Alameda Healthcare & Wellness Center

In the surveyor’s words

From the most serious findings on record at Alameda Healthcare & Wellness Center, in the surveyor’s own words.

• Actual harm, isolatedF687Apr 23, 2024

  Based 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. […]

• Actual harm, isolatedF600Oct 21, 2021

  Based on interview and record review, the facility failed to ensure one of three residents (Resident 1) was free from neglect when staff did not assess or monitor Resident 1 for a change of condition after Resident 1 fell and began to have difficulty speaking. The failure to reassess for change of condition resulted in delayed treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings: A review of Resident 1's Minimum Data Set (MDS, a resident assessment tool used to guide care) dated 2/19/21, indicated Resident 1 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS indicated Resident 1 had minimal hearing impairment, clear speech, was understood by others, and usually understood what others said. […]

• No harm, potential for more than minimal, widespreadF880Aug 10, 2024

  Based 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. […]

• No harm, potential for more than minimal, patternF812Aug 11, 2026

  Based on observation, interview, and record review, the facility failed to store food in accordance with professional standards, when nine cups of six ounces of milk in each cup, were stored at room temperature for an hour on a food preparation table in the kitchen. This failure had the potential to result in food borne illness for residents in the facility.Findings:During a concurrent observation and interview on 8/10/26, at 1:35 p.m., with Dietary Aide 1 (DA 1) a tray with nine (9) cups of six (6) ounces of milk in each cup, was kept on the food preparation table in the kitchen. DA 1 stated the milk cups were left at room temperature, however, they were to be placed in the refrigerator for later use. DA 1 stated the kitchen staff forgot to put it back in the refrigerator. […]

• No harm, potential for more than minimal, patternF880Sep 4, 2025

  Based 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… […]