Health inspection·January 21, 2025

F 0600 conservator did not give consent for Resident 1 to participate in any sexual activity. Level of Harm - Minimal harm or potential for actual harm During a concurrent observation and interview on 12/23/24, at 10:00 a.m., with Resident 1, Resident 1 was in their wheelchair and was not interviewable. Residents Affected - Few During an interview on 12/23/24, at 10:15 a.m., with Certified Nursing Assistant 2 (CNA 2), CNA 2 stated they had worked with Resident 1 for a long time. CNA 2 stated Resident 1 had an intellectual disability and staff typically tried to anticipate her needs due to communication difficulties. During a phone interview on 12/23/24, at 9:00 p.m., with CNA 1, CNA 1 stated on 11/30/24, at around 2:20 a.m., CNA 1 heard Resident 1 crying. CNA 1 immediately went into Resident 1 ' s room and found Resident 2 at Resident 1 ' s bed with his pants down thrusting his hip against Resident 1 ' s hip. Resident 1 was laying on their bed with their pants on but pulled down exposing the diaper. CNA 1 immediately called for RN 2 who came and pulled Resident 2 away from Resident 1. CNA 1 stated Resident 1 complained of arm pain to RN 1. CNA 1 stated while CNA 1 and RN 1 were assessing Resident 1 for injury, Resident 1 stated she was making babies. During a phone interview on 12/23/24, at 3:05 p.m., with RN 2, RN 2 stated on 11/30/24, at around 2:20 a.m., CNA 1 called RN 2 for help because Resident 2 was in Resident 1 ' s room. RN 2 stated she entered the room and saw Resident 2 at the side of Resident 1 ' s bed with his pants down. RN 2 stated Resident 2 was performing a rocking motion against Resident 1 ' s pelvis. RN 2 then pulled Resident 2 away, placed him on a wheelchair and removed him from the room. During a phone interview on 12/23/24, at 2:30 p.m., with Registered Nurse 1 (RN 1), RN 1 stated on 11/30/24, at approximately 2:20 a.m., she was called over to Resident 1 ' s room to check on Resident 1 for an incident. RN 1 stated she did not witness the incident and was called to assess Resident 1 after it. RN 1 stated Resident 1 told her he held my elbow and was complaining of elbow pain. RN 1 stated they gave Resident 1 pain medication. RN 1 stated Resident 1 began to claim she was pregnant and hadn ' t made those claims before. During a record review of Resident 1 ' s nursing progress note titled, Significant Event, dated 11/30/24, at 3:23 a.m., by RN 1, the progress note indicated CNA noted Resident 2 was standing beside bed with pants down by the hip with back and forth motion towards resident, she was lying on her back on bed with pants on .separated them right away. CNA reported that resident states, ' He wanna make a baby ' .complaint of pain on left elbow .acetaminophen (a pain relieving medication) . given as ordered for left elbow pain. During a record review of Resident 2 ' s nursing progress note titled, Significant Event, dated 11/30/24, at 3:36 a.m., by RN 2, the progress note indicated at 2:20 a.m. RN 2 was informed by CNA 1 that Resident 2 was in Resident 1 ' s room. When I entered the room, 2 CNAs .were already in the room. I found Resident 2 standing in front of [Resident 1] with pants down buttocks out, both hands leaning forward in bed. He was in the act of pumping the resident. During an interview on 12/23/24, at 1:00 p.m., with Social Services Director (SSD), the SSD stated Resident 1 was not able to make their own decisions for care and was conserved. During a record review of Resident 1 ' s hospital history and physical (H&P) titled ED Provider Notes Physician H&P Sexual Assault Response Team, dated 12/4/24, the H&P indicated a primary chief complaint of sexual assault of adult. H&P indicated hospital staff were unable to get history from pt (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555381 If continuation sheet Page 2 of 3 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 01/21/2025 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete developmentally delayed with functioning of 3rd grade level, uses wheelchair .and doesn ' t stand up .Pt has 24hour care - sister is guardian - conservator. During a record review of police report titled, [City] Police Department Criminal Report, dated 1/13/25, the report indicated on 11/30/24, at 2:38 a.m., facility staff called the police to report Resident 2 in Resident 1 ' s room attempting to make a baby. The report indicated at 11/30/24, at around 2:20 a.m., Resident 1 was laying down perpendicular on [their] bed in the supine position. Resident 1 ' s feet were touching the ground and [their] head was against the wall. Resident 2 was between Resident 1 ' s legs with a wide stance. He was laying on top of Resident 1 (chest to chest) and was thrusting his hips towards Resident 1 .the entirety of his buttocks were exposed .his pelvis was in line with Resident 1 ' s pelvis while he was thrusting. The report further indicated Resident 1 ' s cognitive state caused her incapable of giving legal consent for sexual activity .did not believe she voluntarily turned her body 90 degrees on her own power .Resident 2 ' s medical documentation did not list any factors which would have reasonably indicated his cognitive function was so impaired that was not capable of committing a crime .based on the above evidence, I placed Resident 2 under arrest for: 261(a)(1) PC/664 PC - Attempted Rape of a Victim who is incapable of Giving Consent 220(a)(1) PC - Assault with Intent to Rape. Event ID: Facility ID: 555381 If continuation sheet Page 3 of 3