The failure occurred during an active outbreak of invasive group A streptococcus at Alameda Care Center, a severe infection that can lead to necrotizing fasciitis and death. Federal inspectors found that nurses repeatedly failed to identify and report infected wounds, delaying critical treatment and isolation measures that could have prevented the infection's spread.
Licensed Vocational Nurse 3 was responsible for monitoring Resident 76 for signs of the streptococcus infection on July 23, 2024. She documented in his medication record that he showed no symptoms of skin infection. But when inspectors observed the resident the next day, they found multiple open wounds on his left arm with clear dried substance crusted on his wrist.
"I only scanned the resident while administering his medications," LVN 3 told inspectors. "If I would have done a thorough skin assessment on 7/23/2024, she would have identified a change of condition."
The infection preventionist had given clear guidance to staff during the outbreak: monitor all residents for signs of infection, including open wounds with redness, drainage, or swelling. Any resident with suspicious wounds should be immediately placed in isolation, tested for the streptococcus bacteria, and started on antibiotics.
Treatment Nurse 1 also failed to report an infected wound she discovered. She noticed on July 23 that Resident 76's left wrist was "irritated and moist" but told no one. The next morning, when she made rounds with a wound care consultant, the wrist had become "crustier" and the consultant verbally ordered antibiotics for the infection.
"I did not notify the IP or DON that Resident 76 had an open skin wound with an infection because I was very busy," TN 1 told inspectors.
The infection preventionist said the delay had serious consequences during an active outbreak. "TN 1 should have notified me immediately because there is an OB," she said. "We want to prevent the OB from spreading to other residents."
The facility's outbreak began sometime before July 17, when physician orders show staff were already monitoring residents for streptococcus symptoms. Invasive group A streptococcus spreads through respiratory droplets or contaminated surfaces and can invade parts of the body where bacteria are not usually found. The infection can progress to necrotizing fasciitis, a life-threatening condition that destroys soft tissue.
But the monitoring failures extended beyond the outbreak response. Inspectors found that staff had ignored a hospice patient's escalating arm pain for weeks without proper assessment or notification of physicians.
Resident 68 had been receiving physical therapy exercises and wearing splints for contractures in both arms and legs. Starting in June 2024, the restorative nursing aide documented that the resident repeatedly refused the exercises and splints, reporting pain in her right arm.
The aide noted the refusals weekly through June and July. During a monthly meeting on June 28, staff discussed that Resident 68 "held the arm not wanting the RNA to move the arm" due to pain.
By July 23, a nursing assistant observed the resident using her left arm to hold and protect her right arm. When the assistant attempted to lift the right arm, "Resident 68 immediately used the left arm to grab and guard the right arm, had a facial wince, and had tears in the left eye."
The assistant said the resident appeared to be in "10 out of 10 pain" and had been complaining of right elbow pain for one to two weeks.
During an inspection observation on July 24, Resident 68 was lying in bed with obvious swelling throughout her right arm compared to her left. When the restorative aide attempted exercises, "Resident 68 immediately held onto the right arm using the left hand and flexed the body as a pain response."
Yet no nurse had completed a change of condition assessment or notified the resident's physician about the escalating pain and treatment refusals. The Director of Staff Development said a change of condition form should have been completed after the resident's fourth refusal on June 20.
"The licensed nurses should have completed documentation indicating Resident 68's right arm pain, refusal to participate in RNA, and a COC Form Assessment, which would have included notification to MD 1," the Director of Nursing told inspectors.
The hospice nurse finally learned about the problem on July 15, when a facility nurse reported increased swelling and pain. During her visit, the hospice nurse observed "whole arm swelling and pain with movement when gentle ROM was attempted" and called the resident's family to discuss the worsening condition.
The resident's responsible party said the facility never contacted them directly about the pain and treatment refusals. "RP 1 felt uncomfortable that the facility did not contact RP 1 directly and wanted to know the cause of Resident 68's right arm pain."
The Director of Nursing acknowledged the facility failed to follow its own change of condition policy, which requires prompt physician notification, completion of nursing reports, and family contact for any significant changes in a resident's status.
Other inspection findings revealed additional care failures. Staff failed to conduct required quarterly assessments for a resident using a bed alarm, which the Director of Nursing acknowledged was actually a physical restraint despite being ordered as a "non-restraint" intervention.
The facility also hired a restorative nursing assistant in April 2019 but didn't complete a background check until January 2022, nearly three years later. The check revealed a criminal record for driving with a suspended license.
"The delay put the residents at risk," the Director of Staff Development told inspectors.
Federal inspectors cited the facility for failing to ensure residents received necessary care and services, failing to properly use physical restraints, and failing to implement abuse prevention policies. The violations occurred at a 120-bed facility that has faced previous federal scrutiny for care deficiencies.
The missed infections and ignored pain complaints illustrate how communication breakdowns can leave vulnerable residents without timely medical intervention, even during declared health emergencies requiring heightened surveillance.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Alameda Care Center from 2024-07-26 including all violations, facility responses, and corrective action plans.
