Alameda Hospital D/P SNF

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 1) received services in the facility with reasonable accommodation of resident needs when Resident 1's Active Order for skin care precautions indicating foot cradle (a supportive frame placed at the end or side of a mattress to elevate bed linens and to keep blankets/bedclothes away from the feet or legs of the user) use was not put in place. This deficient practice resulted in Resident 1 not receiving the needed care, assistive device, and/or service as ordered. A review of Resident 1's Inpatient Information, printed on 5/19/26, indicated Resident 1 was admitted to the facility on [DATE] with multiple diagnoses that included dementia (memory loss), Cerebrovascular Accident (CVA, a stroke), and hemiplegia (muscle weakness on one side of the body, complete paralysis). [...]

Inspectors wroteBased on observation, interview and record review the facility failed to protect one of three sampled residents, (Resident 1), from physical and emotional abuse when Resident 2 punched Resident 1 in the face twice with his fist and put him in a choke hold. This failure resulted in Resident 1 having a contusion (an area of skin discoloration caused by broken blood vessels under the skin, which happens when soft tissue is damaged by an impact), on Resident 1's face requiring transfer to an acute care hospital. Resident 1 stated he was fearful of Resident 2 and did not feel safe at the facility. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of three residents (Resident 1) were free from sexual abuse when Resident 2 sexually abused Resident 1 who had severe intellectual disability and was unable to provide consent. This failure resulted in Resident 1 ' s elbow pain from being held down during the sexual abuse and had the potential for serious physical and psychosocial injury.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure discontinued medications were discarded when they were kept with ready to use medications in medication refrigerator. This failure had the potential to result in residents receiving the medication erroneously, which could lead to new health problems or adverse reactions.

Inspectors wroteBased on observation, interview and record review, the facility had 11 resident rooms (Rooms 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, and 11) with multiple beds that provide less than 80 square feet (sq. ft.) per resident who occupy these rooms. This failure had the potential to result in inadequate space for the delivery of care to each of the residents in each room or for storage of the residents' belongings.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure infection control practices were implemented when one of four residents, Resident 21's bedside commode (a portable toilet) was visibly soiled. This failure placed the facility's residents at risk for healthcare-associated infections.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food was stored and prepared in accordance with professional standards of food and safety when: 1. The food preparation area was adjacent to the hand wash station/sink with inadequate protection from potential splashes of contaminated water and soap from handwashing. 2. The ready-to-use pans stored above the food preparation area were wet. 3. Dietary Clerk (DC) did not cover hair completely while in the kitchen and during tray-line. These failures had the potential to result in food-borne illnesses.

Inspectors wroteBased on interview and record review, for one (Resident 3) of three sampled discharged residents, the facility failed to complete and transmit Minimum Data Set (MDS, an assessment tool used to direct resident care) within 14 days of discharge from the facility. The failure to complete and transmit the Discharge Assessment for five months and 25 days after Resident 3 transferred to the acute care hospital and did not return, resulted in lack of tracking of residents leaving the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two Certified Nursing Assistants (CNA 2 and CNA 3) demonstrated competency in skills and techniques for provision of resident care according to resident care plans. The failure to ensure CNA 2 and CNA 3 completed annual performance and competency appraisals had the potential to result in inadequate or improper care for the CNAs assigned residents.

Inspectors wroteBased on observations, interviews, and document reviews the facility failed to be free of medication error rates of five percent or greater when three medication errors were observed out of 28 opportunities. The medication error rate was calculated as follows: three divided by 28 then multiplied by 100, which was equal to 10 percent. This failure had the potential to result in ineffective medication regimen for the effected residents (Residents 104, 117, and 125).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one employee (Certified Nursing Assistant 1, CNA 1) wore required personal protective equipment (PPE, protective items or garments worn to protect the body or clothing from hazards that can cause injury) and performed required hand hygiene after providing direct care to a resident in a room on contact, droplet, and airborne precautions. (Contact and droplet precautions are actions implemented to prevent the spread of infection based upon the transmission mode of direct or indirect contact with respiratory secretions from the resident or environmental surfaces contaminated with respiratory secretions. [...]

Inspectors wroteBased on observation and interview, the South Shore facility had 11 rooms (Rooms 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, and 11) with multiple beds that provided less than 80 square feet (sq.ft.) per resident who occupied these rooms. This failure had the potential to result in a lack of sufficient space for the provision of care by facility staff and for the lack of sufficient space for storage of resident belongings.

Inspectors wroteBased on observation and interview, and record review, the facility failed to ensure food was prepared under sanitary conditions when: a. a manual can opener had metal shavings on the blade, and; b. Dietary Aide 2 rinsed the peeled boiled eggs in the 3 compartment sink. These failures had the potential to result in food contamination and food-borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff competency when Dietary Aide 1: a. used a sanitizing agent test strip not intended for use with the Quat sanitizer (anti-microbial agent) solution to test the Quat sanitizer solution concentration, and; b. immersed a newly washed blender in the sanitizing sink for a few seconds. This failure had the potential to result in food-borne illness.

Inspectors wroteBased on observation, interview and record review the facility failed to follow infection control practices for one (Resident 421) of 34 sampled residents when Registered Nurse (RN) 2 did not perform hand hygiene (wash hands with soap and water or use an alcohol based hand rub) during wound care. This deficient practice did not ensure effective control and prevention of the spread of infection in the facility.

Inspectors wroteBased on observation and interview, the facility had 11 resident rooms (Rooms 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, and 11) with multiple beds that provided less than 80 square feet (sq.ft.) per resident (Rt) who occupied these rooms. This failure had the potential to result in a lack of adequate space for the provision of resident care by the facility staff and for the lack of sufficient space for resident's belongings.