Health inspection·May 23, 2025

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge. Based on interview and record review, the facility failed to provide an accurate medication list that included both prescription and over-the-counter medications at the time of discharge to one out of three (Resident 1) reviewed residents. This failure resulted in Resident 1 not receiving prescribed wound care treatment for six days post discharge. Findings: During a review of Resident 1's admission Record, dated 5/22/25, the document indicated Resident 1 was admitted to the facility in March 2025 with multiple diagnoses, including pressure ulcer of sacral region (lower back), Stage 3 (also known as a bedsore, a wound that affects the top two layers of skin), hypertension (high blood pressure), and pain in left nnee. The document indicated Resident 1 was discharged from the facility on 5/16/25. During a phone interview on 5/22/25 at 2:00 p.m. with Family Member 1 (FM1), FM1 stated when she picked up Resident 1 from the facility on 5/16/25, she did not receive any verbal instructions about wound care. FM1 stated she received handwritten discharge instructions and there was nothing on the handwritten instruction sheet about wound care. FM1 stated she also received a printout written in medical terms. FM1 stated the printed instructions read, Instructions for sacrum, cleanse with NS apply Medihoney cover with foam dressing, secure tape as needed, TX every evening shift. FM1 stated she does not know what TX or NS means, and stated she did not receive a prescription for Medihoney (a gel to help heal wounds) and does not know if it could be purchased over the counter. FM1 stated she did not understand how to follow these instructions or have access to the necessary supplies. FM1 stated that Resident 1 did not receive the prescribed wound care between the time he was discharged from the facility on 5/16/25 until the home health nurse arrived on 5/22/25. In a concurrent interview and record review on 5/23/25 at 11:03 a.m. with the Director of Nursing (DON), Resident 1's Physician's Other Order, dated 5/14/25, was reviewed. DON stated the document indicates Resident 1 may discharge home with current medication orders and treatment. DON stated the current medication orders for Resident 1 included the application of Medihoney to his sacrum for his stage 3 pressure ulcer. In a concurrent interview and record review on 5/23/25 at 11:08 a.m. with DON, Resident 1's Discharge Medication, dated 5/14/25, Nursing Discharge Summary Instructions, dated 5/16/25, and Order Summary Report, dated 5/1/25 were reviewed. DON stated Resident 1 should have received all three of the documents at the time of discharge. DON stated there were no wound care medications or instructions on Nursing Discharge Summary Instructions or Discharge Medication documents. DON stated the only mention of wound care instructions was on the Order Summary Report . DON stated the Order Summary Report Page 1 of 2 055809 055809 05/23/2025 St Anthony Care Center 553 Smalley Avenue Hayward, CA 94541

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated, Tx to sacrum PU stage 3: Cleanse with NS, apply Medihoney, cover with foam dressing, secured with tape every evening shift until further notice . DON stated these instructions were written using medical terminology and they are not written in a way that non-medical professionals could easily understand. DON stated the order for Medihoney should have been discontinued and an order for Zinc Oxide cream (a barrier cream that is put on wounds to help them heal) should have been entered. DON stated instructions for wound care should have been written on the Discharge Medication document under the section Discharge Medications (Over the Counter) . In a concurrent interview and record review on 5/23/25 at 11:08 with DON, the Electronic Medical Record (EMR) for Resident 1 was reviewed. DON stated she could not find a record in the EMR that wound education was completed with Resident 1 prior to discharge. In a review of facility's policy titled Transfer or Discharge, Preparing a Resident for, dated 12/2016, the policy indicated A post-discharge plan is developed for each resident prior to his or her transfer or discharge. This plan will be reviewed with the resident, and/or his or her family, at least twenty-four (24) hours before the resident's discharge or transfer from the facility and Nursing Services is responsible for: . preparing the discharge summary and post-discharge plan . 055809 Page 2 of 2