Health inspection·June 1, 2023

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, for one of five sampled residents (Resident 1), the facility failed to make prompt efforts to resolve a grievance when Resident 1's request to not receive care from Licensed Vocational Nurse (LVN) 1 was not honored. This failure had resulted in Resident 1's emotional distress. Findings: Review of Resident 1's Significant Event indicated Resident 1 was re-admitted to the facility on [DATE] with diagnoses that included exacerbated congestive heart failure (heart can't pump enough oxygen-rich blood to meet your body's needs), obstructive lung disease (condition that makes it hard to breathe) and diabetes (abnormally high levels of blood sugar). The record indicated Resident 1 was alert, responsive and oriented x 4 (understands who they are, where they are, approximate date or part of the day, and what is happening). [Reference:https://medical-dictionary.com]. Review of Resident 1's Minimum Data Set (MDS, an assessment tool used to direct resident care), dated 5/2/23, indicated Resident 1 had a Brief Interview for Mental Status (BIMS, an assessment tool for resident's orientation to time and capacity to remember) score of 15. The BIMS score range is from 0-15, with zero as the most impaired. [Reference:https://downloads.cms.gov/files/mds-3.0-rai-manual-v1.17.1_October_2019.pdf] During a telephone interview on 5/30/23, at 12:56 p.m., with Resident 1, Resident 1 stated, before Resident 1 was transferred to the hospital on 3/21/23, the facility knew of Resident 1's complaint about LVN 1 turning off the CPAP (Continuous Positive Air Pressure, a machine that uses mild air pressure to keep airways open while you sleep) machine while Resident 1 was asleep. Resident 1 stated she returned to the facility on 3/31/23 from the hospital. Resident 1 stated, on 4/1/23, a day after returning from the hospital, Resident 1 communicated, via text message, with Associate Administrator (AA) about LVN 1's improper care. Resident 1 stated she told AA she did not want to be under LVN 1's care. Resident 1 stated, on 4/4/23, Resident 1 had to send a text message again to AA, after being under LVN 1's care again for two consecutive days (4/3/23 and 4/4/23). Resident 1 stated she felt like no one cared and felt terrified that LVN 1 continued to provide care against Resident 1's will. During an interview on 4/24/23, at 12:57 p.m., with AA, AA stated Resident 1 had complained on (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: 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 06/01/2023 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)