Alameda Healthcare & Wellness Center

Inspectors wroteBased on observation, interview and record review the facility failed to follow infection control practices to prevent the spread of infection in the facility during a Coronavirus Disease (COVID-19 - an infectious disease caused by the SARS-CoV-2 virus) outbreak when the following was observed:The facility did not notify the California Department of Public Health they had a COVID-19 outbreak. The facility did not have signs at their front entrance to notify visitors, residents or anyone coming into the facility about their COVID-19 outbreak. One [NAME] Aid (CA 1), and one Laundry Aid (LA 1) wore a surgical mask in the resident hallways. Three facility staff including one receptionist, one Certified Nursing Assistant (CNA 1), and one Restorative Nursing Assistant (RNA 1), did not appropriately wear their face masks. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a safe, functional, sanitary and comfortable environment for all residents, staff and the public when the following occurred:1. Facility was overcome with offensive odors from morning to late afternoon on four different days, (7/21-8/8/25).2. Facility did not provide a sufficient amount of clean linens to meet needs of all Residents. 3. Facility did not ensure fans in Station 2 and Laundry room were appropriately cleaned. This failure resulted in Residents feeling forgotten, staff feeling environment is dirty, and anxious about not having enough supplies to perform duties, and exposed the public to unwarranted, offensive odors. 1. During an observation and facility tour on 7/21/25, at 08:30 a.m., the facility smelled like urine and feces throughout all stations in facility. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide enough nursing staff to provide timely medication administration and prevent medication errors when five of eight sampled residents (Residents 1, 2, 3, 4 and 5) did not receive medications according to physician orders and resident care plans. This failure resulted in: 1. Licensed Vocational Nurse 1 (LVN 1) administering 12 medications late to Resident 1 which included a medication to manage seizures (episodes of uncontrolled and abnormal firing of brain cells that may cause changes in attention or behavior such as bodily movements) which had the potential to increase Resident 1 ' s risk of seizure, 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure quality of care for five of eight sampled residents (Residents 1, 2, 3, 4 and 5) when staff did not provide medications according to physician ' s order and resident care plan. This failure resulted in: 1. Licensed Vocational Nurse 1 (LVN 1) administering 12 medications late to Resident 1 which included a medication to manage seizures (episodes of uncontrolled and abnormal firing of brain cells that may cause changes in attention or behavior such as bodily movements) which had the potential to increase Resident 1 ' s risk of seizure, 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of eight sampled residents (Resident 2) were free from significant medication errors when Registered Nurse 2 (RN 2) administered a dose of methadone (a narcotic medication to control pain [narcotics are substances that have an accepted medical use, medications which fall under US Drug Enforcement Agency (DEA) Schedules II-V, and have a potential for abuse, ranging from low to high, and may also lead to physical or psychological dependence]) five times higher than ordered by the provider to Resident 2, who had received narcotic medications before and after the medication error. This failure resulted in Resident 2 vomiting and placed Resident 2 at risk of narcotic overdose potentially leading to death.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain proper storage of medications including controlled medications (substances that have an accepted medical use, medications which fall under US Drug Enforcement Agency (DEA) Schedules II-V, and have a potential for abuse, ranging from low to high, and may also lead to physical or psychological dependence) when the medication room for the sub-acute area was left unlocked and a refrigerator containing an emergency kit (e-kit, kit containing doses of emergency medication) which contained one vial of lorazepam (a controlled medication which is used for sedation)] was also left unlocked. This failure to adequately secure medications had the potential for drug diversion and unauthorized access to medications.

Inspectors wroteBased on observation, interview and record review, the facility quality assurance committee failed to adequately and effectively implement the QAPI program when a QAPI project to reduce medication errors and prevent late medication administration was not fully implemented, did not adequately address the cause of late medication administration and errors, did not monitor and did not reassess or change the program interventions when medication errors and late medication administrations continued for five of eight sampled residents (Resident 1, 2, 3, 4 and 5) and potentially for all residents in the facility. This failure resulted in: 1. [...]

Inspectors wroteBased on interview and record review, for one of two sampled residents (Resident 1), the facility failed to develop and implement written policies and procedures that included re-training and re-education of a staff alleged of abuse/mistreatment before returning to work with residents. This failure had the potential to result in exposing vulnerable residents to abuse/mistreatment.

Inspectors wroteBased on interview and record review, for one of two sampled residents (Resident 1), the facility failed to ensure Resident 1 received treatment and care to maintain good foot health when Podiatry service was not provided after Resident 1's left great toenail came off due to fungal infection (disease caused by fungi). This failure had the potential to result in delayed treatment and further spread of fungal infection on Resident 1's toes.

Inspectors wroteBased on observations, interviews, record reviews, and facility policy reviews the facility failed to ensure infection control was maintained for nine residents (Resident (R)15, R19, R30, R81, R87, R92, R94, R99, and R109) out of a total sample of 46 residents. Specifically, the facility did not maintain a sanitary urinal for R109, did not maintain hand hygiene during incontinent care for R15, R30, R87, and R99; did not maintain proper PPE protocol infection for residents on enhanced barrier precautions (EBP) protocol for R19, R81, R92, and R94. These failures had the potential to result in infection and the spread of infection.

Inspectors wroteBased on observations, interviews, record reviews, and review of facility policy, the facility failed to ensure side rails were used appropriately for three of four sampled residents (Resident (R)4, R30 and R99). This failure increased the risk for entrapment or injury for the three residents.

Inspectors wroteBased on observations, interviews, record reviews, and facility policy reviews the facility failed to provide administration of medication according to physician orders for nine of nine residents (Resident (R)16, R29, R33, R37, R38, R44, R45, R73 and R90) reviewed for medication administration. Specifically, the facility failed to properly document medication administration, failed to administer medication to one resident (R16), and failed to administer medications on time to eight of nine residents reviewed for medication administration (R29, R33, R37, R38, R44, R45, R73, and R90). These failures had the potential to result in decreased therapeutic results of the medications prescribed for the effected residents.

Inspectors wroteBased on interview, observation, and facility policy review, the facility failed to ensure the two of two dumpsters located in a fenced area located behind the building was not propped open as well as failed to ensure there was no bagged trash or refuse loose on the ground in the dumpster area. These failures could lead to vermin gathering around the dumpsters and potentially entering the facility.

Inspectors wroteBased on observations, interviews, record review, and policy review, the facility failed to ensure that three of three residents (Resident (R) 21, 77, and 89) reviewed for dignity out of a sample of 47 residents, did not have signs hanging above bed with medical information on them.

Inspectors wroteBased on observations, interviews, record review, and policy review, the facility failed to ensure residents who self-administered medications had a self-administration of medication assessment, a physician's order, and a care plan completed for two of two residents (Resident (R) 44 and R73) reviewed for self-administration of medications. This failure to assess and care plan residents for self-administration of medications increases the potential risk of medication errors for residents.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to provide privacy during care in the resident's room for one of 45 sampled residents (Residents (R) 108). This failure could potentially have a negative impact on the quality of life for the affected resident.

Inspectors wroteBased on observations and interviews, the facility failed to maintain air conditioning filters for one of four residential units. This failure had the potential to negatively affect the respiratory system of 21 residents residing on the subacute unit, 11 of 21 residents were on ventilators.

Inspectors wroteBased on interviews, record review and policy review, the facility failed to ensure that an allegation of physical abuse was reported to the State survey agency (SSA) for one of one resident (Resident (R) 23) reviewed for abuse out of a sample of 47 residents.

Inspectors wroteBased on interviews, record reviews, and policy review, the facility failed to ensure one of three residents (Resident (R) 30) reviewed for hospitalization out of a total sample of 46 were given a written notice prior to or as soon as practical following transfer to the hospital. Additionally, there was no documentation that the Ombudsman was notified of the transfer for R30. This failure created the potential for residents or their responsible party to not have the information needed to understand their transfer to the hospital.

Inspectors wroteBased on interview, record review, and policy review, the facility failed to ensure two out of two sampled residents who were reviewed for hospitalization (Residents (R)30 and R100) were provided with a bed hold notice within 24 hours of emergent transfer to the hospital. This failure increased the potential that residents would not know to request a bed hold and may be unable to return to the facility.

Inspectors wroteBased on record review, interview, and review of the Resident Assessment Instrument (RAI manual) the facility failed to ensure that one resident (Resident (R) 86) out of 47 sampled residents' Minimum Data Set (MDS) assessments were transmitted in a timely manner.

Inspectors wroteBased on interviews, record reviews, and facility policy review, the facility failed to ensure two of three residents (Resident (R)4 and R99) had accurate care plans which were reviewed and revised on a quarterly basis. Additionally, the facility failed to ensure that one of three residents (R101) was invited to participate in care conferences. This failure increased the risk of the residents' preferences and concerns not being included in the plan of care.

Inspectors wroteBased on interviews, record reviews, and facility policy review, the facility failed to develop, assist, and follow through to completion with discharge plans for one of 46 sampled residents (Resident (R)101) reviewed for discharge planning. The facility did not have a person-centered discharge plan for R101.

Inspectors wroteBased on interview, and record review, the facility failed to make an ophthalmologist referral order for one out of one resident (Resident (R)100) who needed cataract surgery. This failure effected one of 45 sampled residents.

Inspectors wroteBased on record review, observation, and interviews, the facility failed to follow physician orders for enteral feeding for one resident (Resident (R) 38) out of 24 residents with feeding tubes. This failure increased the risk for dehydration and weight loss for the resident.

Inspectors wroteBased on interviews, record review and policy review, the facility failed to ensure that dialysis communication sheets were complete for one of one resident (Resident (R) 16) reviewed for dialysis out of a total sample of 47 facility residents. This failure placed all residents that receive dialysis at this center in potential risk of impaired continuity of care.

Inspectors wroteBased on observations, record review, staff interviews, and policy review, the facility failed to ensure the facility provided appropriate treatment and services for one of one resident (Resident (R) 89) reviewed for suicidal ideations (SI). This failure had the potential to contribute to continued suicidal thoughts that could result in self-harm for R89.

Inspectors wroteBased on observations, staff interview, and policy review, the facility failed to remove expired medications, treatment, and intravenous supplies and topicals stored in one (Sub-Acute Medication Room) of four medication rooms.

Inspectors wroteBased on interviews, record review and policy review, the facility failed to ensure that a contract was completed for a dialysis facility for one of one resident (Resident (R) 16) reviewed for dialysis out of a sample of 47 total facility residents. This failure placed all residents that receive dialysis at this center in potential risk.

Inspectors wroteBased on interview and record review, the Social Services Department staff failed to provide medically related social services for one of three sampled residents (Resident 1) when Resident 1 did not have social services follow through documentation, comprehensive care plan development, and 72-hour resident monitoring following an alleged theft and loss abuse incident between Resident 1 and Resident 2. This deficient practice failed to ensure that sufficient and appropriate social services were provided to meet Resident 1's physical, mental, and psychosocial needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain proper storage of medications including controlled medications (substances that have an accepted medical use, medications which fall under US Drug Enforcement Agency (DEA) Schedules II-V, and have a potential for abuse, ranging from low to high, and may also lead to physical or psychological dependence) when: 1. Medication room [ROOM NUMBER] ' s door was left ajar by staff allowing unauthorized access to medications and syringes with needles, 2. The medication room for the sub-acute area was ajar allowing access to an unlocked open, cabinet containing an emergency kit (e-kit, kit containing doses of emergency medication) which contained one vial of valium (a controlled medication which is used for sedation), 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one (Resident 1) of three residents received services to maintain good foot health when Resident 1 did not receive podiatry services for one year. The facility failed to obtain podiatry services which resulted in excessive toenail growth which resulted in a wound on the great right toe when the nails were trimmed. The wound on the right great toe developed a severe infection progressing to osteomyelitis (bone infection) and required hospitalization and antibiotic treatments.

Inspectors wroteBased on interview and record review the facility failed to ensure the responsible party (RP 1) of one (Resident 1) of three residents consented to COVID-19 vaccination before vaccinating Resident 1. This failure resulted in denial of the right to refuse vaccination, and the vaccination caused swelling and probable pain, of Resident 1 ' s vaccinated arm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have the ordered medication Sinemet (used for treatment of symptoms of Parkinson ' s disease) for one of two residents (Resident 1). This failure of not having this medication on 7/19/23 resulted in Resident 1 ' s delayed treatment and potential worsening of symptoms of Parkinson ' s disease (disease of nervous system with symptoms of tremors, muscle stiffness and unsteady movement).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1), had medical records that accurately documented insulin administration on July 16, 2023 and July 25, 2023. This failure had the potential to result in Resident 1 getting his insulin twice and having a low blood sugar.

Inspectors wroteBased on interview and record review, for six (Residents 122, 38, 123, 130, 58, and 62) of 31 residents, the facility failed to implement a care plan when: 1. Resident 122 did not have an antidepressant and antianxiety medications careplan; 2. Resident 38 did not have an antidepressant medication careplan; 3. Resident 123 did not have a range of motion (ROM) and mobility careplan; 4. Resident 130 did not have an inhaler medication self administration careplan; 5. Resident 58 did not have an edema careplan, and; 6. Resident 62 did not have a suprapubic catheter careplan. These failures had the potential to result in Residents 122, 38, 123, 130, 58, 26, 62, and 114 not receiving needed care.

Inspectors wroteBased on record review and interview, for three (Residents 16, 114, and 63) of six residents with limited range of motion (ROM - a joint or body part cannot move through its normal range of motion), the facility failed to ensure Residents 16, 114, and 63 received services and assistance to maintain or improve mobility when: 1. Resident 16 did not receive physical therapy (PT) and occupational therapy (OT) evaluations; 2. Resident 114 did not receive PT, OT, and speech therapy (ST) evaluations, and; 3. Resident 63 was without Restorative Nursing Assistant (RNA) services. For Residents 16, 63, and 114, this deficient practice resulted in the delay of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store food in accordance with professional standards for food service safety when: 1. In the dry storage room, there were bulk food items stored in containers with partially opened lids that also had cracks and big gaps. 2. Resident Food Refrigerators in Nursing Station 2 and Nursing Station 3 had multiple food items that were not labeled and dated, and the refrigerator's freezer section did not have a thermometer. These deficient practices had the potential to result in foodborne illness.

Inspectors wroteBased on interview and record review, the facility failed to employ a qualified social worker on a full-time basis and the two social service assistants functioning as the social worker did not meet the regulatory specified qualifications. This deficient practice had the potential to result in the residents' inability to attain or maintain their highest practicable psychosocial wellbeing by not receiving medically needed social services. During an interview with the Director of Nursing (DON) on 7/16/19, at 12:55 p.m., DON stated the facility did not have a full-time social worker. During an interview with the Administrator (ADM) on 7/17/19 9:03 a.m., ADM stated the facility did not have a social worker full time, but had two social service designees (SSDs). ADM stated the facility should have a full time social worker, but the former social worker resigned in March 2019. [...]

Inspectors wroteBased on observation, interview, and record review, for one (Resident 142) of two residents with dignity concerns, the facility failed to ensure Resident 142's right to privacy during personal care when Treatment Nurse (TN) 1 and Licensed Vocational Nurse (LVN) 1 performed a skin assessment that involved Resident 142's chest area and took a picture without providing privacy for Resident 142. This failure had the potential to result in Resident 142 feeling bad.

Inspectors wroteBased on interview and record review, for one (Resident 305) of three sampled residents, the facility failed to implement their Personal Property policy and procedure to prevent the misappropriation of resident property when Registered Nurse (RN) 1 and Certified Nursing Assistant (CNA) 1 did not do an inventory and document Resident 305's personal property upon her transfer to the acute hospital. This deficient practice resulted in the facility's inability to account for Resident 305's missing purse, money, credit cards, automatic teller machine (ATM) cards, and checkbook.

Inspectors wroteBased on interview and record review, for one of 31 sampled residents (Resident 130), the facility failed to complete a Minimum Data Set (MDS - an assessment tool used to direct resident care) admission assessment within 14 days of Resident 130 admission to the facility. For Resident 130, this failure had the potential to result in unassessed and unmet care needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure a significant change of status Minimum Data Set (MDS-an assessment tool used to guide care) was completed within 14 days after one (Resident 302) of 31 sampled residents was placed on hospice (care for the terminally ill). This deficient practice had the potential for Resident 302 not to receive appropriate care and services.

Inspectors wroteBased on interview and record review, for two (Resident 2 and 4) of two sampled residents, the facility failed to transmit Resident 2's Annual Minimum Data Set (MDS - an assessment tool used to direct care) Assessment and Resident 4's Quarterly MDS Assessment in a timely manner. These deficient practices resulted in the delay of resident-specific information to reflect residents' overall status, necessary for the provision of care.

Inspectors wroteBased on interview and record review, the facility failed to provide assistance in arranging vision services for one (Resident 60) of one sampled residents. This deficient practice resulted in Resident 60 having a delay in treatment.

Inspectors wroteBased on observation, interview and record review, for one of one resident (Resident 130) who was triggered for accident hazard, the facility failed to provide supervision to prevent accidents when Resident 130 was allowed to keep and administer inhaler by herself without proper instructions. For Resident 130, this failure had the potential to result in unwanted side effects and accidental overdose of medications.

Inspectors wroteBased on observation, interview and record review, for one (Resident 62) of one residents with a urinary catheter (a tube placed in the body to drain and collect urine from the bladder), the facility failed to ensure Resident 62 received care and services to prevent urinary tract infection when Resident 62's: a. suprapubic catheter was positioned over his hip and under his right shoulder; b. suprapubic catheter site care was not provided, and; c. suprapubic catheter was not changed as ordered. For Resident 62, this failure had the potential to result in recurring urinary tract infection.

Inspectors wroteBased on observation, interview and record review, for two (Residents 26 and 304) of six residents on a feeding tube, the facility failed to provide care and services to promote nutrition when licensed staff did not manage the tube feeding pumps properly and Residents 26 and 304 did not receive the calculated amount of tube feedings that were ordered by the physician. This failure had the potential to result in weight loss.

Inspectors wroteBased on interview and record review, for one (Resident 203) of one residents with behavior symptoms, the facility failed to ensure Resident 203 received behavioral health services when a psychiatric evaluation was not completed as ordered by the Attending Physician. For Resident 203, this failure had the potential to result in exacerbation of behavioral symptoms without appropriate treatment.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide pharmaceutical services when: 1. Resident 204's medication suboxone (controlled substance that treats pain and addiction to narcotic pain killers) was not available for administration for two days. This failure had the potential to result in unwanted withdrawal symptoms. 2. Resident 61's medications hydrochlorothiazide (controls blood pressure) and plavix (prevents blood clot) were not available for administration during medication pass. This failure had the potential to result in uncontrolled high blood pressure.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure its medication error rate did not exceed five percent. There were three medication errors out of 27 opportunities for error that totaled 11.11 percent (%) when: a. For Resident 204, Homology 15 units (a fast acting insulin, lowers blood sugar) was administered an hour after the time frame ordered by the physician. This failure had the potential to result in untreated high blood sugar; b. For Resident 204, Suboxone 2 milligram (mg) per 0.5 mg. sublingual film (controlled substance that treats pain as well as addiction to narcotic pain relievers) was not administered as ordered by the physician. This failure had the potential to result in unpleasant withdrawal symptoms, and; c. For Resident 61, hydrochlorothiazide (medication that lowers blood pressure) 12.5 mg capsule was not administered as ordered. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure clinical records were complete and accurately documented for two (Resident 93 and Resident 35) of 31 sampled residents when: 1. Resident 93's July 2019 physician's order indicated Resident 93 had an order to receive 100 milliliters (ml) of MedPlus (a nutritional supplement) three times a day, which did not reflect the original order, dated 5/25/19, for Resident 93 to receive 180 ml of MedPlus three times a day. This deficient practice had the potential for Resident 93 not to receive the required amount of calories and to potentially have weight loss. 2. Resident 35's clinical record had both old and new Restorative Nursing Assistance (RNA) orders. This deficient practice had the potential for Resident 35 not to receive needed care, services and treatments.

Inspectors wroteBased on observation, interview and record review, the facility failed to observe infection control practices for one (Resident 304) of one sampled residents when a Licensed Nurse did not wash her hands between glove changes during wound care and left a soiled brief (disposable diaper) under the resident during a wound care treatment. This deficient practice had the potential to result in the spread of infection.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain the facility's kitchen convection oven in proper working condition when the Dietary Staff (DS) did not clean the oven according to manufacturer's guidelines. This failure had the potential to result in food borne illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 29 sampled residents (Resident 201) maintained their dignity when Resident 201 waited for 35 minutes in her soiled undergarment before Certified Nursing Assistant (CNA) 2 changed it. This failure resulted in Resident 201 not feeling good about waiting in her soiled undergarment.

Inspectors wroteBased on observation, interview and record review, for one (Resident 123) of 29 sampled residents, the facility failed to notify the physician of the need to alter treatment when Resident 123 developed an open area on the left great toe. This failure had the potential to result in infection and a delay in treatment.

Inspectors wroteBased on interview and record review, for one (Resident 145) of 3 sampled residents, the facility failed to develop and implement a baseline care plan to address Resident 145's use of CPAP (Continuous Positive Airway Pressure - a machine that forces air through the airways to treat sleep apnea to maintain good blood oxygen levels during sleep. Apnea is a sleep disorder, when a person's breathing stops or is interrupted during sleep). This failure had the potential to result in Resident 145 not having restful sleep and decreased levels of oxygen.

Inspectors wroteBased on interview and record review, the facility failed to develop and document a discharge care plan for one of 29 sampled residents (Resident 70) when the discharge care plan for Resident 70 was not developed and discussed with Resident 70's Responsible Party (RP). This failure had the potential to cause the residents and responsible parties emotional distress.

Inspectors wroteBased on observation, interview and record review, for one (Resident 123) of 29 sampled residents, the facility failed to ensure Resident 123 received treatment and services when Resident 123 developed an open area on the left great toe without assessment and initiation of treatment. For Resident 123, this failure had the potential to result in the delay of treatment and infections.

Inspectors wroteBased on observation, interview, and record review, for one (Resident 70) of 29 sampled residents the facility failed to ensure Resident 70 received treatment and services to maintain her highest practicable level of functioning and well-being when Licensed Vocational Nurse (LVN) 2 did not implement the facility's Behavior Management policy and procedure. For Resident 70, this failure had the potential to result in increased episodes of crying, yelling, and screaming.

Inspectors wroteBased on interview and record review, for one of 13 sampled residents (Resident 69), the facility failed to ensure Resident 69 was free of significant medication error when Resident 69 did not receive Renvela (a phosphate binder that helps lower increased levels of phosphorus in residents with kidney disease) with meals, as ordered by the physician. This failure had the potential to result in increased phosphorus levels which may lead to bone disease, vascular calcification (accumulation of calcium deposits in major arteries) and cardiovascular disease.