Health inspection·August 25, 2022

F 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, for one (Resident 3) of three sampled discharged residents, the facility failed to complete and transmit Minimum Data Set (MDS, an assessment tool used to direct resident care) within 14 days of discharge from the facility. Residents Affected - Few The failure to complete and transmit the Discharge Assessment for five months and 25 days after Resident 3 transferred to the acute care hospital and did not return, resulted in lack of tracking of residents leaving the facility. Findings: A review of Resident 3's annual MDS dated [DATE], indicated Resident 3 had been in the facility for more than three years with a current diagnosis of respiratory failure (impaired breathing function). A review of Resident 3's progress notes dated 4/21/22, indicated Resident 3 was unresponsive, pulseless, and was transferred to the hospital. During an interview and concurrent record review on 8/25/22 at 10:51 a.m., with the Director of Nursing (DON), Resident 3's MDS records were reviewed. The DON stated the annual assessment dated [DATE], was the last MDS transmitted for Resident 3. The DON stated Resident 3 had become unresponsive and was transferred to the hospital on 4/21/22 and had not returned to the facility. The DON stated Resident 3 had not had a discharge MDS completed or transmitted yet. The DON stated a discharge MDS should be completed and transmitted within 14 days of a resident's discharge. A review of the Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated 2019, indicated, The following situations warrant a Discharge assessment, regardless of facility policies - when resident is transferred and admitted to a hospital or other care setting regardless of whether the nursing home discharges or formerly closes the record. The User's Manual indicated discharge assessments consist of discharge return anticipated and discharge return not anticipated. The User's Manual indicated a Discharge Assessment-Return Not Anticipated: must be completed within 14 days after the discharge date when the resident is discharged from the facility and the resident is not expected to return to the facility indicated for Discharge Assessment-Return Anticipated: must be completed within 14 days after the Page 1 of 8 555381 555381 08/25/2022 Alameda Hospital D/P Snf 2070 Clinton Ave Alameda, CA 94501

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Based on observation, interview, and record review, the facility failed to ensure two Certified Nursing Assistants (CNA 2 and CNA 3) demonstrated competency in skills and techniques for provision of resident care according to resident care plans. The failure to ensure CNA 2 and CNA 3 completed annual performance and competency appraisals had the potential to result in inadequate or improper care for the CNAs assigned residents. Findings: During a record review and concurrent interview on 8/24/22 at 11:47 a.m., with the Supervisor for HR Service and Compliance (SHRSC) the personnel files of CNA 2 and CNA 3 were reviewed. SHRSC stated CNA 3 had a hire date in January of 2019 and should have had an annual performance review in January of 2022, but CNA had not had a performance review this year. SHRSC stated CNA 2 had a hire date in August of 2008 but had not a performance evaluation completed since 2020. A review of the policy titled, Performance Appraisal, revised date 5/2020, the policy indicated the purpose of the performance appraisal was: To establish communication, focused on constructive performance feedback. To identify areas that need improvement and establish goals to facilitate positive change. To provide career counseling, coaching, mentoring and morale building. To challenge employees to higher levels of performance and competency. To recognize employee accomplishments and unique contributions. To evaluate staff performance in accordance with the Joint Commission HRM.01.07.01 . The policy further indicated an annual performance appraisal, based on the employee's month of hire or focal date, would be conducted between the employee and the employee's supervisor, to provide both oral and written feedback on performance. 555381 Page 2 of 8 555381 08/25/2022 Alameda Hospital D/P Snf 2070 Clinton Ave Alameda, CA 94501

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 rates of five percent or greater when three medication errors were observed out of 28 opportunities. The medication error rate was calculated as follows: three divided by 28 then multiplied by 100, which was equal to 10 percent. Residents Affected - Few This failure had the potential to result in ineffective medication regimen for the effected residents (Residents 104, 117, and 125). Findings: 1. A review on 8/23/22 of the manufacturers insert for Advair HFA (fluticasone/salmeterol-medication used for Asthma) indicated, INSTRUCTIONS FOR USE ADVAIR HFA .How to use your ADVAIR HFA inhaler Follow these steps every time you use ADVAIR HFA .Step 3. Breathe out through your mouth and push as much air from your lungs as you can .Step 7. Rinse your mouth with water after breathing in the medicine. Spit out the water. Do not swallow it . During an observation on 8/23/22 at 8:15 a.m., Licensed Vocational Nurse 1 (LVN 1) did not instruct Resident 104 to breathe out as much air as possible prior to the administration of the Advair HFA. LVN 1 did not provide Resident 104 with a water mouth rinse after breathing in the Advair HFA. During an interview on 8/23/22 at 8:45 a.m., LVN 1 stated she had not followed step 3 and step 7 as indicated by the Advair HFA manufacturers insert. LVN 1 stated she had forgotten to instruct Resident 104 to breath out as much air as possible prior to administration. LVN 1 stated the exhalation before administration was important so the medication could be fully distributed throughout the lungs. LVN 1 stated she had provided Resident 104 with a non-prescription mouthwash for a post-administration mouth rinse as a substitute for the manufacturer's water rinse direction. 2. A review on 8/24/22 of the manufacturers insert for Lantus Insulin Pen (Insulin Glargine-medication used for diabetes) indicated, Use your thumb to press the injection button all the way down. When the number in the dose window returns to 0 as you inject, slowly count to 10 before removing. (Counting to 10 will make sure you get your full insulin dose.) During an observation on 8/24/22 at 8:05 a.m., Registered Nurse 2 (RN 2) administered an injection of insulin via the Lantus Insulin Pen to Resident 117. RN 2 injected the insulin and without waiting for ten seconds, removed the needle immediately. During an interview on 8/24/22 at 9:30 a.m., RN 2 stated she had not injected the Lantus Insulin Pen for 10 seconds before removing the needle during administration of Resident 117's insulin. RN 2 stated she had not been aware it was necessary to hold the Lantus Insulin Pen for 10 seconds while injecting. 3. A review of Resident 125's clinical record on 8/24/22 indicated a physician's order for Artificial Tears: two drops into the left eye, and two drops into the right eye. During an observation on 8/24/22 at 8:30 a.m., Licensed Vocational Nurse 3 (LVN 3) administered Artificial Tears to Resident 125: one drop into the left eye, and one drop into the right eye. 555381 Page 3 of 8 555381 08/25/2022 Alameda Hospital D/P Snf 2070 Clinton Ave Alameda, CA 94501

F 0759 Level of Harm - Minimal harm or potential for actual harm During an interview on 8/24/22 at 8:40 a.m., LVN 3 stated she had squeezed the Artificial Tears bottle twice for each eye when instilling the eye drops but had not given the bottle sufficient time to refill between squeezes, so had only instilled one eye drop into each eye. Residents Affected - Few 555381 Page 4 of 8 555381 08/25/2022 Alameda Hospital D/P Snf 2070 Clinton Ave Alameda, CA 94501

F 0812 Level of Harm - Minimal harm or potential for actual harm 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 ensure food was stored and prepared in accordance with professional standards of food and safety when: Residents Affected - Some 1. The food preparation area was adjacent to the hand wash station/sink with inadequate protection from potential splashes of contaminated water and soap from handwashing. 2. The ready-to-use pans stored above the food preparation area were wet. 3. Dietary Clerk (DC) did not cover hair completely while in the kitchen and during tray-line. These failures had the potential to result in food-borne illnesses. Findings: 1. During an observation and concurrent interview on 8/22/22 at 10 a.m., with Assistant Director of Food and Nutrition (ADFN), in the kitchen, the food preparation area had a tray of chopped raw vegetables being prepared for lunch service. The chopped vegetable tray was approximately five inches away from a splash guard which separated the food preparation area from a handwashing sink. The length of the chopped vegetable tray extended beyond the edge of the splash guard for over six inches. There were visible droplets of soapy water on the kitchen floor on both the splash guard side and the front edge of the chopped vegetable tray/food preparation area. ADFN stated the handwash station was used by employees for handwashing during food preparation. 2. During an observation and concurrent interview on 8/24/22 at 9:50 a.m., with Systems Director of Food and Nutrition (SDFN) in the kitchen, there were food pans stacked in the storage area above the food preparation sink. The pan on top of the stack was still wet. SDFN stated all pots and pans should be allowed to air dry before being stored. Review of the facility's undated policy and procedure titled Cleaning Procedures for Pots and Pans indicated after pots and pans were washed and sanitized, Remove the ware from sanitizing sink and invert on drain board. Do not wipe and let air dry. 3. During a tray-line observation on 8/24/22 at 12:10 p.m., DC wore a cover coat with sleeves rolled up to the mid-forearm, exposing black-stained shirtsleeve cuffs. DC also wore a head cover, with hair protruding outside the confines of the head while placing the resident food trays inside the food carts for delivery. A review of the facility's policy and procedure titled, Dress Code for Food and Nutrition Services, last approved August 2016, indicated staff must, Maintain personal hygiene such as, daily bathe, brush teeth and wear a clean uniform/clothing. A review of the United States Food and Drug Administration Food Code 2017, under the section titled, Hygienic Practices, Hair Restraints, section 2-402.11 indicated, FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLESERVICE and SINGLE-USE ARTICLES. 555381 Page 5 of 8 555381 08/25/2022 Alameda Hospital D/P Snf 2070 Clinton Ave Alameda, CA 94501

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure one employee (Certified Nursing Assistant 1, CNA 1) wore required personal protective equipment (PPE, protective items or garments worn to protect the body or clothing from hazards that can cause injury) and performed required hand hygiene after providing direct care to a resident in a room on contact, droplet, and airborne precautions. (Contact and droplet precautions are actions implemented to prevent the spread of infection based upon the transmission mode of direct or indirect contact with respiratory secretions from the resident or environmental surfaces contaminated with respiratory secretions. Airborne precautions are actions taken to prevent or minimize the transmission of infectious agents/organisms that remain infectious over long distances when suspended in the air.) Residents Affected - Few The failure to wear a gown and gloves and to perform hand hygiene after direct care and before exiting from a room with a resident in isolation for exposure to COVID-19 (a contagious respiratory disease that can result in difficulty breathing and death), had the potential to result in spread of COVID-19 infection. Findings: A review of Resident 50's Minimum Data Set (MDS, a resident assessment tool used to guide care) dated 3/10/22, indicated Resident 50 was admitted in March 2022 with a need for rehabilitation after having a stroke (impaired circulation to the brain). During an observation, on 8/22/22, at 10:05 a.m., the door to Resident 50's room was open, with a posted sign on the hallway side of the door which indicated: Contact and Droplet and Airborne Precautions. COVID-19 PUI (Persons Under Investigation, a person without symptoms or a positive lab test, but potentially infectious with COVID) Yellow Zone (the color code for the area used for PUI residents). The sign indicated, Everyone must: perform hand hygiene before entering and leaving room, wear gown before entering room, wear gloves before entering room . Visible through the open doorway, Resident 50 sat in a wheelchair adjacent to her bed, while CNA 1 adjusted Resident 50's bed linen and a face towel on top of the bed. CNA 1 wore no cover gown or gloves. CNA 1 then exited Resident 50's room without performing hand hygiene. During an interview on 8/22/22, at 10:06 a.m., with CNA 1, in the hallway outside Resident 50's room, CNA 1 stated she had not worn a cover gown or gloves because it was hot. During an interview on 8/25/22 at 8:45 a.m., with the Infection Preventionist (IP), IP stated CNA 1 should have worn a cover gown and gloves when in direct contact with a Yellow Zone resident/resident's environment. During a review of the facility's policy and procedure (P & P) titled, Covid-19 Mitigation Plan, dated 8/2/22, the P & P, indicated, Personal Protective Equipment (PPE) - For patient care activities in the yellow zone, HCP generally need to wear eyewear (face shield or goggles), N95, gloves and gown . A review of the Centers for Disease Control, Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes, dated 2/22/22, indicated, HCP caring for residents with suspected or confirmed SARS-CoV-2 infection should use full PPE (gowns, gloves, eye protection, and a NIOSH-approved N95 or equivalent or higher-level respirator). 555381 Page 6 of 8 555381 08/25/2022 Alameda Hospital D/P Snf 2070 Clinton Ave Alameda, CA 94501

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of the facility's policy and procedure (P & P) titled, Handwashing/Hand Hygiene, dated August 2019, the P & P indicated the facility considered hand hygiene the primary means to prevent the spread of infections. The P & P indicated, Use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap (antimicrobial of non-antimicrobial) and water for the following situations: .Before and after direct contact with residents After contact with a resident's intact skin; . After contact with objects .in the immediate vicinity of the resident; .Before and after entering isolation precaution settings; .when in contact with a resident, or the equipment or environment of a resident, who is on contact precautions . 555381 Page 7 of 8 555381 08/25/2022 Alameda Hospital D/P Snf 2070 Clinton Ave Alameda, CA 94501

F 0912 Level of Harm - Potential for minimal harm Residents Affected - Some Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the South Shore facility had 11 rooms (Rooms 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, and 11) with multiple beds that provided less than 80 square feet (sq.ft.) per resident who occupied these rooms. This failure had the potential to result in a lack of sufficient space for the provision of care by facility staff and for the lack of sufficient space for storage of resident belongings. Findings: During an observation on 8/24/22 at 10:00 a.m., with the Operations Manager (OP),the following resident rooms and corresponding square footage (sq.ft.) were identified: Room- Activity- Room- Size- Floor Area 1 Res Room- 2 bedroom [ROOM NUMBER] sq.ft. 77 sq.ft. 2 Res Room- 2 bedroom [ROOM NUMBER] sq.ft. 77 sq.ft. 3 Res Room- 2 bedroom [ROOM NUMBER] sq.ft. 77 sq.ft. 4 Res Room- 2 bedroom [ROOM NUMBER] sq.ft. 77 sq.ft. 5 Res Room- 4 bedroom [ROOM NUMBER] sq.ft. 71.75 sq.ft. 6 Res Room- 4 bedroom [ROOM NUMBER].5 sq.ft. 70.88 sq.ft. 7 Res Room- 2 bedroom [ROOM NUMBER].88 sq.ft. 77.45 sq.ft. 8 Res Room- 2 bedroom [ROOM NUMBER].88 sq.ft. 77.45 sq.ft. 9 Res Room- 2 bedroom [ROOM NUMBER].69 sq.ft. 78.34 sq.ft. 10 Res Room- 2 bedroom [ROOM NUMBER].22 sq.ft. 74.65 sq.ft. 11 Res Room- 2 bedroom [ROOM NUMBER].77 sq.ft. 74.88 sq.ft. During random observations of care and services from 8/22/22 to 8/25/22, there was sufficient space for the provision of care for the resident in all rooms. There was no heavy equipment kept in the rooms that might interfere with resident care, and each resident had adequate personal space and privacy. There were no complaints from residents regarding insufficient space for their belongings. There were no negative consequences attributed to the decreased space and/or safety concern in the 11 rooms. Recommend granting room size waiver. 555381 Page 8 of 8