Health inspection·March 11, 2024

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on interview, and record review, the facility failed to provide preventive care for pressure injury/ulcer (PI/PU, injury to skin and underlying tissue resulting from prolonged pressure) consistent with professional standards of practice for one of eight sampled residents (Resident 8) when Resident 8's physician's order of turning and repositioning every two hours was not consistently implemented. Residents Affected - Few This failure resulted in Resident 8's sacral (lower back near the crease of the buttocks) wound to get worse and had the potential for Resident 8's skin condition to get worse, develop complications, and/or possible development of other pressure related injuries. Findings: A review of Resident 8's clinical record indicated Resident 8 was admitted July of 2023 and had diagnoses that included respiratory failure (a serious condition that develops when the lungs can't get enough oxygen into the blood and makes it difficult for a person to breathe on his own), nontraumatic subdural hemorrhage (a condition where a pool of blood is formed between the brain and the skull causing structural, biochemical or electrical abnormalities in the brain), and resistance to multiple antibiotics. A review of Resident 8's admission Minimum Data Set (MDS- an assessment tool used to guide care) Cognitive Patterns, dated 7/19/23, indicated Resident 8 was rarely or never understood. A review of Resident 8's admission MDS Skin Conditions, dated 7/19/23, indicated Resident 3 was at risk of developing pressure ulcers/injuries, had zero unhealed pressure ulcers/injuries, and had moisture associated skin damage (MASD- general term for inflammation or skin erosion caused by prolonged exposure to a source of moisture such as urine, stool, sweat, wound drainage, saliva, or mucus). A review of Resident 8's Wound Management Detail Report, dated 7/14/23, indicated, Patient [Resident 8] with skin redness and multiple skin excoriation [area where the skin is scraped] in coccyx [very bottom area of the lower back], bilateral [both sides] buttocks, and bilateral groin . A review of Resident 8's physician's order, dated 8/4/23, indicated, TURNING AND REPOSITIONING EVERY 2 HOURS AND AS NEEDED Every Shift; Shift 1 07:00 AM - 03:00 PM, Shift 2 03:00 PM - 11:00 PM. Shift 3 11:00 PM - 07:00AM. The order was discontinued on 12/6/23. A review of Resident 8's Wound Management Detail Report, dated 9/27/23, indicated, Noted sacral wound open area measuring 11 x 5 cm [centimeters- unit of measurement] with irregular edges .with noted dti [deep tissue injury- a serious form of PI which presents as purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure Page 1 of 14 555533 555533 03/11/2024 Driftwood Healthcare Center - Hayward 19700 Hesperian Boulevard Hayward, CA 94541

F 0686 and/or shear] measuring 3 x 2.6 cm, no drainage, no odor, no pain . Level of Harm - Minimal harm or potential for actual harm During a concurrent interview and record review on 3/12/24 at 10:13 a.m. with the Director of Nursing (DON), Resident 8's clinical record was reviewed. The DON confirmed that there was no documentation that Resident 8 was turned and repositioned every 2 hours on the following dates and shifts: Residents Affected - Few 8/7/23- Shift 2 8/8/23- Shift 1 8/11/23- Shift 3 8/13/23- Shift 1 8/18/23- Shift 3 8/25/23- Shift 1 8/26/23- Shift 3 9/7/23- Shift 1 9/12/23- Shift 1 9/13/23- Shift 1 9/14/23- Shift 1 9/21/23- Shift 1 10/15/23- Shift 1 10/17/23- Shift 1 11/13/23- Shift 1 The DON stated Resident 8 was bedbound (patients who has become very weak and is no longer able to move easily, which made them confined to their bed) and needed turning and repositioning in bed. The DON further stated, .I know, if it's [turning and repositioning every 2 hours] not documented, it's not done .There are 4 opportunities [of turning and repositioning Resident 8] in every shift; 8 hours per shift .So the risk [if resident 8 was not turned or repositioned every 2 hours] is, because of heat and moisture, the potential for skin breakdown will increase .There are no documentations that she was refusing to be turned or repositioned. A review of Resident 8's Wound Management Detail Report, dated 10/24/23, indicated Resident 8 had an Unstageable pressure ulcer (PU-full-thickness tissue loss type of pressure injuries in which the base is obscured) on the sacrum measuring 11.7 x 13 cm, with 60% (percent- measurement of one part in every hundred) slough (a dead tissue, usually cream or yellow in color), and with moderate serosanguineous (pale red or pink, thin and watery) exudate (secretion). 555533 Page 2 of 14 555533 03/11/2024 Driftwood Healthcare Center - Hayward 19700 Hesperian Boulevard Hayward, CA 94541

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of Resident 8's hospital admission records, encounter date of 11/15/23, indicated, .MUSCULOSKELETAL [relating to muscles, bones, and other tissues that gives the body its structure, support and lets the body move]: .base of sacral decubitus [other term for PI/PU] with areas of necrosis [death of body tissue] and foul odor. Thickened surrounding skin. A review of the facility's policy and procedure (P&P) titled, Pressure Ulcer & Skin Care Management, undated, indicated, 9. The nursing staff reviews the pressure ulcer prevention and treatment procedures with the resident's physician .b. The licensed nurse implements the wound care treatment procedures in accordance with current standards of practice. 555533 Page 3 of 14 555533 03/11/2024 Driftwood Healthcare Center - Hayward 19700 Hesperian Boulevard Hayward, CA 94541

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure proper handling and delivery of respiratory care consistent with the facility's policy and procedures (P&P) and the professional standards of practice for three out of eight sampled residents (Resident 3, Resident 5, and Resident 7) when: Residents Affected - Some 1. Resident 3's nasal cannula (a medical device with two prongs that is connected to an oxygen source used to deliver supplemental oxygen directly into the nostrils) was not labeled with the date it was first used; 2. Resident 5's nasal cannula and nebulizer (machine that turns liquid medicine into a mist that can be easily inhaled) simple facemask and tubing was not labeled with the date it was initially used and Resident 5's physician's orders for oxygen therapy were not followed; and, 3. Resident 7's nasal cannula was not labeled with the date it was first used and Resident 7 had no physician's order for the use of oxygen therapy. These failures had the potential to result in unsafe and unsanitary delivery of oxygen to Resident 3, Resident 5, and Resident 7. Findings: 1. A review of Resident 3's clinical record indicated Resident 3 was admitted January of 2024 and had diagnoses that included respiratory failure (a serious condition that develops when the lungs can't get enough oxygen into the blood and makes it difficult for a person to breathe on his own), chronic obstructive pulmonary disease (COPD- a group of diseases that causes airflow blockage and breathing-related problems), and dementia (memory loss that interferes with daily functions). A review of Resident 3's Minimum Data Set (MDS- an assessment tool used to guide care) Cognitive Patterns, dated 1/23/24, indicated Resident 3 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 6 out of 15 which indicated Resident 3 had a severely impaired cognition. A review of Resident 3's MDS Special Treatments, Procedures, and Programs, dated 1/23/24, indicated Resident 3 had oxygen therapy while he is a resident in the facility. A review of Resident 3's active physician's order, dated 1/17/24, indicated, O2 [oxygen] @ [at] 5 LITERS/MINUTE [lpm- unit of measurement for oxygen administration] FOR SOB [shortness of breath] WHEEZING [a high-pitched whistling sound made while breathing which is a sign that a person may be having breathing problems] CONGESTION [sic] Q [every] SHIFT . During a concurrent observation and interview on 3/11/24 at 11:17 a.m. with Resident 3 in Resident 3's room, Resident 3 was observed using an oxygen concentrator at 5 lpm delivered via nasal cannula. Resident 3's nasal cannula was not labeled with the date of when it was first used. Resident 3 confirmed the observation. Resident 3 stated she does not know when the last time her nasal cannula was changed. During a concurrent observation and interview on 3/11/24 at 11:31 a.m. with Licensed Nurse (LN) 1 in Resident 3's room, LN 1 confirmed that Resident 3's nasal cannula was not labeled with the date it was first used. LN 1 stated, It [nasal cannula] should have the date [when it was first used] .So 555533 Page 4 of 14 555533 03/11/2024 Driftwood Healthcare Center - Hayward 19700 Hesperian Boulevard Hayward, CA 94541

F 0695 we know when to change it [nasal cannula] .It's [regularly changing nasal cannula] to prevent infection. Level of Harm - Minimal harm or potential for actual harm 2. A review of Resident 5's clinical record indicated Resident 5 was admitted February of 2024 and had diagnoses that included respiratory failure, COPD, and diabetes mellitus (a chronic condition causing too much sugar in the blood that can affect lung function and breathing). Residents Affected - Some A review of Resident 5's MDS Cognitive Patterns, dated 2/9/24, indicated Resident 5 had a BIMS score of 14 out of 15 which indicated Resident 5 had an intact cognition. A review of Resident 5's MDS Special Treatments, Procedures, and Programs, dated 2/9/24, indicated Resident 5 had oxygen therapy while he is a resident in the facility. A review of Resident 5's active physician's order, dated 2/9/24, indicated, O2 3 LPM VIA NASAL CANNULA. Special Instructions: APPLY O2 3LPM VIA NC [nasal cannula] (CONTINUES) [sic] FOR OXYGEN THERAPHY [sic] . A review of Resident 5's active physician's order, dated 2/9/24, indicated, albuterol sulfate solution [a liquid medicine used to prevent and treat symptoms caused by lung diseases which is administered via nebulizer] for nebulization .Special Instructions: Give 1 vial [a cylindrical container use for holding liquid medicines] every 6 hours as needed for SOB or wheezing . A review of Resident 5's active physician's order, dated 2/9/24, indicated, ipratropium-albuterol solution [a liquid medicine used to prevent and treat symptoms caused by lung diseases which is administered via nebulizer] for nebulization .Special Instructions: ADMINISTER 3 ML [milliliters- unit of measurement] Q 6 HOURS ATC [around the clock] FOR SOB WHEEZING CONGESTION [sic] . A review of Resident 5's active physician's order, dated 2/29/24, indicated, budesonide suspension [a liquid medicine used to prevent and treat symptoms caused by lung diseases which is administered via nebulizer] for nebulization .Special Instructions: Administer 2ml via nebulizer q 12 hours as needed for SOB WHEEZING CONGESTION [sic] . A review of Resident 5's active physician's order, dated 3/5/24, indicated, formoterol fumarate solution [a liquid medicine used to prevent and treat symptoms caused by lung diseases which is administered via nebulizer] for nebulization .Special Instructions: Administer 1 vial via nebulizer BID [twice a day] for SOB and Wheezing . During a concurrent observation and interview on 3/11/24 at 11:36 a.m. with Resident 5 in Resident 5's room, Resident 5 was observed using an oxygen concentrator at 4.5 lpm delivered via nasal cannula which was not labeled with the date it was first used. Resident 5 was also observed to be using a nebulizer for her breathing treatment delivered via simple facemask which was also not labeled with the date it was first used. Resident 3 confirmed the observation. Resident 3 stated she does not know when the last time her nasal cannula and simple facemask was changed. During a concurrent observation and interview on 3/11/24 at 11:46 a.m. with LN 2 in Resident 5's room, LN 2 confirmed that Resident 5's nasal cannula, simple facemask, and respiratory tubing were not labeled with the date it was first used. LN 2 also confirmed that Resident 5's oxygen flow rate was set at 4.5 lpm. LN 2 stated, They [nasal cannula, simple facemask, and respiratory tubing] should be labeled with paper tape .Should be labeled with date, Resident initials and room number .So we [staff] know when it [nasal cannula, simple facemask, and respiratory tubing] was last changed and who 555533 Page 5 of 14 555533 03/11/2024 Driftwood Healthcare Center - Hayward 19700 Hesperian Boulevard Hayward, CA 94541

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some is it for .[This is] To prevent infection, to make sure it ' s [nasal cannula, simple facemask, and respiratory tubing] clean. It ' s for infection control. A review of Resident 5's care plan approach, dated 1/9/24, indicated, Provide oxygen as prescribed. During a concurrent interview and record review on 3/12/24 at 8:46 a.m. with the Director of Staff Development (DSD), Resident 5's clinical records was reviewed. The DSD confirmed that Resident 5's order for oxygen therapy is at 3 lpm. The DSD stated, .We need to follow the doctors order. If it's [oxygen] given higher [than the physician's order], the risk is hyperoxygenation [a condition in which the body is exposed to an unusual high amount of oxygen causing respiratory and/or neurological problems] .It [administering higher rate of oxygen than what is ordered] will cause health problems . A review of the facility's policy and procedure (P&P) titled, Oxygen Administration, dated 12/18/23, indicated, A resident will need oxygen therapy when hypoxemia (low oxygen in blood) occurs .clinical examinations will determine the adequacy of oxygen therapy .9. Turn the unit on to the desired flow rate . 3. A review of Resident 7's clinical record indicated Resident 7 was admitted January of 2024 and had diagnoses that included heart failure (a condition in which the heart cannot pump oxygen-rich blood efficiently to the rest of the body affecting lung function and breathing), end stage renal disease (occurs when the gradual loss of kidney function reaches an advanced state where kidneys no longer work as they should to meet the body's needs), and dependence on renal dialysis (the process of removing excess water, particles, and toxins from the blood in people whose kidneys can no longer perform these functions naturally). A review of Resident 7's MDS Cognitive Patterns, dated 1/14/24, indicated Resident 7 had a BIMS score of 12 out of 15 which indicated Resident 7 had a moderately impaired cognition. During a concurrent observation and interview on 3/11/24 at 2:44 p.m. with Resident 7 in Resident 7's room, Resident 7 was observed using an oxygen concentrator at 2 lpm delivered via nasal cannula. Resident 7's nasal cannula was not labeled with the date of when it was first used. Resident 7 confirmed the observation. Resident 7 stated she does not know when the last time her nasal cannula was changed. During a concurrent observation and interview on 3/11/24 at 2:55 p.m. with Treatment Nurse (TN) in Resident 7's room, TN confirmed that Resident 7's nasal cannula was not labeled with the date it was first used. TN stated, We [staff] usually label it [nasal cannula] . we [staff] put the date, time, and initial it [nasal cannula] .For infection control. During a concurrent interview and record review on 3/11/24 at 4:36 p.m. with the Infection Preventionist (IP), Resident 7's clinical records were reviewed. The IP confirmed that there was no physician's order for Resident 7's use of oxygen therapy. The IP stated, It ' s [not having a physicians order for oxygen therapy] not safe .we always need to have a doctor's order [for oxygen therapy] as a standard of practice. During an interview on 3/12/24 at 10:13 a.m. with the Director of Nursing (DON), the DON stated, .[My] expectation is to change it [nasal cannula, simple facemask, and respiratory care tubing] every week .Label it [nasal cannula, simple facemask, and respiratory care tubing] with date, time, and nurse initial .It ' s infection control risk if it's [nasal cannula, simple facemask, and respiratory 555533 Page 6 of 14 555533 03/11/2024 Driftwood Healthcare Center - Hayward 19700 Hesperian Boulevard Hayward, CA 94541

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some care tubing] not changed every week. The DON also stated, .if the resident needs it [oxygen therapy], there should be an order before the resident receives it [oxygen therapy]. Whoever applied the oxygen should communicate with their supervisor to ensure that the order [for oxygen therapy] is there . The DON further stated, .[I] expect it [physician's order for oxygen therapy] to be followed .To ensure the correct [oxygen] regulation is given [to the resident]. If it ' s [oxygen therapy delivery] higher [than what is ordered], it could cause hyperoxygenation and it could result to respiratory problems . A review of the Centers for Medicare and Medicaid Services (CMS) document titled, Respiratory Therapy (Respiratory Care), revised 7/22/21, indicated, There must be a specific written order by the physician for all respiratory therapy (respiratory care) services. (https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?LCDId=34430) A review of the facility's P&P titled, Care and Handling of Respiratory Equipment, undated, indicated, Care should be exercised in handling respiratory equipment to prevent contamination .5. Equipment should be changed based on the following schedule: a. Change within every seven days .Cannula and humidifier, Simple facemask, Oxygen tubing . Based on observation, interview, and record review, the facility failed to ensure proper handling and delivery of respiratory care consistent with the facility's policy and procedures (P&P) and the professional standards of practice for three out of eight sampled residents (Resident 3, Resident 5, and Resident 7) when: 1. Resident 3's nasal cannula (a medical device with two prongs that is connected to an oxygen source used to deliver supplemental oxygen directly into the nostrils) was not labeled with the date it was first used; 2. Resident 5's nasal cannula and nebulizer (machine that turns liquid medicine into a mist that can be easily inhaled) simple facemask and tubing was not labeled with the date it was initially used and Resident 5's physician's orders for oxygen therapy were not followed; and, 3. Resident 7's nasal cannula was not labeled with the date it was first used and Resident 7 had no physician's order for the use of oxygen therapy. These failures had the potential to result in unsafe and unsanitary delivery of oxygen to Resident 3, Resident 5, and Resident 7. Findings: 1. A review of Resident 3's clinical record indicated Resident 3 was admitted January of 2024 and had diagnoses that included respiratory failure (a serious condition that develops when the lungs can't get enough oxygen into the blood and makes it difficult for a person to breathe on his own), chronic obstructive pulmonary disease (COPD- a group of diseases that causes airflow blockage and breathing-related problems), and dementia (memory loss that interferes with daily functions). A review of Resident 3's Minimum Data Set (MDS- an assessment tool used to guide care) Cognitive Patterns, dated 1/23/24, indicated Resident 3 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 6 out of 15 which indicated Resident 3 had a severely impaired cognition. A review of Resident 3's MDS Special Treatments, Procedures, and Programs, dated 1/23/24, 555533 Page 7 of 14 555533 03/11/2024 Driftwood Healthcare Center - Hayward 19700 Hesperian Boulevard Hayward, CA 94541

F 0695 indicated Resident 3 had oxygen therapy while he is a resident in the facility. Level of Harm - Minimal harm or potential for actual harm A review of Resident 3's active physician's order, dated 1/17/24, indicated, O2 [oxygen] @ [at] 5 LITERS/MINUTE [lpm- unit of measurement for oxygen administration] FOR SOB [shortness of breath] WHEEZING [a high-pitched whistling sound made while breathing which is a sign that a person may be having breathing problems] CONGESTION [sic] Q [every] SHIFT . Residents Affected - Some During a concurrent observation and interview on 3/11/24 at 11:17 a.m. with Resident 3 in Resident 3's room, Resident 3 was observed using an oxygen concentrator at 5 lpm delivered via nasal cannula. Resident 3's nasal cannula was not labeled with the date of when it was first used. Resident 3 confirmed the observation. Resident 3 stated she does not know when the last time her nasal cannula was changed. During a concurrent observation and interview on 3/11/24 at 11:31 a.m. with Licensed Nurse (LN) 1 in Resident 3's room, LN 1 confirmed that Resident 3's nasal cannula was not labeled with the date it was first used. LN 1 stated, It [nasal cannula] should have the date [when it was first used] .So we know when to change it [nasal cannula] .It's [regularly changing nasal cannula] to prevent infection. 2. A review of Resident 5's clinical record indicated Resident 5 was admitted February of 2024 and had diagnoses that included respiratory failure, COPD, and diabetes mellitus (a chronic condition causing too much sugar in the blood that can affect lung function and breathing). A review of Resident 5's MDS Cognitive Patterns, dated 2/9/24, indicated Resident 5 had a BIMS score of 14 out of 15 which indicated Resident 5 had an intact cognition. A review of Resident 5's MDS Special Treatments, Procedures, and Programs, dated 2/9/24, indicated Resident 5 had oxygen therapy while he is a resident in the facility. A review of Resident 5's active physician's order, dated 2/9/24, indicated, O2 3 LPM VIA NASAL CANNULA. Special Instructions: APPLY O2 3LPM VIA NC [nasal cannula] (CONTINUES) [sic] FOR OXYGEN THERAPHY [sic] . A review of Resident 5's active physician's order, dated 2/9/24, indicated, albuterol sulfate solution [a liquid medicine used to prevent and treat symptoms caused by lung diseases which is administered via nebulizer] for nebulization .Special Instructions: Give 1 vial [a cylindrical container use for holding liquid medicines] every 6 hours as needed for SOB or wheezing . A review of Resident 5's active physician's order, dated 2/9/24, indicated, ipratropium-albuterol solution [a liquid medicine used to prevent and treat symptoms caused by lung diseases which is administered via nebulizer] for nebulization .Special Instructions: ADMINISTER 3 ML [milliliters- unit of measurement] Q 6 HOURS ATC [around the clock] FOR SOB WHEEZING CONGESTION [sic] . A review of Resident 5's active physician's order, dated 2/29/24, indicated, budesonide suspension [a liquid medicine used to prevent and treat symptoms caused by lung diseases which is administered via nebulizer] for nebulization .Special Instructions: Administer 2ml via nebulizer q 12 hours as needed for SOB WHEEZING CONGESTION [sic] . A review of Resident 5's active physician's order, dated 3/5/24, indicated, formoterol fumarate solution [a liquid medicine used to prevent and treat symptoms caused by lung diseases which is 555533 Page 8 of 14 555533 03/11/2024 Driftwood Healthcare Center - Hayward 19700 Hesperian Boulevard Hayward, CA 94541

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some administered via nebulizer] for nebulization .Special Instructions: Administer 1 vial via nebulizer BID [twice a day] for SOB and Wheezing . During a concurrent observation and interview on 3/11/24 at 11:36 a.m. with Resident 5 in Resident 5's room, Resident 5 was observed using an oxygen concentrator at 4.5 lpm delivered via nasal cannula which was not labeled with the date it was first used. Resident 5 was also observed to be using a nebulizer for her breathing treatment delivered via simple facemask which was also not labeled with the date it was first used. Resident 3 confirmed the observation. Resident 3 stated she does not know when the last time her nasal cannula and simple facemask was changed. During a concurrent observation and interview on 3/11/24 at 11:46 a.m. with LN 2 in Resident 5's room, LN 2 confirmed that Resident 5's nasal cannula, simple facemask, and respiratory tubing were not labeled with the date it was first used. LN 2 also confirmed that Resident 5's oxygen flow rate was set at 4.5 lpm. LN 2 stated, They [nasal cannula, simple facemask, and respiratory tubing] should be labeled with paper tape .Should be labeled with date, Resident initials and room number .So we [staff] know when it [nasal cannula, simple facemask, and respiratory tubing] was last changed and who is it for .[This is] To prevent infection, to make sure it's [nasal cannula, simple facemask, and respiratory tubing] clean. It's for infection control. A review of Resident 5's care plan approach, dated 1/9/24, indicated, Provide oxygen as prescribed. During a concurrent interview and record review on 3/12/24 at 8:46 a.m. with the Director of Staff Development (DSD), Resident 5's clinical records was reviewed. The DSD confirmed that Resident 5's order for oxygen therapy is at 3 lpm. The DSD stated, .We need to follow the doctors order. If it's [oxygen] given higher [than the physician's order], the risk is hyperoxygenation [a condition in which the body is exposed to an unusual high amount of oxygen causing respiratory and/or neurological problems] .It [administering higher rate of oxygen than what is ordered] will cause health problems . A review of the facility's policy and procedure (P&P) titled, Oxygen Administration, dated 12/18/23, indicated, A resident will need oxygen therapy when hypoxemia (low oxygen in blood) occurs .clinical examinations will determine the adequacy of oxygen therapy .9. Turn the unit on to the desired flow rate . 3. A review of Resident 7's clinical record indicated Resident 7 was admitted January of 2024 and had diagnoses that included heart failure (a condition in which the heart cannot pump oxygen-rich blood efficiently to the rest of the body affecting lung function and breathing), end stage renal disease (occurs when the gradual loss of kidney function reaches an advanced state where kidneys no longer work as they should to meet the body's needs), and dependence on renal dialysis (the process of removing excess water, particles, and toxins from the blood in people whose kidneys can no longer perform these functions naturally). A review of Resident 7's MDS Cognitive Patterns, dated 1/14/24, indicated Resident 7 had a BIMS score of 12 out of 15 which indicated Resident 7 had a moderately impaired cognition. During a concurrent observation and interview on 3/11/24 at 2:44 p.m. with Resident 7 in Resident 7's room, Resident 7 was observed using an oxygen concentrator at 2 lpm delivered via nasal cannula. Resident 7's nasal cannula was not labeled with the date of when it was first used. Resident 7 confirmed the observation. Resident 7 stated she does not know when the last time her nasal cannula was changed. 555533 Page 9 of 14 555533 03/11/2024 Driftwood Healthcare Center - Hayward 19700 Hesperian Boulevard Hayward, CA 94541

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a concurrent observation and interview on 3/11/24 at 2:55 p.m. with Treatment Nurse (TN) in Resident 7's room, TN confirmed that Resident 7's nasal cannula was not labeled with the date it was first used. TN stated, We [staff] usually label it [nasal cannula] . we [staff] put the date, time, and initial it [nasal cannula] .For infection control. During a concurrent interview and record review on 3/11/24 at 4:36 p.m. with the Infection Preventionist (IP), Resident 7's clinical records were reviewed. The IP confirmed that there was no physician's order for Resident 7's use of oxygen therapy. The IP stated, It's [not having a physicians order for oxygen therapy] not safe .we always need to have a doctor's order [for oxygen therapy] as a standard of practice. During an interview on 3/12/24 at 10:13 a.m. with the Director of Nursing (DON), the DON stated, .[My] expectation is to change it [nasal cannula, simple facemask, and respiratory care tubing] every week .Label it [nasal cannula, simple facemask, and respiratory care tubing] with date, time, and nurse initial .It's infection control risk if it's [nasal cannula, simple facemask, and respiratory care tubing] not changed every week. The DON also stated, .if the resident needs it [oxygen therapy], there should be an order before the resident receives it [oxygen therapy]. Whoever applied the oxygen should communicate with their supervisor to ensure that the order [for oxygen therapy] is there . The DON further stated, .[I] expect it [physician's order for oxygen therapy] to be followed .To ensure the correct [oxygen] regulation is given [to the resident]. If it's [oxygen therapy delivery] higher [than what is ordered], it could cause hyperoxygenation and it could result to respiratory problems . A review of the Centers for Medicare and Medicaid Services (CMS) document titled, Respiratory Therapy (Respiratory Care), revised 7/22/21, indicated, There must be a specific written order by the physician for all respiratory therapy (respiratory care) services. (https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?LCDId=34430) A review of the facility's P&P titled, Care and Handling of Respiratory Equipment, undated, indicated, Care should be exercised in handling respiratory equipment to prevent contamination .5. Equipment should be changed based on the following schedule: a. Change within every seven days .Cannula and humidifier, Simple facemask, Oxygen tubing . 555533 Page 10 of 14 555533 03/11/2024 Driftwood Healthcare Center - Hayward 19700 Hesperian Boulevard Hayward, CA 94541

F 0880 Provide and implement an infection prevention and control program. 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 follow and maintain an effective infection prevention and control program for a census of 78 residents when: Residents Affected - Some 1. Three facility staff entered a contact isolation precaution room (an isolation precaution implemented when a patient infected with a bacteria, virus, or other microorganism which is transmittable through direct or indirect contact with the patient or the patient ' s environment) without using all the required personal protective equipment (PPE); and, 2. Resident 3 and Resident 7's nasal cannula, and Resident 5's respiratory care tubing were not labeled with the date it was initially used. These failures resulted in an increased risk for cross-contamination (movement or transfer of harmful bacteria from one person, object, or place to another), potential exposure of Resident 3, Resident 7, and Resident 5 to germs, and may cause infection among residents, staff, and visitors. Findings: 1. During an observation on 3/11/24 at 12:58 p.m., room [ROOM NUMBER] had a red STOP sign posted on the left side of the door which indicated, CONTACT PRECAUTIONS. EVERYONE MUST: Clean their hands, including before entering and when leaving the room. PROVIDERS AND STAFF MUST ALSO: Put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. Do not wear the same gown and gloves for the care of more than one person. Use dedicated or disposable equipment. Clean and disinfect reusable equipment before use on another patient. Below the STOP sign was also a signage which indicated, SEQUENCE FOR PUTTING ON PERSONAL PROTECTIVE EQUIPMENT (PPE) . 1. GOWN . 2. MASK OR RESPIRATOR . 3. GOGGLES OR FACE SHIELD . 4. GLOVES . Certified Nurse Assistant (CNA) 3 was observed entering room [ROOM NUMBER] only wearing facemask. During a concurrent observation and interview on 3/11/24 at 1:01 p.m. with Certified Nursing Assistant (CNA) 3, in front of room [ROOM NUMBER], CNA 3 confirmed that she entered room [ROOM NUMBER] and provided care to resident in bed A while only wearing facemask. CNA 3 stated she was aware that the residents in room [ROOM NUMBER] were on contact isolation precaution and she knows about the sign posted at the door that everyone needs to wear gloves and gown before entering the room. CNA 3 further stated, .The risk [of not wearing the required PPE] is I might get infected During an observation on 3/11/24 at 4:20 p.m. in front of room [ROOM NUMBER], a male facility staff, wearing navy blue scrub suit, was observed entering room [ROOM NUMBER] wearing only facemask. The staff talked to Resident in bed A, touched the bed rails and personal items of the resident in bed A. During a concurrent interview and record review on 3/11/24 at 4:36 p.m. with the Infection Preventionist (IP), the IP confirmed that room [ROOM NUMBER] was on contact isolation precaution and the resident in bed A was incontinent. The IP stated she would expect that everyone going inside room [ROOM NUMBER] to wear the required PPE such as gloves and gown, especially when doing patient care to the residents. The IP further stated, . [Staff entering room [ROOM NUMBER] should wear gloves and gown] Because they [staff] might get infected, and they [staff] can give it [infection] to other staff or residents . 555533 Page 11 of 14 555533 03/11/2024 Driftwood Healthcare Center - Hayward 19700 Hesperian Boulevard Hayward, CA 94541

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 3/12/24 at 10:13 a.m. with the Director of Nursing (DON), the DON stated, .[I] expect the [contact isolation precaution] signage [posted on the door] should be followed .Donning [putting on] and doffing [removing] of the [required] PPE .They [staff] should do hand hygiene, wear gloves and gown when entering the room [room [ROOM NUMBER]] and doing patient care . [staff should] Do another donning and doffing every time the staff re-enters the room [room [ROOM NUMBER]] .The risk [of not wearing the required PPE] is they [staff] can get it [infection] and spread it [infection]. During a concurrent observation and interview on 3/12/24 at 11:39 a.m. with Licensed Nurse (LN) 3, in front of room [ROOM NUMBER], LN 3 was observed coming out from room [ROOM NUMBER] wearing only facemask and gloves. LN 3 confirmed that he entered room [ROOM NUMBER] and provided care to resident in bed A while only wearing facemask and gloves. LN 3 stated he was aware that the residents in room [ROOM NUMBER] were on contact isolation and knows that he should wear both gloves and gown before entering room [ROOM NUMBER]. LN 3 stated, Yes, I am supposed to wear gown too .It ' s [wearing the required PPE] for infection control. A review of the facility's policy and procedure (P&P) titled, Transmission Precautions: Contact, dated 4/7/23, indicated, 2. Gloves and Hand Hygiene. Wear clean, non-sterile gloves when entering the room .Do this to avoid transfer of microorganisms to other residents or environments. 3. Gowns. Wear a clean, non-sterile gown upon entering the resident's room if you anticipate substantial contact between your clothing and the resident, environmental surfaces, or items in the room. Wear gown if the resident is incontinent . 2a. A review of Resident 3's clinical record indicated Resident 3 was admitted January of 2024 and had diagnoses that included respiratory failure (a serious condition that develops when the lungs can't get enough oxygen into the blood and makes it difficult for a person to breathe on his own), chronic obstructive pulmonary disease (COPD- a group of diseases that causes airflow blockage and breathing-related problems), and dementia (memory loss that interferes with daily functions). A review of Resident 3's Minimum Data Set (MDS- an assessment tool used to guide care) Cognitive Patterns, dated 1/23/24, indicated Resident 3 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 6 out of 15 which indicated Resident 3 had a severely impaired cognition. A review of Resident 3's MDS Special Treatments, Procedures, and Programs, dated 1/23/24, indicated Resident 3 had oxygen therapy while he is a resident in the facility. A review of Resident 3's active physician's order, dated 1/17/24, indicated, O2 [oxygen] @ [at] 5 LITERS/MINUTE [lpm- unit of measurement for oxygen administration] FOR SOB [shortness of breath] WHEEZING [a high-pitched whistling sound made while breathing which is a sign that a person may be having breathing problems] CONGESTION [sic] Q [every] SHIFT . During a concurrent observation and interview on 3/11/24 at 11:17 a.m. with Resident 3 in Resident 3's room, Resident 3 was observed using an oxygen concentrator at 5 lpm delivered via nasal cannula. Resident 3's nasal cannula was not labeled with the date of when it was first used. Resident 3 confirmed the observation. Resident 3 stated she does not know when the last time her nasal cannula was changed. During a concurrent observation and interview on 3/11/24 at 11:31 a.m. with Licensed Nurse (LN) 1 in Resident 3's room, LN 1 confirmed that Resident 3's nasal cannula was not labeled with the date it was first used. LN 1 stated, It [nasal cannula] should have the date [when it was first used] .So 555533 Page 12 of 14 555533 03/11/2024 Driftwood Healthcare Center - Hayward 19700 Hesperian Boulevard Hayward, CA 94541

F 0880 we know when to change it [nasal cannula] .It ' s [regularly changing nasal cannula] to prevent infection. Level of Harm - Minimal harm or potential for actual harm 2b. A review of Resident 7's clinical record indicated Resident 7 was admitted January of 2024 and had diagnoses that included heart failure (a condition in which the heart cannot pump oxygen-rich blood efficiently to the rest of the body affecting lung function and breathing), end stage renal disease (occurs when the gradual loss of kidney function reaches an advanced state where kidneys no longer work as they should to meet the body's needs), and dependence on renal dialysis (the process of removing excess water, particles, and toxins from the blood in people whose kidneys can no longer perform these functions naturally). Residents Affected - Some A review of Resident 7's MDS Cognitive Patterns, dated 1/14/24, indicated Resident 7 had a BIMS score of 12 out of 15 which indicated Resident 7 had a moderately impaired cognition. During a concurrent observation and interview on 3/11/24 at 2:44 p.m. with Resident 7 in Resident 7's room, Resident 7 was observed using an oxygen concentrator at 2 lpm delivered via nasal cannula. Resident 7's nasal cannula was not labeled with the date of when it was first used. Resident 7 confirmed the observation. Resident 7 stated she does not know when the last time her nasal cannula was changed. During a concurrent observation and interview on 3/11/24 at 2:55 p.m. with Treatment Nurse (TN) in Resident 7's room, TN confirmed that Resident 7's nasal cannula was not labeled with the date it was first used. TN stated, We [staff] usually label it [nasal cannula] . we [staff] put the date, time, and initial it [nasal cannula] .For infection control. 2c. A review of Resident 5's clinical record indicated Resident 5 was admitted February of 2024 and had diagnoses that included respiratory failure, COPD, and diabetes mellitus (a chronic condition causing too much sugar in the blood that can affect lung function and breathing). A review of Resident 5's MDS Cognitive Patterns, dated 2/9/24, indicated Resident 5 had a BIMS score of 14 out of 15 which indicated Resident 5 had an intact cognition. A review of Resident 5's MDS Special Treatments, Procedures, and Programs, dated 2/9/24, indicated Resident 5 had oxygen therapy while he is a resident in the facility. A review of Resident 5's active physician's order, dated 2/9/24, indicated, O2 3 LPM VIA NASAL CANNULA. Special Instructions: APPLY O2 3LPM VIA NC [nasal cannula] (CONTINUES) [sic] FOR OXYGEN THERAPHY [sic] . A review of Resident 5's active physician's order, dated 2/9/24, indicated, albuterol sulfate solution [a liquid medicine used to prevent and treat symptoms caused by lung diseases which is administered via nebulizer] for nebulization .Special Instructions: Give 1 vial [a cylindrical container use for holding liquid medicines] every 6 hours as needed for SOB or wheezing . A review of Resident 5's active physician's order, dated 2/9/24, indicated, ipratropium-albuterol solution [a liquid medicine used to prevent and treat symptoms caused by lung diseases which is administered via nebulizer] for nebulization .Special Instructions: ADMINISTER 3 ML [milliliters- unit of measurement] Q 6 HOURS ATC [around the clock] FOR SOB WHEEZING CONGESTION [sic] . A review of Resident 5's active physician's order, dated 2/29/24, indicated, budesonide suspension 555533 Page 13 of 14 555533 03/11/2024 Driftwood Healthcare Center - Hayward 19700 Hesperian Boulevard Hayward, CA 94541

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some [a liquid medicine used to prevent and treat symptoms caused by lung diseases which is administered via nebulizer] for nebulization .Special Instructions: Administer 2ml via nebulizer q 12 hours as needed for SOB WHEEZING CONGESTION [sic] . A review of Resident 5's active physician's order, dated 3/5/24, indicated, formoterol fumarate solution [a liquid medicine used to prevent and treat symptoms caused by lung diseases which is administered via nebulizer] for nebulization .Special Instructions: Administer 1 vial via nebulizer BID [twice a day] for SOB and Wheezing . During a concurrent observation and interview on 3/11/24 at 11:36 a.m. with Resident 5 in Resident 5's room, Resident 5 was observed using an oxygen concentrator at 4.5 lpm delivered via nasal cannula which was not labeled with the date it was first used. Resident 5 was also observed to be using a nebulizer for her breathing treatment delivered via simple facemask which was also not labeled with the date it was first used. Resident 3 confirmed the observation. Resident 3 stated she does not know when the last time her nasal cannula and simple facemask was changed. During a concurrent observation and interview on 3/11/24 at 11:46 a.m. with LN 2 in Resident 5's room, LN 2 confirmed that Resident 5's nasal cannula, simple facemask, and respiratory tubing were not labeled with the date it was first used. LN 2 stated, They [nasal cannula, simple facemask, and respiratory tubing] should be labeled with paper tape .Should be labeled with date, Resident initials and room number .So we [staff] know when it [nasal cannula, simple facemask, and respiratory tubing] was last changed and who is it for .[This is] To prevent infection, to make sure it ' s [nasal cannula, simple facemask, and respiratory tubing] clean. It ' s for infection control. During an interview on 3/12/24 at 10:13 a.m. with the Director of Nursing (DON), the DON stated, .[My] expectation is to change it [nasal cannula, simple facemask, and respiratory care tubing] every week .Label it [nasal cannula, simple facemask, and respiratory care tubing] with date, time, and nurse initial .It ' s infection control risk if it's [nasal cannula, simple facemask, and respiratory care tubing] not changed every week. A review of the facility's P&P titled, Care and Handling of Respiratory Equipment, undated, indicated, Care should be exercised in handling respiratory equipment to prevent contamination .5. Equipment should be changed based on the following schedule: a. Change within every seven days .Cannula and humidifier, Simple facemask, Oxygen tubing . 555533 Page 14 of 14