Alameda County Medical Center D/P SNF

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 106 of 106 residents had food prepared and stored in a safe and sanitary manner when: 1. frozen raw tilapia and frozen raw shrimp was stored above ready to eat chicken enchiladas and bean and cheese pupusas. 2. a dispensing scoop was stored in panko breadcrumbs. 3. staff did not perform hand hygiene when their hands were contaminated by picking up a clipboard which fell on the floor. These failures placed the facility's 106 residents who received food from the kitchen at risk of foodborne illness.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure safe practices on storage and handling of the hazardous medications (or HD, Drugs that pose short- or long-term harm upon exposure to human via skin or inhalation) in three out of six medication carts with resident census of 106 based on CDC's (Centers for Disease Control and Prevention, a federal agency leading the science-based, data-driven, service organization that protects the public's health) National Institute for Occupational Safety and Health (NIOSH a federal agency that is part of the CDC; NIOSH conducts research and makes recommendations for the prevention of work-related hazards, injury and illness) guidelines. The unsafe storage and handling of hazardous medications could pose health risk to staff and residents.

Inspectors wroteBased on interview and record review the facility failed to ensure safe use of antibiotic eye medication called erythromycin ophthalmic (eye) ointment (ointment a smooth oily preparation mixed with antibiotic to treat eye infection) for ongoing long-term use in one out of five residents reviewed for unnecessary medication (Resident 36). This unsafe practice could contribute to ineffective use of antibiotic for an unapproved indication and risk of antibiotic becoming ineffective with long term use.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure safe storage practices for medications and medical supplies stored in medication carts, treatment cart and refrigerators with census of 106 when: 1. Medication Cart 2 in Unit B2 stored undated inhalation medication called Ipratropium/Albuterol (or DuoNeb, an inhalation solution used to treat breathing problems) and opened packets of a skin patch called lidocaine topical system (or Ztlido, a numbing agent used to treat pain). 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff followed policies and procedures designed to prevent infection in two out of 12 residents observed for medication administration observation and blood sugar testing (Resident 81 and Resident 407) when: 1. For one of 12 residents (Resident 81), Licensed Nurse 1 (LN 1) failed to clean the pill cutter (an instrument used to cut pills to provide an accurate dose) before and after use or practice hand hygiene. 2. For two of 12 residents (Resident 81 and Resident 407), Licensed Nurse 1 (LN 1) failed to clean the blood glucometer (instrument to check the level of sugar in the blood: blood glucose) in between resident use based on standards of practice and facility's policy. These failures had the potential to cause infection or spread infection in the facility.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure the facility had a medication error rate of less than 5 percent when nursing staff failed to follow physician orders for administration of medication for two of eight sampled residents (Resident 89 and Resident 231) during medication pass: Resident 89 did not receive an ordered blood test before meals and Resident 231 did not receive the correct dosage of medication during medication pass. The failure to follow medication administration instructions during two of 28 opportunities of medication administration resulted in an error rate of 7.1 percent.

Inspectors wrote2. A review of Resident 83's Minimum Data Set (MDS, an assessment tool used to guide care), dated 6/15/23, indicated Resident 83 had a diagnosis of dementia (memory loss). A review of Resident 83's Physician Order, dated 7/13/23, indicated, Cleanse Sacral (the spinal area between the lower back and tailbone) wound with normal saline (NS, used to clean wounds), pat dry .Pack loosely with plain packing strip (thin strips of material used to fill deep pockets in wounds), adding wound gel (ointment for the wound). Cover with Mepilex (bordered foam dressing that is moisture-proof and bacteria-proof) dressing . During a concurrent observation and interview on 7/27/23, at 11:15 a.m., with Licensed Vocational Nurse 1 (LVN 1), in Resident 83's room, LVN 1 completed Resident 83's wound care. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 22 sampled residents (Resident 72) was treated with dignity and respect when a Certified Nursing Assistant 1 (CNA 1) failed to provide visual privacy during provision of care for ADLs (activities of daily living such as personal hygiene, bathing, dressing, toileting). The failure to fully enclose Resident 72's bed by use of the privacy curtain had the potential to result in public exposure of Resident 72's body during provision of care and cause emotional distress.

Inspectors wroteBased on interview and record review, the facility did not provide competency training to provide services for dialysis-dependent (dialysis - a process where a machine filters the blood of wastes when the kidneys are not healthy enough to do it) residents in accordance with the facility assessment. This failure had the potential to result in dialysis-dependent residents receiving inappropriate care and services.

Inspectors wroteBased on interview and record review, for one of 24 (Resident 65) sampled residents, the facility failed to consistently monitor Resident 65's behaviors and side effects related to the use of psychotropic (capable of affecting the mind, emotions, and behaviors) medications during the months of July 2019, August 2019, and September 2019. For Resident 65, this deficient practice had the potential to result in the physician receiving and using inaccurate information to make decisions regarding the need to continue, increase, or decrease of the use of psychotropic medications.

Inspectors wroteBased on observation, interview and record review, for two of 27 sampled residents (Residents 49 and 76 and 94), the facility failed to ensure Residents 49 and 76 were free of significant medication errors when: 1. Resident 49 did not receive Renvela (a phosphate binder medication that prevents the absorption of phosphorus in the blood) as ordered by the physician, and; 2. Resident 76 did not receive Renagel (a type of phosphate binder) and Lomotil (medication to treat diarrhea) as ordered by the physician. For Residents 49 and 76, this failure had the potential to result in increased phosphorus levels adverse effects (e.g. body changes that pull calcium out of your bones, making them weak). For Resident 76, this failure had the potential to result in dehydration.

Inspectors wroteBased on observation, interview, and record review, for two of four sampled residents (Residents 104 and 107) the facility failed to implement their infection prevention and control policy and procedures when: 1. Resident 104's indwelling catheter uncovered drainage bag was touching the floor, and; 2. Registered Nurse (RN) 3 did not perform hand hygiene (general term that applies to hand washing, antiseptic hand wash, and alcohol-based hand rub) hands between glove changes and touched clean gauze with bloody gloves. For Residents 104 and 107, these deficient practices had the potential to result in the spread of infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of four sampled residents (Residents 36 and Resident 104) were treated with dignity and respect when: 1. Certified Nursing Assistant (CNA) 7 entered Resident 36's room without knocking and/or without permission. This failure resulted in Resident 36 feeling mad that his privacy was not respected. 2. Resident 104's urinary catheter (small flexible tube inserted through the urethra and into the bladder to drain urine) drainage bag was not covered by a urinary catheter drainage bag cover. For Resident 104, this failure had the potential to result in the loss of dignity.

Inspectors wroteBased on interview and record review, for one of 27 (Resident 51) sampled residents, the facility failed to inquire about Advance Directive (a legal document in which a person specifies what actions should be taken for their health if they are no longer able to make decisions for themselves because of illness or incapacity) from Resident 51 and/or their representative. This failure had the potential to result in Resident 51 not receiving care in accordance with his wishes.

Inspectors wroteBased on observation, interview, and record review, for one (Resident 94) of 27 sampled residents, the facility failed to develop and implement comprehensive care plans to address medical and nursing needs of the residents when there was no comprehensive care plan to address indwelling catheter. This failure had the potential to result in delayed or unrecognized catheter related adverse affects.

Inspectors wroteBased on interview and record review, the facility failed to complete comprehensive Minimum Data Set assessments (MDS - an assessment tool used to guide care) for five of 27 sampled residents (Residents 259, 260, 25, 17, and 9) within the regulatory specified timeframes when: 1. the Minimum Data Set Coordinator (MDSC) did not complete the admission MDS assessment for Resident 259 and 260 within 14 calendar days of their respective admission to the facility. 2. the MDSC did not complete the annual MDS for Resident 25, 17, 21, and 9 within 12 months of their respective previous annual MDSs. This deficient practice had the potential to delay care planning for Residents 259, 260, 25, 17, and 9.

Inspectors wroteBased on interview and record review, for one (Residents 27) of 27 sampled residents the facility failed to ensure a Minimum Data Set (MDS - a resident assessment tool used to guide care) Significant Change in Status Assessment (SCSA - major decline or improvement in a resident's status) was done within 14 days after it was determined. Minimum Data Set Coordinator (MDSC) completed Resident 27's SCSA 64 days after it was due. This deficient practice had the potential to result in Resident 27 not receiving care based on their current health status.

Inspectors wroteBased on interview and record review, for 13 of 27 (Resident 2, 4, 7, 10, 8, 14, 6, 22, 1, 12, 18, 15, and 77) sampled residents, the facility failed to complete Quarterly Minimum Data Set (MDS, an assessment too used to direct care) Assessments in the regulatory specified manner. This failure had the potential for Residents 2, 4, 7, 10, 8, 14, 6, 22, 1, 12, 18, 15, and 77 to not receive care and services needed based on their current health status.