Health inspection·February 13, 2020

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Based on observation, interview and record review, the facility did not treat one (Resident 2) of nine sampled residents in a dignified manner. Resident 2 asked to have his brief (diaper) changed and staff denied his request. This failure resulted in Resident 2 experiencing unnecessary distress. Findings: The record review on 2/12/20 of the document Face Sheet showed the facility admitted Resident 2 on 8/8/19. A record review of the document used to assess patients condition and care needs titled, MDS (minimum data set) 3.0 dated 1/31/20, showed Resident 2's diagnoses included dementia. (symptoms that affects memory, thinking, and social abilities, enough to interfere with daily life). The record review of the nursing Departmental Notes dated 1/17/20 to 1/23/20 showed Resident 2 was, Alert and responsive. A record review of the plan of care dated 8/8/19 indicated Resident 2 was dependent on staff for assistance with toileting, was unable to walk, and incontinent of bowel and bladder (unable to control urine or bowel movements), and was at risk for skin breakdown. The interventions included, Peri care (personal hygiene) every shift and after each incontinence and keep clean and dry. During an observation on 2/10/20 at 12:40 p.m., Resident 2 was observed in bed yelling out in distress and pointing down at the brief he was wearing. The facility's Director of Staff Development (DSD) was walking by and continued to walk down the hall past Resident 2's room without stopping. DSD stated, He does that. He (Resident 2) yells out. During concurrent interviews with Resident 2 and Licensed Vocational Nurse 2 (LVN 2) on 2/10/20 at 12:50 p.m., Resident 2 stated he had a bowel movement and continued to point to his brief. LVN 2 stated the staff do not change residents at meal times, and it will Have to wait. During a concurrent interview and observation at 1:15 p.m. (35 minutes after Resident 2 needed pericare), the Certified Nursing Assistant 3 (CNA 3) confirmed Resident 2 needed to be changed and proceeded to change his brief. A record review of the policy and procedure titled, Dignity dated 2009 showed, Each resident shall Page 1 of 18 555499 555499 02/13/2020 Redwood Healthcare Center LLC 3145 High Street Oakland, CA 94619

F 0550 Level of Harm - Minimal harm or potential for actual harm be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. Residents shall be treated with dignity and respect at all times .Demeaning practices and standards of care that compromise dignity are prohibited. Staff shall promote dignity and assist residents as needed by .promptly responding to the resident's request for toileting assistance . Residents Affected - Few 555499 Page 2 of 18 555499 02/13/2020 Redwood Healthcare Center LLC 3145 High Street Oakland, CA 94619

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Based on observation, interview, and record review, the facility did not notify the physician for changes in condition for four(Residents 24, 28, 194 and 297) of nine sampled residents. Resident 297 had incomplete vital sign (temperature, pulse, respiratory rate, blood pressure) records, and was subsequently sent to the hospital's emergency department (ED). The doctors were not notified when Resident 28 stopped eating, and of Residents 24 and 194's elevated blood pressure (BP). These failures resulted in the staff's failure to identify and monitor for changes in condition which had resulted in, or had the potential, for a decline in the resident's health. Findings 1. A record review of the document, Face Sheet showed Resident 24 had diagnoses that included cerebrovascular disease (condition that affects blood supply to the brain- also known as a stroke). During an observation of the medication pass, on 2/10/20 at 8:10 a.m., Licensed Vocational Nurse 2 (LVN 2) checked Resident 24's BP, which was 188/102 (normal range 120/80). LVN 2 stated, Oh, that's high, and continued to administer medications to Resident 24 and to other residents. She did not re-check Resident 24's BP or notify the doctor. The record review of Resident 24's Monthly Vital Signs reflected on 1/9/20, the BP was 127/77. On 2/9/20, the BP was 128/80. In an interview on 2/10/20 at 1:26 p.m., LVN 2 stated she had Forgotten about Resident 24's elevated BP and did not call the doctor. In a subsequent interview, on 2/11/20 at 10:40 a.m., LVN 2 stated she did not call the doctor about Resident 24's high BP because she had administered Pradaxa. According to the food & drug administration (FDA), Pradaxa is a blood-thinning medication used to reduce the risk of stroke and blood clots in patients. In an interview on 2/12/20 at 10:41 a.m., the Director of Nursing (DON) stated it was important for staff to monitor Resident 24's BP because of her history of stroke. Furthermore, DON stated staff should have re-checked the BP and, if still high, notify the doctor. 2. The record review of the document, Face Sheet showed Resident 28 had diagnoses which included a heart attack. Further review of the nursing notes showed the following food intake for Resident 28: 12/11/19: 50% of dinner 12/12/19: refused both breakfast and lunch and, Only drank 2 cups of fluids. 12/12/19: 50% of dinner and, Won't open his mouth. 12/14/19: Did not eat breakfast. Consumed 25% of lunch. 555499 Page 3 of 18 555499 02/13/2020 Redwood Healthcare Center LLC 3145 High Street Oakland, CA 94619

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 12/15/19: .refused breakfast and lunch. The doctor came to visit and ordered IV (intravenous, into the vein) hydration to replenish fluids and 9-1-1 was called. Resident 28's oxygen saturation (percent of oxygen in the blood) was 63% (normal range 90's). In an interview on 2/13/20 at 12:15 p.m., LVN 1 stated he did not notify the doctor when Resident 28 was refusing his breakfast and lunch on 2/12/20, and had eaten 50% of his dinner the night before. During an interview on 2/13/20 at 12:41 p.m., the Director of Staff Development (DSD) stated there was no I&O (intake and output) or documented weights for Resident 28. (Note: Monitoring I&O during a 24-hour period is an important aspect of fluid balance assessment. Body weight is an important indicator of fluid status, including fluid loss and potential signs of dehydration). During an interview on 2/13/20 at 2:38 p.m., DON stated when a resident is showing signs of dehydration , staff should monitor the vital signs, weights, and notify the doctor. A record review of the facility's document, Transfer and Referral Record dated 12/15/19 showed Resident 28 was sent to the hospital with lethargy and weakness. The record review of the document, ED to Hosp (hospital)-Admission dated 12/27/19 showed Resident 28's diagnoses included, but was not limited to, severe sepsis (bodies response to an infection) and hypernatremia (when sodium is too high for the amount of fluid in the body). 3. A record review of the Face Sheet showed Resident 194 had diagnoses that included cerebrovascular disease. The record review of the Physician Orders dated 3/16/19 showed Resident 194 was to receive Atenolol (BP) medication, 50 milligrams (mg) every day. A record review of Resident 194's, Medication Administration Record showed the following BP's: 2/8/20: 158/86 2/9/20: 166/83 2/10/20: 179/74 In an interview on 2/11/20 at 2:57 p.m., DON stated residents taking BP medications have their BP's checked every day. DON further stated staff are to call the doctor if the readings are outside the established parameters, which are greater than 150/90 or less than 100/50. In a subsequent interview on 2/12/20 at 10:41 a.m., DON confirmed Resident 194 had consistently high BP's and the doctor was not notified. DON further stated the doctor should have been called so the medication dosage could be re-evaluated. During an observation of the medication pass on 2/10/20 at 8:10 a.m., LVN 2 was checking Resident 194's BP and was 179/74. LVN 2 did not recheck the BP. 555499 Page 4 of 18 555499 02/13/2020 Redwood Healthcare Center LLC 3145 High Street Oakland, CA 94619

F 0580 Level of Harm - Minimal harm or potential for actual harm In a subsequent interview, on 2/10/20 at 1:26 p.m., LVN 2 stated she had not rechecked the BP or call the doctor because the resident, . gets BP medication. 4. A record review of the document, Face Sheet showed Resident 297 had diagnoses that included muscle weakness and difficulty swallowing. Residents Affected - Some A review of the nursing notes dated, 10/22/29, 10/23/19, 10/24/19, and 11/4/19, showed no documented vital signs. On 11/4/19, the notes indicated Patient 297 was lethargic and sent to the ED. The record review of the facility's document titled, Transfer and Referral Record dated 11/4/19, reflected the reason for the transfer to the hospital was because Resident 297 was, Lethargic, with signs and symptoms of dehydration. In an interview on 2/13/20 at 2:16 p.m., DSD confirmed there was no vital signs taken before Patient 297 condition changed and was transferred to the hospital's ED on 11/4/19. DSD further stated that tracking (monitoring) Patient 297's BP and heart rate could have shown signs of possible dehydration. The record review of the hospital's, Discharge Summary dated 11/9/19 showed the reason for Resident 297's hospital admission was due to, Lethargy, weakness, poor po (per os, oral) intake. Resident 297 was treated with IV fluids. A record review of the facility's policy and procedure, Change in a Resident's Condition or Status dated 11/'15 indicated, The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been: .A significant change in the resident's physical/emotional/mental condition; .A need to alter the resident's medical treatment significantly. 555499 Page 5 of 18 555499 02/13/2020 Redwood Healthcare Center LLC 3145 High Street Oakland, CA 94619

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to provide personal hygiene care in a timely manner for one (Resident 2) of nine sampled residents. Resident 2 gestured to have his brief (diaper) changed and staff did not immediately respond. Residents Affected - Few This failure resulted in Resident 2 experiencing discomfort and had the potential for skin breakdown. Findings: A record review of the document used to assess patients condition and care needs titled, MDS (minimum data set) 3.0 dated 1/31/20, showed Resident 2's diagnoses included dementia (symptoms that affects memory, thinking, and social abilities, enough to interfere with daily life). The record review of the nursing Departmental Notes dated 1/17/20 through 1/23/20 showed Resident 2 was, Alert and responsive. A record review of the care plan titled, Communication problem dated 8/8/19 indicated one goal was for Resident 2 to communicate needs daily. The interventions included for staff to become familiar with nonverbal cues, gestures and body language . A record review of the plan of care dated 8/8/19 indicated Resident 2 was dependent on staff for assistance with toileting, was unable to walk, and incontinent of bowel and bladder (unable to control urine or bowel movements). Resident 2 was at risk for skin breakdown. The interventions included, Peri care (personal hygiene) every shift and after each incontinence and keep clean and dry. During an observation on 2/10/20 at 12:40 p.m., Resident 2 was observed in bed yelling out in distress and pointing down at the brief he was wearing. The facility's Director of Staff Development (DSD) was walking by and continued to walk down the hall past Resident 2's room without stopping. DSD stated, He does that. He (Resident 2) yells out. During concurrent interviews with Resident 2 and Licensed Vocational Nurse 2 (LVN 2) on 2/10/20 at 12:50 p.m., Resident 2 stated he had a bowel movement and continued to point to his brief. LVN 2 stated the staff do not change residents at meal times, and it will Have to wait. During a concurrent observation and interview on 2/10/20 at 1:15 p.m., (35 minutes after Resident 2 had a BM), the Certified Nursing Assistant 3 (CNA 3) confirmed Resident 2 needed to be changed and proceeded to change his brief. 555499 Page 6 of 18 555499 02/13/2020 Redwood Healthcare Center LLC 3145 High Street Oakland, CA 94619

F 0726 Level of Harm - Minimal harm or potential for actual harm 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, interviews, and record review, the facility failed to ensure competencies and skills for one of three sampled licensed nursing staff. Residents Affected - Few This failure resulted in the licensed nurse not receiving the required skills competency check to ensure safe care of residents. [Refer to F 726 and F 759] Findings: During a record review on 02/13/20, the employee personnel file for LVN 2, hired 2/3/20, contained a document titled, Nurse Assistant Orientation & Competency Evaluation Nursing Skills Performance and the skills checklist was not completed. There was no licensed nursing skills check list in LVN 2's employee file. During an interview on 2/13/20 at 8:04 AM, the Director of Staff Development (DSD) stated the facility does a skills checklist for new nursing staff, and the skills checklist is done annually at time of hire. DSD further stated the competency is done by observing if staff are following protocols and watching nursing care being given to residents. During an interview on 2/13/20 at 2:06 PM, DSD stated the wrong form was used to evaluate LVN 2, and the Nursing Assistant Competency form, should have been completed. DSD stated the facility did not have a Licensed Nurse Competency done for LVN 2. During a concurrent interview and record review on 02/13/20 at 2:57 PM, the Director of Nursing (DON) was unable to find any documentation of LVN 2 being evaluated for medication administration competency by the pharmacy consultant. 555499 Page 7 of 18 555499 02/13/2020 Redwood Healthcare Center LLC 3145 High Street Oakland, CA 94619

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility did not maintain a medication error rate of 5% or less. The medication error rate was 7.69%. Resident 17 was administered the incorrect amount of pain medication. Residents Affected - Few This failure resulted in the potential for ineffective pain relief. Findings: Record review on 2/10/20 of the document, Administering Medications, dated 2012, showed Medications shall be administered in a safe and timely manner, and as prescribed. Record review of the document, Face Sheet showed Resident 17 had diagnoses that included lung disease and muscle weakness. Record review of the document, Medication Administration Record dated 11/5/19, showed Resident 17 was to receive, Voltaren (antiinflammatory) 1% gel. Give 4 gms (grams) BID (twice a day) for pain in hands. Resident 17 also received, Gabapentin 600 mg tablet, give 1.5 tab (tablet) by mouth TID (three times a day) for neuropathy (a disease of the body's nerves which can cause numbness or weakness). During an observation of the medication pass on 2/10/20 at 8:10 a.m., Licensed Vocational Nurse 2 (LVN 2) administered Resident 17's Voltaren gel. LVN 2 stated there was a measuring device for the Voltaren but she was unable to locate it. LVN 2 further stated she would Just estimate, the amount and started to squeeze the tube of Voltaren gel into a cup. When asked if there was any consequence to not measuring the Voltaren gel, LVN 2 stated, No, I don't think so. LVN 2 then put one tablet of Gabapentin into another medication cup. The physician order was for 1.5 tab. During an observation and interview on 2/12/20 at 10:41 a.m., the facility's Director of Nursing (DON) stated medication should only be administered in the amount as ordered by the doctor and should be measured accurately or Not given. DON confirmed there was no measuring device for Voltaren gel in the medication cart. 555499 Page 8 of 18 555499 02/13/2020 Redwood Healthcare Center LLC 3145 High Street Oakland, CA 94619

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview and record review, licensed nursing staff did not store medication in a secured manner. A lidocaine patch (pain reliever] was left unattended on top of the medication cart. This failure had the potential for unauthorized access and use of medication by other persons which could result in harm. Findings: During an observation of the medication pass on 2/12/20 at 9:30 a.m., Licensed Vocational Nurse 2 (LVN 2) lifted the inoperable laptop computer from the top of the medication cart, and went to the nurses station to exchange it for another one. A lidocaine patch which had been underneath the laptop was left unattended. In a concurrent interview, LVN 2 confirmed the lidocaine patch was underneath the laptop because she was hiding, it and saving it to give to another resident. In an interview on 2/12/20 at 9:40 a.m., the Director of Nursing (DON) verified the lidocaine patch was left unattended on top of the medication cart. DON stated if a nurse leaves the cart for any reason, all medication must be locked and secured within the medication cart. A record review of the document, Medication Storage In The Facility dated 2008 indicated, Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. Only licensed nurses, pharmacy personnel, and those lawfully authorized are allowed access to medications. Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access. 555499 Page 9 of 18 555499 02/13/2020 Redwood Healthcare Center LLC 3145 High Street Oakland, CA 94619

F 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 competencies and skills for kitchen staff. This failure resulted in the potential for food borne illness, inaccurate temperature testing of cooked foods, and physician ordered therapeutic diets not being made correctly by kitchen staff. Findings: During an observation on 2/10/20 at 11:45 AM, [NAME] 1 did not fill the scoop fully for the pureed diets during lunch tray line. There was not enough pureed meat for all residents receiving pureed diets. During an interview on 2/10/20 at 12:45 AM, the Dietary Manager (DM) stated [NAME] 1 should have made more pureed food to ensure residents were given the amount of pureed food as ordered by their physician. During a record review of employee file for [NAME] 1, employed since 2018, there was no orientation, no evaluation, or competency training contained in the employee file. During a record review of the Food Service in-services for dietary staff, there was no signature for [NAME] 1 on the attendance sign-in sheet for the months of 1/2019, 2/20/19, 11/2019, and 12/2019. During a record review of the dietary in-service for [NAME] 1, [NAME] 1 did not attend the dietary in-service conducted on 1/4/19 and given by the DM on scoop size. During a record review of [NAME] 1's employee file, a document titled Verification of Job Competency Demonstration-Cooks dated 2019, was only partly completed by [NAME] 1 and the DM. During an observation on 2/11/20 at 11:45 PM, DM demonstrated thermometer calibration for testing cooked food temperatures. Three of three kitchen thermometers were calibrated to zero instead of 32 degrees Fahrenheit. During a record review of the facility's policy and procedure titled, Thermometer Use and Calibration dated 2018 indicated, .3. If the thermometer does not read 32 degrees Fahrenheit, then the thermometer must be calibrated or discarded. During an interview on 2/11/20 at 10:25 AM, the dietician stated the facility does brief monthly in-services for dietary staff. Training for new staff, including hands on training is done mostly by DM. The Dietician does training based on audits (evaluation) and emergency procedures. The Dietician stated she had not viewed the staff training logs for in-services done by the DM. The dietician did not recall providing dietary education to [NAME] 1. During an interview on 2/11/20 at 10:27 AM, the Dietician stated the kitchen thermometers are calibrated by the kitchen staff once a week. During an interview on 2/12/20 at 9:47 AM, the administrator (ADM) stated the dietician is expected to do in-service for dietary staff. 555499 Page 10 of 18 555499 02/13/2020 Redwood Healthcare Center LLC 3145 High Street Oakland, CA 94619

F 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. Based on observation, interview, and record review, the facility failed to serve therapeutic diets (diet ordered by a physician for treatment of a disease or clinical condition) as ordered for the Controlled Carbohydrate Diet (CCHO), low sodium, fortified and pureed diets for approximately 25 residents. This failure resulted in under and overserved portions of food and meals not served according to the planned menu. This also had the potential for compromised medical and nutritional status for residents. During an observation of the tray line on 2/10/20 at 11:45 a.m., and review of the winter menu for Monday Week 2, showed the following: 1. The menu indicated for 4 ounce (oz) servings. [NAME] 1 weighed 1 cooked beef patty at 3 oz for the CCHO regular diet. [NAME] 1 served 3 oz of the meat patty for the CCHO regular diets. 2. There were eight CCHO Regular diets, one 3 oz southern style meat patty and 4 oz of mashed potatoes. The menu planned was for 4 oz beef patty and 2 oz of mashed potatoes. 3. For twelve fortified diets, [NAME] 1 served 4 oz of melted butter on mashed potatoes. The menu directions specified the amount was supposed to be one-half oz. 4. One puree double portion diet received one 6 oz scoop, plus a little extra pureed meat, as [NAME] 1 ran out of pureed meat. The Dietary Supervisor Staff (DSS) stated the double should receive two serving of 6 ounces. [NAME] 1 did not prepare adequate quantities of pureed meat to serve all of the portions required. 5. Four No Added Salt (NAS) diets received regular gravy with beef patty. During an observation and taste sample of the test tray on 2/10/20 at 12:48 p.m., DSS tasted the meat and stated it, tastes salty. During an interview on 2/11/20 at 10:25 a.m., with the Registered Dietician (RD), RD read the gravy mix ingredients and stated, This would be an issue for NAS diets. 555499 Page 11 of 18 555499 02/13/2020 Redwood Healthcare Center LLC 3145 High Street Oakland, CA 94619

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 and record reviews, the facility failed to ensure food for residents was prepared under sanitary conditions. This failure had the potential to cause food borne illness. Residents Affected - Few Findings: During an observation on 2/10/20 at 10:23 AM, [NAME] 1 used a soiled cleaning towel with debris present to wipe down the kitchen food preparation counters, then placed the counter with container of cooked food on top of it. [NAME] 1 then picked up the soiled towel from the counter and placed it in the sink near the raw meat was thawing in a pan. [NAME] 1 left the soiled towel in the sink for a couple of minutes before removing the towel from the sink. [NAME] 1 did not clean the sink after removing the soiled towel. During a record review of the facility's policy and procedure titled, Cleaning and Sanitizing(undated) indicated, 1. Food contact surfaces must be cleaned .b. each time there is a change from working with raw foods to working with ready-to eat food, and 7. Food contact surfaces and utensils must be sanitized before each use. During a record review of the facility's policy and procedure titled, Cleaning and Sanitizing (undated) indicated, 5. Keep sinks clean and sanitized. 555499 Page 12 of 18 555499 02/13/2020 Redwood Healthcare Center LLC 3145 High Street Oakland, CA 94619

F 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors. Level of Harm - Minimal harm or potential for actual harm Based on interviews and record reviews, the facility failed to provide education to families regarding food brought in from home for the residents. The facility also failed to have a system for staff to ensure food from home was re-heated to a safe temperature. Residents Affected - Some This had the potential to result in burn injuries from hot food. Findings: During an interview on 2/11/20 at 9:16 AM, registered nurse 1 (RN 1) stated nursing staff reheats food in the microwave in the break room, but was not sure what temperature food is supposed to be heated. During an interview with the Dietician on 2/11/20 at 10:25 AM, the Dietician stated she does not train facility staff on the safety of food brought from home for residents. The Dietician further stated she has no involvement with how staff re-heats outside food brought into the facility for residents. She stated a re-heated food temperature of 165 degrees was too hot to eat directly, but staff was probably thinking of temperatures for other food items, such as poultry. The Dietician stated she does not provide education to families regarding food safety and food brought into the facility from home. During an interview on 2/11/20 at 10:30 AM, the certified nursing assistant 2 (CNA 2) stated time frames for reheating a resident's food depends on what type of food is being heated. CNA 2 indicated the staff use the buttons on the microwave to guide re-heating foods and does not check food temperatures. During an interview on 2/11/20 at 10: 38 AM, the Director of Nursing (DON) confirmed staff does not use thermometers for temperature testing during food re-heating but rely on common sense to know when re-heated food is the appropriate temperature for residents to safely consume. During a record review of the facility's policy and procedure titled, Food Preparation: Leftover Foods dated 2018 indicated, Leftover foods will be stored and served in a safe manner .2) Reheat all leftover foods to an internal temperature of 165 degrees Fahrenheit for at least 15 seconds. During a record review of the facility's policy and procedure titled, Foods Brought by Family/Visitors, (undated)indicated, 1. Family members should inform nursing staff of their desire to bring foods into the facility. The Dietician or a Nurse Supervisor should assure that the food is not in conflict with the resident's prescribed diet plan, and 3. The Dietician will counsel residents or families about requests that conflict with resident's dietary restrictions and whenever diets cannot be liberalized. 555499 Page 13 of 18 555499 02/13/2020 Redwood Healthcare Center LLC 3145 High Street Oakland, CA 94619

F 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation and interview, the facility failed to ensure that one of two dumpsters were closed shut. Residents Affected - Few This failure resulted in unsanitary conditions and attracted flying pests. During an observation on 2/10/20 at 10:15 a.m., one of two dumpsters was left open and overfilled with garbage that had insects flying above it. During an interview on 2/11/20 at 9 a.m. with Maintenance Director, he stated that the garbage is picked up on Monday, Wednesdays and Fridays. No trash was picked up on Monday. Review of the facility's policy titled, Food-Related Garbage and Rubbish Disposal indicated, all garbage and rubbish containers shall be provided with tight-fitting lids or covers and must be kept covered when stored. Outside dumpsters .will be kept closed and free of surrounding litter. 555499 Page 14 of 18 555499 02/13/2020 Redwood Healthcare Center LLC 3145 High Street Oakland, CA 94619

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 that staff performed hand hygiene after contaminating their hands while passing meal trays. This failure resulted in a certified nursing assistant passing meal trays to residents after contaminating her hands by touching her nose and lips. Residents Affected - Some Findings: During an observation on 2/10/2020 at 12:30 p.m. adjacent to the dining room, Certified Nursing Assistant (CNA) 1 touched the underside of her nose and/or her lips with her hand six times while passing trays to residents in the dining room. CNA 1 did not perform hand hygiene after she touched her nose and/or mouth. During an interview on 2/10/2020 at 2:05 p.m., with CNA 1, CNA 1 stated she did not perform hand hygiene each time after she touched her nose and/or mouth with her hand while passing trays. CNA 1 stated she was supposed to perform hand hygiene after each time she touched her nose and/or mouth. During an interview on 2/11/2020 at 2:07 p.m., with Director of Staff Development (DSD), DSD stated that staff are required to do hand hygiene when passing food trays to residents for infection control. DSD stated that staff touching the end of their nose or lips would contaminate the staff's hands and the staff was therefore, required to do hand hygiene after touching their nose or lips before passing a tray. During a review of the facility's policy and procedure titled, Hand Hygiene Program, (undated), indicated hand hygiene should be done before and after serving food to residents and when hands are likely to be contaminated. 555499 Page 15 of 18 555499 02/13/2020 Redwood Healthcare Center LLC 3145 High Street Oakland, CA 94619

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, interview, and record review, the facility failed to provide 23 of 43 residents in resident Rooms 9,10,11,12,14,15,16,18, and 19 with at least 80 square (sq) feet (ft) of living space per resident. This failure had the potential to result in a lack of sufficient space for the provision of care by facility staff, and lack of sufficient space for residents to have personal belongings at the bedside. Findings: room [ROOM NUMBER] had three beds that measured 17 ft. by 12.7 ft., providing 71.31 sq. ft. per resident. room [ROOM NUMBER] had three beds that measured 17 ft. by 12.6 ft., providing 70.83 sq. ft. per resident. room [ROOM NUMBER] had three beds that measured 17 ft. by 12.7 ft., providing 71.31 sq. ft. per resident. room [ROOM NUMBER] had three beds that measured 17 ft. by 12.7 ft., providing 71.31 sq. ft. per resident. room [ROOM NUMBER] had three beds that measured 17 ft. by 12.8 ft., providing 71.89 sq. ft. per resident. room [ROOM NUMBER] had three beds that measured 17 ft. by 12.7 ft., providing 71.31 sq. ft. per resident. room [ROOM NUMBER] had three beds that measured 17 ft. by 12.8 ft., providing 71.89 sq. ft. per resident. room [ROOM NUMBER] had three beds that measured 17 ft. by 12.8 ft., providing 71.89 sq. ft. per resident. room [ROOM NUMBER] had three beds that measured 17 ft. by 12.10 ft., providing 72.72 sq. ft. per resident. During observations on 2/10/2020 at 9:05 a.m., and 2/11/2020 at 10 a.m., showed the useful living space in the affected residents' rooms provided sufficient space to move about, without obstruction or interference from furniture or closets. Residents in the affected rooms had privacy, as well as, storage space for personal possessions. There were no resident complaints from residents in the affected rooms. The facility staff were able to provide nursing services to meet the individual needs of each resident. During an interview and concurrent record review on 2/13/2020 at 4 p.m., the Administrator (ADM) confirmed the previously approved room waiver was currently in effect. 555499 Page 16 of 18 555499 02/13/2020 Redwood Healthcare Center LLC 3145 High Street Oakland, CA 94619

F 0912 Level of Harm - Potential for minimal harm Residents Affected - Some During an interview on 12/13/2020 at 2:15 p.m., with the Director of Staff Development (DSD), DSD stated they had enough space and there was enough room to work in Rooms 9, 10, 11, 12, 14, 15, 16, 18, and 19. During an interview on 2/10/2020 at 11:30 a.m., with Resident 37, Resident 37 stated she liked her room and had enough room for her personal things. There were no negative consequences attributable to the decreased living space in rooms 9, 10, 11, 12, 14, 15, 16, 17, 18, and 19 and no safety concerns identified. 555499 Page 17 of 18 555499 02/13/2020 Redwood Healthcare Center LLC 3145 High Street Oakland, CA 94619

F 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure for one of eight sampled residents (Resident 20), that the call light was in working order. This failure resulted in Resident 20 being unable to turn the call light on to request help from facility staff. Residents Affected - Few Findings: During an observation and interview, on 2/11/2020 at 8 a.m., Resident 20 stated her call light was broken. The button to press and turn on the call light was missing. During an immediate interview on 2/11/2020, at 8 a.m., with Certified Nursing Assistant 3 (CNA 3), CNA 3 stated the call light was not broken and retrieved the call light from underneath the blankets and confirmed Resident 20's call light was broken. CNA 3 notified the Maintenance Director (MTN). During an interview and record review on 2/11/2020 at 8:10 a.m., MTN stated Resident 20's call light was broken and he replaced it. MTN provided the weekly maintenance log for the facility's call light system, and Resident 20's call light was checked and working on 2/7/20. MTN further stated the CNAs are supposed to write down anything that needs repair in the maintenance log. There was no request for Resident 20's call light to be repaired. During an interview on 2/11/2020 at 8:43 a.m., with the Director of Staff Development (DSD), DSD stated the CNAs are supposed to check their residents' call lights each shift to ensure the call lights are working. During a review of the facility's policy titled, Maintenance Inspections (undated), indicated call lights are to be inspected daily. During a review of the facility's policy titled, Answering the Call Light dated and revised October 2010, indicated all defective call lights were to be reported to the nurse supervisor promptly. 555499 Page 18 of 18