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 Page 1 of 3 055338 055338 04/10/2023 Sage Post Acute 1832 B Street Hayward, CA 94541

F 0684 interventions included to administer treatment per physician order. Level of Harm - Minimal harm or potential for actual harm During an interview on 2/13/23 at 11:45 a.m., Admin stated the facility had staffing challenges and was trying to hire more nurses. Residents Affected - Few 055338 Page 2 of 3 055338 04/10/2023 Sage Post Acute 1832 B Street Hayward, CA 94541

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on interviews and record review, the facility failed to ensure accurate documentation of the medical records for one (Resident 2) of three sampled residents. Resident 2's Treatment Administration Record (TARs) for wound care treatment to the left foot, gangrenous toes was signed off (initialed) as done by the Registry (temporary contracted employee) Licensed Vocational Nurse (RLVN) for six days, when RLVN was not present or assigned to care for Resident 2. This failure resulted in inaccurate medical record wound care documentation. Findings: Review of the Annual-Minimum Data Set (MDS - an assessment screening tool used to guide care), dated 11/08/22, indicated: Resident 2's Basic Interview of Mental status (BIMS) score was 15 (meaning cognitively intact). Resident 2 had diabetic (blood sugar disorder) foot ulcers and dressing. Resident 2 ' s diagnoses included diabetes mellitus and peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the lmbs). Review of the order summary report dated 2/26/23, indicated the physician ordered Resident 2 ' s left foot gangrenous toes be applied with A&D to dry areas and may wrap foot with loose kerlix (gauze) for comfort, daily in the morning. Review of the Treatment Administration Record (TAR) dated 2/6/23 through 2/11/23 indicated wound care treatments for Resident 2's left foot gangrene toes was signed off as done with LVN's initials. During a review of the TARs and concurrent interview on 2/13/23 at 11:25 a.m., Licensed Vocational Nurse (LVN 1) stated she was the charge nurse on day shift . LVN 1 stated she did not do the wound treatments for Resident 2 ' s wounds. LVN 1 further stated the initial on the TAR documentation was not her initials. Review of Nursing staffing assignment and sign-in-sheet, indicated LVN 1 was assigned to day shift to provide care for Resident 2 on 2/6/23 to 2/11/23. During an interview on 2/13/23 at 1:54 p.m., Admin stated the facility did not use Registry LVN on the day shift for the week of 2/6/23 through 2/11/23. During an interview on 3/7/23 at 10:30 a.m., DON stated LVN 1 no longer worked at the facility. DON further stated the expectation was for licensed nurses to document according to standards of practice. The facility ' s policy and procedure titled, Wound Care, undated indicated the following information should be recorded in the resident ' s medical record: The type of wound care given. The date and time the wound care was given. The name and titled of the individual performing the wound care. The signature and title of the person recording the data. 055338 Page 3 of 3