Health inspection·April 10, 2023

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 Based on interviews and record review, the facility failed to ensure one (Resident 1) of three sampled residents received treatment and care services in accordance to professional standards of practice when the Licensed Vocational Nurse (LVN 1) did not provide wound care treatment as ordered by the physician for Resident 1's ruptured blisters on both feet. Residents Affected - Few This failure had the potential to result in the wounds to worsen and or cause infection. Findings: During an interview on 2/13/23 at 9:24 a.m., Resident 1 stated it had been two days since wound care treatments were done on both of her feet. Resident 1 said wound treatment is supposed to be done once a day. Resident 1 further stated the day shift nurse did not provide wound treatment and the night shift will say the day shift will do it. Resident 1 stated her feet hurt. Review of the Admission-Minimum Data Set (MDS - an assessment screening tool used to guide care), dated 12/29/22, indicated, Resident 1's Basic Interview of Mental status (BIMS) score was 15 (meaning cognitively intact). Resident 1 had clear speech, was able to make self-understood and able to understand others. Resident 1 had diabetic foot ulcers and application of dressing. Resident 1 ' s diagnoses included diabetes mellitus (blood sugar disorder) and septicemia (blood poisoning caused by bacteria or their toxins). Review of the order summary report dated 1/3/23, indicated Resident 1 ' s physician ordered staff to apply betadine (antiseptic) solution to both feet and cover with a dry dressing once a day. Further review indicated on 1/16/23 , the physician ordered to apply triad paste (absorbs excess wound exudate or fluid while maintaiing a moist wound enviornment) to Resident 1 ' s bilateral lower extremities wound, twice a day (day and evening shift). Review of the Treatment Administration Record (TAR) for February 2023 indicated Resident 1 had not received wound care treatment to both feet and lower extremities on 2/6/23, 2/7/23, and 2/11/23. During an interview on 2/13/23 at 10:55 a.m., in the presence of the Administrator (Admin) and Director of Nursing (DON), the Licensed Vocational Nurse (LVN 1) stated she was the charge nurse on the day shift on 2/6/23, 2/7/23, and 11/2023. LVN 1 further stated she had broken fingers and cannot do the treatments for Resident 1 ' s wounds. LVN 1 stated Admin and the Director of Staff Development (DSD) were aware that she cannot do the wound care treatments for her assigned residents. Review of the skin impairment care plan initiated on 1/4/23 indicated Resident 1 was admitted with gangreneous (dead tissue caused by infection or lack of blood flow) wound to bilateral feet, and (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 3 Event ID: 055338 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 055338 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sage Post Acute 1832 B Street Hayward, CA 94541 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)