Health inspection·May 19, 2022

F 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Level of Harm - Potential for minimal harm Based on interview and record review, the facility failed to ensure the Discharge Assessment Minimum Data Set (MDS, an assessment tool used to guide care) was completed within 14 calendar days for one of two sampled residents (Resident 53). Residents Affected - Some This failure resulted in delayed completion and submission of Resident 53's Discharge Assessment MDS. Findings: A review of Resident 53's admission Record, undated, indicated Resident 53 was admitted to the facility in 2021 with a diagnosis of respiratory failure (a condition that makes it difficult to breath on your own), and being dependent on a ventilator (a machine to assist breathing). During an interview and concurrent record review on 5/19/22, at 8:17 a.m., with the MDS Coordinator, Resident 53's MDS assessments were reviewed. The MDS Coordinator stated Resident 53 had transferred to the hospital on 1/18/22, and had not returned to the facility. The MDS Coordinator stated there had not been a Discharge Assessment MDS completed or submitted after Resident 53's discharge, which made the MDS Discharge Assessment than 107 days overdue. A review of the MDS manual, Centers of Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual, dated September 2010, indicated, For Discharge Assessment - return discharge date and Transmission Date no later than 14 days after the MDS Completion . Page 1 of 4 555809 555809 05/19/2022 All Saint's Subacute & Transitional Care 1652 Mono Avenue San Leandro, CA 94578

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. 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 ensure that one of two sampled residents (Resident 14) received the physician-ordered treatment for his pressure ulcers. (A pressure ulcer refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device, commonly known as bed sores.) Residents Affected - Few The failure to use the wound treatment ointment ordered by the physician, had the potential to result in delayed healing of Resident 14's pressure ulcers. Findings: A review of Resident 14's admission Record, dated 5/18/22, indicated Resident 14 was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus (a disorder of high blood sugar level), persistent vegetative state (absence of responsiveness and awareness), and pressure ulcers. A review of Resident 14's Minimum Data Set (MDS, an assessment tool used to guide care), dated 2/7/22, indicated Resident 14 had a Stage 3 pressure ulcer (full thickness skin loss which may extend into the subcutaneous tissue layer) and multiple Stage 4 pressure ulcers (full thickness skin and tissue loss with exposed bone, tendon, or muscle) present upon admission to the facility. A review of Resident 14's Care Plan for the Stage 4 coccyx pressure ulcer, dated 4/8/22, indicated, Administer treatments as ordered and monitor for effectiveness . A review of Resident 14's care plan for the Stage 4 right sacral pressure ulcer, dated 4/8/22, indicated, Do treatment as ordered. A review of Resident 14's Medication Administration Record (MAR) dated May 2022, indicated a physician order, start date 4/22/22, for the sacral pressure ulcer and coccyx pressure ulcer to be cleaned with normal saline (dilute saltwater solution), patted dry, triple antibiotic ointment applied, then dressed with a calcium alginate dressing. During a wound treatment observation on 5/17/22, at 9:45 a.m., in Resident 14's room, Treatment Nurse 1 (TN 1) provided wound treatment for Resident 14's pressure ulcers on the coccyx and sacral area. TN 1 removed the dressing covering both the coccyx and sacral area, cleaned the areas, applied Santyl ointment (an ointment used to assist in removal of dead tissue) to both the coccyx and sacral wounds, then covered the wounds with a calcium alginate dressing. The coccyx and sacral area pressure ulcers appeared clean, with wound beds pink in color, and no drainage. During an interview on 5/18/22 at 9:27 a.m., with TN 1, TN 1 stated Santyl ointment had been used on the coccyx and sacral pressure ulcers during the wound treatment because the previous treatment order was to apply Santyl. TN 1 stated the current order as of 4/22/22, was for triple antibiotic ointment to be applied to the coccyx and sacral wounds, but she wanted to use the Santyl because the wound still seemed deep. TN 1 stated the wound treatment physician visited Resident 14 weekly and updated the wound treatment as needed. During an interview on 5/19/22, at 9:05 a.m., the Wound Medical Doctor (MD) stated Resident 14's current wound treatment order for the coccyx and sacral area pressure ulcers was for application of triple antibiotic ointment before covering the wounds with a calcium alginate dressing. The Wound MD stated there had been a previous order to apply Santyl ointment to the pressure ulcers, but the order 555809 Page 2 of 4 555809 05/19/2022 All Saint's Subacute & Transitional Care 1652 Mono Avenue San Leandro, CA 94578

F 0686 Level of Harm - Minimal harm or potential for actual harm had been discontinued and he had ordered application of triple antibiotic ointment on 4/21/22. The Wound MD stated Santyl was a prescription ointment used to assist in the removal of dead tissue from wounds. The Wound MD stated Resident 14's wounds no longer needed the Santyl ointment because there was no dead tissue in the wound beds, so the order was changed to triple antibiotic ointment application. Residents Affected - Few 555809 Page 3 of 4 555809 05/19/2022 All Saint's Subacute & Transitional Care 1652 Mono Avenue San Leandro, CA 94578

F 0912 Level of Harm - Potential for minimal harm Residents Affected - Some Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility had six resident (Rt) rooms (Transitional care unit-TCU rooms 2, 3, 9, and North rooms 7, 12, 16) with multiple beds that provided less than 80 square feet (sq.ft) per resident who occupied these rooms. This deficient practice had the potential to result in inadequate space for the delivery of care to each of the residents in each room, or for storage of the residents' belongings. Findings: During an observation on 5/17/22, at 9:15 a.m., the following rooms and corresponding square footage (sq. ft) per bed were identified: Room Activity Room Size Floor Area TCU #2 Rt room [ROOM NUMBER].12 sq ft 77.56 sq ft/bed TCU #3 Rt room [ROOM NUMBER].12 sq ft 77.56 sq ft/bed TCU #9 Rt room [ROOM NUMBER].74 sq ft 72.87 sq ft/bed North #7 Rt room [ROOM NUMBER].5 sq ft 79.75 sq ft/bed North # 12 Rt room [ROOM NUMBER].4 sq ft 77.2 sq ft/bed North #16 Rt room [ROOM NUMBER].75 sq ft 77.9 sq ft/bed During random observations of care and services from 5/16/22 through 5/19/22, there was sufficient space for the provision of care for the residents in all rooms. There was no heavy equipment kept in the rooms that might interfere with residents' care and each resident had adequate personal space and privacy. There were no complaints from the residents regarding insufficient space for their belongings. There were no negative consequences attributed to the decreased space and/or safety concerns in the six rooms. Granting of room size waiver recommended. 555809 Page 4 of 4