Health inspection·August 29, 2024

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 1), received treatment and care for a non-pressure ulcer (open area that is not caused by shear or pressure but may be caused by poor circulation) when: Residents Affected - Few 1. Resident 1 developed redness to abdominal folds which became worse. 2. Resident 1's Treatment Administration Record (TAR), had multiple dates without initials/documentation that showed assigned licensed nurses had performed the resident's ordered wound treatments. These failures resulted in Resident 1's avoidable abdominal wound dehiscence which reopened and led to infection. Findings: A review of Resident 1's admission Record, printed on 6/24/24, indicated resident was admitted to the facility on [DATE] with multiple diagnoses that included diabetes mellitus (high blood sugar), morbid obesity, and heart disease with heart failure (a condition in which heart does not pump blood as well as it should). A review of Resident 1's Minimum Data Set (MDS, a resident assessment tool used to provide care), dated 4/19/24, indicated Resident 1 had clear speech, was always understood, and was always able to understand. The MDS also indicated Resident 1 required substantial/maximal assist (helper does more than half the effort) to dependent assist (helper does all the effort to complete the activity with the assistance of two or more helpers required for the resident to complete the activity) during her activities of daily living, (ADLs, the basic self-care tasks an individual does on a day-to-day basis). A review of Resident 1's hospital record titled, Interagency Discharge Summary and Orders, dated 4/13/24, prior to Skilled Nursing Facility (SNF) admission on [DATE], did not indicate that resident had unresolved skin issues to her abdominal area. A review of Resident 1's Nursing - Comprehensive Skin Evaluation/Assessment (CSE/A), dated 4/27/24, by Treatment Nurse 1 (TN 1), indicated, 4/22/24 Change of Condition (COC) done for redness with skin tears under abdomen around right iliac crest (the curved part on top of the hip) . Treatment (Tx) initiated: keeping abdominal folds clean and dry. 4/24/24 Nystatin powder was ordered . Review of the Nursing - CSE/A, dated 5/10/24, indicated, Redness with skin tears under abdomen around right iliac crest. - 5/4/24 REDNESS CLEARING UP BUT OPEN AREAS NOTED: RIGHT LATERAL ABDOMINAL (ABD) FOLDS OPEN Page 1 of 5 055239 055239 08/29/2024 East Bay Post-Acute 20259 Lake Chabot Road Castro Valley, CA 94546

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few AREA MEASURES 1.0 CENTIMETER (CM) x 5.5 CM and TWO (2) LEFT LATERAL FOLDS 1.0 CM x 2.0 CM. A review of Resident 1's April 2024 TAR, indicated: Start Date 4/24/24 - Nystatin External Powder 100000 UNIT/GM (Nystatin Topical) Apply to redness to abdominal fold topically two times a day for fungal infection for two weeks. Cleanse with normal saline (NS), pat dry and apply Nystatin powder. Further review of April TAR also indicated: Start date 4/24/24 - Treatment - Right side abdominal fold, reddened, moist, and fragile, every shift. A review of Resident 1's May 2024 TAR, indicated: Start Date: 5/4/24 - Moisture-Associated Skin Damage (MASD) to abdominal folds lateral sides: Cleanse with NS, pat dry, apply Medi honey gel, then cover with foam dressing daily until resolved. Discontinued Date: 5/22/24. Further review of May 2024 TAR also indicated: MASD to abdominal folds left and right sides: Cleanse with NS, pat dry, apply Medi honey gel, cover with Calcium (Ca) Alginate, apply Triad paste to peri wound then cover with dry dressing daily until resolved. During a telephone interview on 6/24/24, at 12:40 p.m., with the TN 1, TN 1 stated Resident 1 developed the abdominal fold open areas over time during resident's stay at the facility. TN 1 stated Resident 1 was referred to the Wound Doctor on 5/22/24. During a concurrent interview and record review on 8/28/24, at 11:42 a.m., Registered Nurse 1 (RN 1) stated Resident 1's May 2024 TAR were not initialed/signed by the scheduled LNs for the following treatment orders and dates: 1. Nystatin External Powder 100000 UNIT/GM (Nystatin Topical) Apply to redness to abdominal fold topically two times a day for fungal infection for two weeks. Cleanse with normal saline (NS), pat dry and apply Nystatin powder - at 0900, on 5/2, 5/3, 5/5, and at 1700, on 5/3, 5/4, and 5/5. 2. Right side abdominal fold, reddened, moist, and fragile every shift - Day Shift, on 5/2, 5/3, 5/5, 5/13, and 5/20; and Evening Shift, on 5/3, 5/4, 5/5, 5/10, 5/11, 5/12, 5/17, 5/18, 5/19, 5/21, and 5/24. 3. MASD to abdominal folds lateral sides - Day Shift, on 5/5, 5/13, and 5/20. RN 1 stated if there were no initials on the boxes, it meant ordered treatments were not performed as scheduled. During a concurrent interview and record review on 8/28/24, at 12:15 p.m., Director of Nursing (DON) stated Resident 1 did not have any skin issues on abdomen upon admission to the facility. A review of Resident 1's Progress Notes, dated 5/25/24, 12 p.m., indicated resident had draining wounds to abdominal folds which were assessed and diagnosed by MD 1, on 5/24/24, as cellulitis (a serious bacterial skin infection) and gave an order for antibiotic for seven days. Further review of the Progress Notes, dated 5/25/24, indicated Resident 1 was sent to the hospital via 911 on this same day. Resident 1 did not return back to facility. A review of Resident 1's hospital records titled Discharge Summary, dated 5/29/24, indicated resident was admitted to the hospital on [DATE] and had a Microbiology Work-up (specimen susceptibility testing) of the abdominal wall, collected on 5/26/24, which indicated culture of, Moderate Enterococcus faecalis (enterococcal species that can cause a variety of infections) (This organism is 055239 Page 2 of 5 055239 08/29/2024 East Bay Post-Acute 20259 Lake Chabot Road Castro Valley, CA 94546

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few INTRINSICALLY RESISTANT to cephalosporins, clindamycin, trimethoprim, trimethoprim-sufamethoxazole), Scant Growth Staphylococcus aureus (a bacteria that causes a wide variety of diseases) . A review of Resident 1's hospital clinical records titled, History and Physical (H&P) Notes, dated 5/25/24, by Hospital Medical Doctor (MD), based on Resident Representatives (RR) report indicated, .Patient has developed dehiscence and open wounds over very old lower abdominal surgical sites bilaterally from a very remote tummy tuck surgery (unknown duration), and was started on cephalexin (an antibiotic) one (1) day prior to this admission at SNF for concerns of cellulitis . A review of the facility's policy and procedure (P&P) titled, Wound Care, revision date October 2010, indicated, The purpose of this procedure is to provide guidelines for the care of wounds to promote healing .Documentation - The following information should be recorded in the resident's medical record .the date and time the wound care was given .the name and the title of the individual performing the care . 055239 Page 3 of 5 055239 08/29/2024 East Bay Post-Acute 20259 Lake Chabot Road Castro Valley, CA 94546

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one of two sampled residents (Resident 2) when: Residents Affected - Few 1. Treatment Nurse 2 (TN 2) and Certified Nursing Assistant 1 (CNA 1) did not wear a disposable gown during Resident 2's wound dressing change. Failure to wear the necessary personal protective equipment (PPE such as gloves, gown, face shield, masks, etc.) had the potential to place residents, staff, and visitors at risk for infection. 2. TN 2 did not perform hand hygiene (handwash with soap and water or alcohol-based hand rub) in between glove change during the wound dressing change. This failure had the potential to result in infection and spread of infection. Findings: A review of Resident 2's admission Record, printed 8/28/24, indicated resident was readmitted to the facility on [DATE] with diagnosis of diabetes mellitus (high blood sugar). A review of Resident 2's Minimum Data Set (MDS, an assessment tool used to direct care), dated 6/18/24, indicated resident was at risk for pressure ulcers (injury to skin and underlying tissues resulting from prolonged pressure on the skin). A review of Resident 2's Physician Order, with a start date of 7/26/24, indicated a treatment order for chronic on/off excoriations to buttocks and sacrococcygeal (bottom of the spine or just above the tailbone) region: Cleanse with soap and water, pat dry, apply Triad paste (zinc-oxide based hydrophilic paste for light to moderate levels of wound exudates) daily. During a concurrent observation and record review on 8/28/24, at 10:30 a.m., outside by Resident 2's room doorway was a posted sign which indicated Enhanced Barrier Precautions (EBP, a set of infection control measures used to reduce spread of multidrug-resistant organisms [MDROs] that involved gown and glove use during high-contact activities). Review of the posted sign indicated, .Wear gloves and gown for the following High-Contact Resident Care Activities .Changing briefs or assisting with toileting .Wound Care: any skin opening requiring a dressing . Further observation showed a PPE supply holder hung by Resident 2's room entrance door, which contained two boxes of gloves and multiple disposable gowns. During an observation and concurrent interviews on 8/28/24, at 10:30 a.m., TN 2 prepared for Resident 2's wound dressing change. Both TN 2 and CNA 1 entered Resident 2's room with gloves and N95 respirator mask, but without gowns on. During wound dressing change, TN 2 did not perform hand hygiene in between glove change before applying the Triad paste to the wound. Upon interview, both TN 2 and CNA 1 stated they should have worn their disposable gowns before Resident 2's wound dressing change took place. TN 2 also stated hand hygiene should be performed when moving from wound cleaning (a dirty procedure) to application of a new dressing (a clean procedure) to prevent infection. During an interview on 8/28/24, at 10:45 a.m., with the Infection Preventionist (IP), IP stated EBP 055239 Page 4 of 5 055239 08/29/2024 East Bay Post-Acute 20259 Lake Chabot Road Castro Valley, CA 94546

F 0880 Level of Harm - Minimal harm or potential for actual harm should be observed during resident care with wounds, urinary catheters, tube feedings, or any type of opening or break in the skin, requiring close skin contact. IP stated licensed nurses and CNAs were required to wear gloves and gown when performing close physical contact with residents. IP also stated staff should change gloves and perform hand hygiene in between clean and dirty procedures to prevent spread of infection. Residents Affected - Few 055239 Page 5 of 5