Health inspection·December 5, 2024

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 nursing staff did not perform hand hygiene and infection control prevention to industry standard when handling waste disposal after caring for two residents (Residents 1 and 2). Residents Affected - Few This failure had the potential to cause the spread of infection, which could result in hospitalization and death. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was admitted to the facility in 2023 with diagnoses of malignant neoplasm of prostate (a tumor - an abnormal tissue mass when cells divide and grow more than normal) and mild intermittent asthma (inflammation of the airway caused by allergens, dust, or other particles). During a review of Resident 2 ' s admission Record, the admission Record indicated Resident 2 was admitted to the facility in 2024 with diagnoses of heart failure, bacteremia, and sepsis and chronic obstructive pulmonary disease (COPD, refers to a group of diseases that cause airflow blockage and breathing-related problems. It includes emphysema and chronic bronchitis.). During an observation on 12/5/2024 at 2:20 p.m., License Vocational Nurse 1 (LVN 1) came out of a resident ' s room pushing the treatment cart with a trash bag tied to the treatment cart and filled with waste and used gloves. During an observation on 12/5/2024 at 12:45 p.m., there were two blood pressure machines placed in the hallway outside of rooms 218 and room [ROOM NUMBER], with a trash bag tied to each blood pressure machine filled with trash, used gloves and dirty paper towels. During an observation on 12/5/2024 at 1:05 p.m., Certified Nurse Assistant 1 (CNA 1), removed her dirty gloves after cleaning a standing scale, held the same gloves in one hand and went to the doorway of room [ROOM NUMBER]. CNA 1 placed the dirty gloves in her bent right arm, used hand sanitizer, placed the gloves in one hand and went into the room of Residents 1 and 2. CNA 1 used the dirty gloves to hold the doorknob to open the resident ' s bathroom and then went to assist Resident 1 in bed with the same dirty gloves in her hand. CNA 1 came out of the room, placed the dirty gloves in her bent arm and used hand sanitizer. During an interview on 12/5/2024 at 1:10 p.m., with CNA 1, CNA 1 stated she should have placed the dirty gloves in the trash before she went into the room. CNA 1 also stated to prevent the spread of (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: 555819 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 555819 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elmwood Care Center 2829 Shattuck Avenue Berkeley, CA 94705 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)