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 (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 5 Event ID: 055239 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055239 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE East Bay Post-Acute 20259 Lake Chabot Road Castro Valley, CA 94546 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)