Health inspection·September 19, 2024

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some just in case, and she believed the policy indicated the discontinued medications should be discarded after three months. During an interview on 09/19/24, at 11:57 p.m., with NM, NM stated the expectation was when the medication was discontinued, it needed to be removed and placed in the discarded medications area because there was a high chance that it could be used by mistake if left in the refrigerator. During an interview on 09/19/24, at 12:24 p.m., with Pharmacist (Pharm), Pharm stated discontinued medications needed to be separated from regular medications as soon as possible so they did not get used by mistake by other residents. During a review of the facility's policy and procedure (P&P) titled, Storage of Medications, dated 2007, the P&P indicated, 4). The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs should be returned to the dispensing pharmacy or destroyed. During a review of the facility's P&P titled, Discontinued Medications, dated 2001, .3). Discontinued medications are destroyed or returned to the issuing pharmacy . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555381 If continuation sheet Page 2 of 6 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 09/19/2024 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)

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 ensure infection control practices were implemented when one of four residents, Resident 21's bedside commode (a portable toilet) was visibly soiled. Residents Affected - Few This failure placed the facility's residents at risk for healthcare-associated infections. Findings: During a review of Resident 21's admission Record, dated 9/18/24, the admission Record indicated Resident 21 was admitted to the facility on [DATE]. During a record review of Resident 21's Minimum Data Set (MDS- An assessment tool to guide care), dated 7/24/24, MDS indicated Resident 21 required supervision when walking from room to room and when performing toilet hygiene. The MDS indicated Resident 21 had an active diagnosis of Non-Alzheimer's Dementia (memory loss). During an observation on 9/16/24, at 12:41 p.m., in Resident 21's room, Resident 21 was sitting on the side of her bed eating lunch with her lunch tray on top of her bedside table. Resident 21's bedside table was positioned directly adjacent (next to) a bedside commode. The lid and seat of the bedside commode were made of plastic and were both gray in color. The armrests and legs of the bedside commode were made of metal. The lid of the bedside commode was closed. On the front of the lid were four smears of a brown, crusty material. Each smear measured approximately ½ inch in length. Scattered in between the left armrest and the left side of the lid were white, brown, gray and black dried crumbs of food. During an observation on 9/17/24, at 12:42 p.m., in Resident 21's room, Resident 21 was sitting on the side of her bed eating lunch on her bedside table. Resident 21's bedside table was positioned directly adjacent to a bedside commode. The lid of the bedside commode was closed. On the front of the lid were six smears of a brown, crusty material. Each smear measured approximately ½ inch in length. Scattered in between the left armrest and the left side of the lid were white, brown, gray and black dried crumbs of food. During an observation on 9/18/24, at 11:30 a.m., in Resident 21's room, Resident 21 was sitting on the side of her bed watching television. Resident 21's bedside commode was positioned directly adjacent to her. The lid of the bedside commode was closed. On the front of the lid were seven smears of a brown, crusty material. Each smear measured ½ inch in length. Scattered in between the left armrest and the left side of the lid were white, brown, gray and black dried crumbs of food. During an interview with Certified Nursing Assistant 1 (CNA 1) on 9/18/24, at 11:42 a.m., in the hallway outside of Resident 21's room, CNA 1 stated she had been assigned to Resident 21 previously and that she was familiar with her. CNA 1 stated any surfaces, including the bedside table and the bedside commode in Resident 21's room had to be sanitized and wiped down regularly because Resident 21 often walked around in her room and in the hallways and touched everything. CNA 1 then stated that all CNAs were responsible for cleaning and sanitizing surfaces such as bedside tables and bedside commodes in Residents' rooms. During an interview with the Nurse Manager (NM) on 9/18/24, at 11:48 a.m., at the Nursing Station (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555381 If continuation sheet Page 3 of 6 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 09/19/2024 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)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few directly across the hallway from Resident 21's room, NM stated Resident 21 used her bedside commode regularly. NM stated the CNAs were responsible for removing the waste from inside of the bedside commodes. NM stated if the bedside commode was visibly dirty, the CNA should clean it and sanitize it. NM stated she rounded to resident rooms daily to check for cleanliness. NM stated during the rounds, bedside commodes were checked for cleanliness. NM stated if a bedside commode was dirty, there was a risk of infections spreading. During an interview with CNA 2 on 9/18/24, at 11:53 a.m., in the hallway outside of Resident 21's room, CNA 2 stated she was assigned to care for Resident 21 today. CNA 2 stated she had checked Resident 21's bedside commode earlier in the morning and it appeared clean. During a concurrent observation and interview with NM and CNA 2 on 9/18/24, at 11:56 a.m., in Resident 21's room, Resident 21 was asleep in her bed. Resident 21's bedside commode was positioned adjacent to her bed which was positioned directly adjacent to where her head was laying on her pillow. The lid of the bedside commode was closed. On the front of the lid were seven smears of a brown, crusty material. Each smear measured ½ inch in length. Scattered in between the left armrest and the left side of the lid were white, brown, gray and black dried crumbs of food. CNA 2 stated the smears of brown, crusty material appeared to be fecal material (solid human waste consisting of undigested food, bacteria, mucus and cells which are passed out of the body). NM stated there were crumbs of food and what appeared to be fecal material on the bedside commode. CNA 2 and NM both stated the bedside commode did not look clean. CNA 2 then stated there was a risk of spreading infection from the fecal material on the bedside commode. During a review of the facility's policy and procedure (P&P) titled, Cleaning and Disinfecting Residents' Rooms, dated August 2024, the P&P indicated, Purpose: The purpose of this procedure is to provide guidelines for cleaning and disinfecting residents' rooms and belongings. General Guidelines: 9. Clean medical waste containers intended for reuse (e.g., bins, pails, cans, bedside commodes, etc.) daily or when such receptacles become visibly contaminated with blood, body fluids or other potentially infectious materials . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555381 If continuation sheet Page 4 of 6 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 09/19/2024 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)

F 0912 Level of Harm - Minimal harm or potential for actual 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, interview and record review, the facility had 11 resident rooms (Rooms 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, and 11) with multiple beds that provide less than 80 square feet (sq. ft.) per resident who occupy these rooms. This failure had the potential to result in inadequate space for the delivery of care to each of the residents in each room or for storage of the residents' belongings. Findings: During observations of care and services from 9/16/24 through 9/19/24, the following rooms and corresponding square footage per bed were identified: 1. room [ROOM NUMBER] had two beds, total sq. ft. is 154 and 77 sq. ft. per bed. 2. room [ROOM NUMBER] had two beds, total sq. ft. is 154 and 77 sq. ft. per bed. 3. room [ROOM NUMBER] had two beds, total sq. ft. is 154 and 77 sq. ft. per bed. 4. room [ROOM NUMBER] had two beds, total sq. ft. is 154 and 77 sq. ft. per bed. 5. room [ROOM NUMBER] had four beds, total sq. ft. is 287 and 71.75 sq. ft. per bed. 6. room [ROOM NUMBER] had four beds, total sq. ft. is 283.52 and 70.88 sq. ft. per bed. 7. room [ROOM NUMBER] had two beds, total sq. ft. is 154.9 and 77.45 sq. ft. per bed. 8. room [ROOM NUMBER] had two beds, total sq. ft. is 154.9 and 77.45 sq. ft. per bed. 9. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555381 If continuation sheet Page 5 of 6 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 09/19/2024 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)

F 0912 room [ROOM NUMBER] had two beds, total sq. ft. is 156.68 and 78.34 sq. ft. per bed. Level of Harm - Minimal harm or potential for actual harm 10. room [ROOM NUMBER] had two beds, total sq. ft. is 149.30 and 74.65 sq. ft. per bed. Residents Affected - Some 11. room [ROOM NUMBER] had two beds, total sq. ft. is 149.76 and 74.88 sq. ft. per bed. During random observations of care and services from 9/16/24 through 9/19/24, there was sufficient space for the provision of care for the residents 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 the residents regarding insufficient space for their belongings. There were no negative consequences attributed to the decreased space and/ or safety concerns in the 11 rooms. Granting of room size waiver recommended. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555381 If continuation sheet Page 6 of 6