-microbial agent) solution to test the Quat sanitizer solution concentration, and; b. immersed a newly washed blender in the sanitizing sink for a few seconds. This failure had the potential to result in food-borne illness. Findings: During an observation on 6/17/19, at 9:35 a.m., Dietary Aide 1 used a test strip not intended for use with the Quat Sanitizer to check the Quat sanitizer solution concentration in the three compartment sink. During an interview on 6/17/19, at 9:35 a.m., Food Service Director stated it was not the right strip and told Dietary Aide 1 to use another test strip while pointing to the Quat Sanitizer Test Strips. In an observation on 6/17/19, at 9:35 a.m., Dietary Aide 1 washed the blender on the 3 compartment sink (for washing, rinsing, and sanitizing dishes) and immersed it on the 3rd sink for few seconds to be sanitized. During an interview on 6/17/19, at 9:43 a.m. Food Service Director stated the immersion time should be at least 1 minute and was posted on the wall on top of the three compartment sink. During an interview with Food Service Director and Director of Food and Nutrition on 6/18/19 at 10:54 a.m. they both stated kitchen staff had online trainings and they did shadowing to make sure they know what they were supposed to do. Review of records did not indicate any documentation for skills check or competency and shadowing of kitchen staff. Review of the facility policy and procedure titled, 038: Cleaning Procedures for Pots & Pans, undated, indicated instructions to .Immerse ware into sanitizing sink for at least one minute 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 5 Event ID: 555381 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 555381 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alameda Hospital D/P Snf 2070 Clinton Ave Alameda, CA 94501 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)