Health inspection·October 9, 2024

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure two of three sampled residents (Resident 1 and Resident 3), received the necessary services to maintain good grooming, and personal hygiene when they were not receiving showers consistently and as scheduled. Residents Affected - Few This failure resulted in these residents being unhappy and facility not meeting their physical, mental, and psychological needs. Findings: During a review of Resident 1's face sheet, the face sheet indicated, Resident 1 was admitted to the facility with diagnoses that included Diabetes (a long-term (chronic) disease in which the body cannot regulate the amount of sugar in the blood), severe obesity, generalized weakness, and depression. During a review of Resident 1's Minimum Data Set (MDS, an assessment tool used to guide care), dated 7/21/24, the MDS indicated, a Brief Interview Mental Status (BIMS, a brief scanner to help detect cognitive impairment) score of 15 indicating no cognitive impairment. The MDS also indicated, Resident 1 required substantial/maximal assistance from staff for showers/bathing. During a review of Resident 2's face sheet, the face sheet indicated, Resident 2 was admitted to the facility with diagnoses that included paraplegia (leg paralysis), muscle weakness, and sepsis (the body's extreme response to an infection). During a review of Resident 2's MDS dated [DATE], the MDS indicated, a BIMS score of 15 indicating no cognitive impairment. The MDS also indicated, Resident 1 required staff supervision or touching assistance for showers/bathing. During an interview on 10/9/24 at 11:30 a.m., with Resident 1, Resident 1 stated he was supposed to be getting a shower twice a week (Mondays and Thursdays) but getting it once every three weeks and that is so upsetting to him and he had to fight staff before he could get one, and before he could get a basin for bath. During an interview on 10/9/24 at 11:36 a.m., with Resident 3, Resident 3 stated he needed to remind staff multiple times before he could get his showers. During an interview on 10/9/24 at 12 p.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated all residents have a sponge bath every day and showers twice a week. CNA 1 stated they have a shower Page 1 of 4 056359 056359 10/09/2024 San Pablo Healthcare & Wellness Center 13328 San Pablo Avenue San Pablo, CA 94806

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few schedule that they follow. CNA 1 stated they chart the showers and the bed baths in the computer that is attached on the wall and have the shower book for those staff who do not have an ID for the computer access such as new CNA or orientee. During a review of facility's shower schedule document, the shower schedule indicated Resident 1's shower days are Mondays and Thursdays. During a review of the facility's shower flowsheet record for Resident 1 titled, Bathing: Type dated look back 30 days, from 9/1/24 to 10/3/24, the shower flowsheet indicated, checkmarks indicating Resident 1 had a shower on 9/12/24(Thursday) indicating once in that week, 9/16/24(Monday) indicating once in that week; and no indication of a shower for the last two weeks in September until 10/3/24 (Thursday) when he had shower indicating once in that week. No indication for showers on 9/19/24(Thursday), 9/23/24(Monday), and 9/26 /24(Thursday or other days of those weeks. The flowsheet did not indicate any check mark for Resident refused or Resident not available and the spaces were blank. During a review of facility's shower schedule document, the shower schedule indicated, Resident 3's shower days are Tuesdays and Fridays. During a review of Resident 3's shower flowsheet record, look back 30 days from 9/11/24 to 10/6/24, the shower flowsheet indicated checkmarks for 9/25/24(Wednesday) once for that week, and for 10/4/24(Friday) once for that week, indicating Resident 2 only received shower on those two times in 30 days. The shower flowsheet did not indicate any checkmarks for the weeks from 9/11/24 to 9/23/24 and no checkmarks indicated that Resident 2 refused or unavailable. During a telephone interview on 10/10/24 at 2:15 p.m., with the Director of Nursing (DON), the DON stated they always follow the schedule for showers unless the resident refuses. DON stated for showers, it didn't matter if showers are done in AM (morning) or PM (evening), no specific shift and sometimes the scheduled days may change but each resident should have their shower twice a week. DON was unable to state the reason or provide any documents that indicated a refusal or other reasons for the missed shower days for Resident 1 and 3. During a review of the facility's policy and procedure (P&P) titled,Showering and Bathing, dated January 1, 2012, the P& P indicated, Purpose: A tub or shower bath is given to the residents to provide cleanliness, comfort and to prevent body odors . A review of the facility's P&P titled Resident Rights - Quality of Life, dated March 2017 indicated, Purpose: To ensure that each resident received the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being. 056359 Page 2 of 4 056359 10/09/2024 San Pablo Healthcare & Wellness Center 13328 San Pablo Avenue San Pablo, CA 94806

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation, interview and record review, the facility failed to maintain the physical environment in accordance with standards of practice, when one resident room and the bathroom used by five residents was not clean. This failure did not ensure residents were provided with a clean, sanitary, and comfortable environment. Findings: During an observation on 10/9/24 at 11 a.m., in Resident 1 and 3 ' s bathroom, the bathroom appeared dirty. Over the toilet bowl a raised toilet seat with arms was placed. Inside the toilet bowl, there were dried scattered brown/black substance around its upper surface and some around the raised toilet seat over it. The toilet bowl had yellowish liquid inside which appeared like urine still sitting there not flushed. There was trash can with no trash liner and looked dirty inside. The bathroom floor appeared dirty. During an interview on 10/9/24 at 11:05 a.m., with Resident 2, Resident 2 stated, they don ' t clean the bathroom unless you call them. Resident 2 stated the bathroom is always like that unless they call the housekeeping to clean it. During an observation on 10/9/24 at 11:11 a.m. in residents 1 & 3 ' s room, the room floor appeared dirty, not swept, and with scratches/marks on the floor. During an interview on 10/9/24 at 11:36 a.m., with Resident 3, Resident 3 stated they don ' t clean the bathroom and anytime he used it, he had to clean it himself because it is always dirty. Resident 3 stated the room is always dirty as well. During a concurrent observation and interview on 10/9/24 at 12:12 p.m., with Certified Nursing Assistant (CNA) 1, CNA 1 acknowledged the bathroom is dirty. CNA stated the dirt around the toilet bowl looked old and did not look new. CNA 1 wore gloves and flushed the toilet, and stated she was flushing off the urine. During an interview on 10/9/24 at around 12:40 p.m., Housekeeping Supervisor (HKS) confirmed that the bathroom was not clean and did not look good. HKS confirmed room was not yet mopped. During an interview on 10/9/24 at 2:30 p.m., with the Infection Preventionist (IP), the IP stated the bathrooms need to be cleaned and sanitized 24 hrs. seven days a week, and the rooms and bathrooms are expected to be clean all the time. During an interview on 10/9/24 at 3:05 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated six residents in the two rooms shared the bathroom, and five out of the six residents did go to the bathroom to use it. During a telephone interview on 10/10/24 at 10:42 a.m., with the Director of Nursing (DON), the DON stated it is expected of all staff disciplines to ensure residents ' rooms and bathrooms are always clean and not pose any threat or risk to patients. DON stated if it is dirty and needed to be 056359 Page 3 of 4 056359 10/09/2024 San Pablo Healthcare & Wellness Center 13328 San Pablo Avenue San Pablo, CA 94806

F 0921 cleaned immediately. Level of Harm - Minimal harm or potential for actual harm During a review of the facility ' s policy and procedure (P&P) titled, Resident Rooms and Environment and Housekeeping – Restrooms and Showers dated January 1, 2012, the P&P indicated, to provide residents with a safe, clean, comfortable and homelike environment .to promote the health of residents and staff by maintaining clean and sanitary conditions .Restrooms: empty, clean, and reline wastebaskets, clean thoroughly all surfaces of toilet .make sure all rust or other stains are removed .sweep and mop floor The P&P dated September 2016 titled Housekeeping – Resident rooms indicated, .The floor is swept or vacuumed. The floor is damp mopped with disinfectant solution . Residents Affected - Few 056359 Page 4 of 4