Health inspection·October 13, 2022

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 two of 12 residents (Resident 5, Resident 113) received services according to national standards to prevent and/or promote healing of pressure ulcers (tissue damage because of pressure injury) when: Residents Affected - Some 1. Nursing staff failed to use standardized techniques to assess, measure, and document Resident 5's pressure ulcers. (A pressure ulcer develops when one or more layers of skin and tissue are damaged because of continuous pressure to the area. The depth of skin and tissue damage determines the stage of the pressure ulcer, which is on a scale of stage I to stage IV, with stage I the most superficial, and stage IV the deepest ulcer, including damaged skin and muscle down to the level of bone. A pressure ulcer presenting with a covering of dead tissue (slough or eschar) at the bottom of the wound prevents assessment of the actual depth of the pressure ulcer and is graded as unstageable.) 2. Nursing staff failed to provide foam boots per physician order to prevent pressure ulcer development on Resident 113's heels. These failures resulted in variable description and measurements of Resident 5's pressure ulcer by different staff which impaired the ability to recognize if the pressure ulcer was improving or deteriorating and impaired wound treatment evaluation and had the potential to result in pressure ulcer development on Resident 113's heels. Findings: 1. A review of Resident 5's face sheet, indicated Resident 5 was admitted in August 2022 with diagnoses of Stage 2 pressure injury (Stage 2 Pressure Injury: Partial-thickness skin loss with exposure of the lower layer of skin, the dermis. The wound bed is pink or red, moist, and still living tissue. The wound may also present as an intact or ruptured serum-filled blister.), and a stroke (obstructed blood flow to the brain causes brain damage) with resultant paralysis of the right side of his body, swallowing difficulties, and respiratory failure. During a review of the facility's Minimum Data Set (MDS- an assessment tool used to direct the residents plan of care), dated 8/24/22, the MDS indicated Resident 5 was admitted with one Stage 2 Pressure Injury (A stage 2 ulcer has partial-thickness skin loss, but no exposure to the level of fat or muscle.) and two unstageable wounds. The MDS indicated one of the unstageable pressure ulcers was a suspected, still evolving, deep tissue injury (An injury resulting from intense and/or prolonged pressure and shear forces at the bone-muscle interface.) During a review of the facility's Braden Scale Observation/Assessment (BSOA), dated 8/25/22, the Page 1 of 7 555879 555879 10/13/2022 All Saint's Maubert 15731 Maubert Avenue San Leandro, CA 94578

F 0686 BSOA scored Resident 5 at 11. 10-12 Indicated High Risk. Level of Harm - Minimal harm or potential for actual harm During a review of Resident 5's, Nursing Admission/readmission Assessment, dated 8/24/22, by Registered Nurse 4 (RN 4), the Assessment indicated RN 4 documented presence of: Residents Affected - Some 1. a popped blister on the left iliac crest (rear) [backside of the top of the hip bone] which measured (length by width by depth by Stage) 1.5 centimeters (cm) by 1 cm by NA (not applicable). 2. pressure injury on the sacrococcyx (the combined area of the tailbone and the area above the tailbone above the buttocks) which measured 11 cm by 5 cm by 1 cm, Stage 3. During a review of the Nursing Weekly Wound Evaluation Sheet, dated 10/11/22, the Wound Evaluation Sheet indicated the wound measurements should be documented in centimeters (cm) and the order of length (L) by (x) width (W) x depth (D), Stage or Unable To Determine (UTD). The Wound Evaluation Sheet indicated the following measurements: R (right) Sacral (aka sacrum, bony area above the tailbone) Pressure Wound: 8/25/22- no documentation 9/1/22- 3 cm x 2.0 cm x UTD, unstageable, by Registered Nurse 5 (RN 5) 9/8/22- 3.8 cm x 2.5 cm x 0.6 cm, Stage IV, by RN 5 9/15/22- 3 cm x 2.0 cm x 0.7 cm, Stage IV, by RN 5 9/21/22- 3.5 cm x 1.5 cm x 0.5 cm, Stage IV, by Registered Nurse 3 (RN 3) 9/22/22- 3.5cm X 1.5 cm x .5 cm, Stage IV, by Registered Nurse 6 (RN 6) 9/29/22- 4 cm x 2.0 cm x 0.5 cm, unstageable, by RN 5 10/6/22- 2.5 cmx 2.5 cm x UTD, unstageable, by RN 5 Sacrococcyx (the combined area of sacrum and tailbone) Pressure Wound: 8/24/22- 11 cm x 5 cm x 1 cm, Stage 3, by RN 5 9/1/22- 4.5 cm x 4.5 cm x UTD, unstageable, by RN 5 9/8/22- 5.0 cm x 2.5 cm x UTD, unstageable, by RN 5 9/15/22- 5.0 cm x 2.5 cm x UTD, Stage IV, by RN 5 9/21/22- 5.0 cm x 2.2 cm x 0.5 cm, unstageable, by RN 3 9/22/22- 5 cm x 2.2 cm x 0.5 cm, unstageable, by RN 6 9/29/22- 4.3 cm x 2.3 cm x UTD, unstageable, by RN 5 555879 Page 2 of 7 555879 10/13/2022 All Saint's Maubert 15731 Maubert Avenue San Leandro, CA 94578

F 0686 10/6/22- 4.0 cm x 1.5 cm x UTD, unstageable, by RN 5 Level of Harm - Minimal harm or potential for actual harm The Wound Evaluation Sheet had no description of the wound bed or edges nor any documentation of wound tunneling. Residents Affected - Some During a concurrent observation and interview, on 10/11/22, at 10:51 a.m., with Registered Nurse 2 (RN 2) in Resident 5's room, RN 2 provided wound care to Resident 5's pressure wounds on his sacrum and sacrococcyx. Resident 5 had a wound with three distinct parts: one area had intact eschar, one area was a full skin thickness with visible muscle at the wound bed, and one area had full thickness/visible muscle with tunneling. RN 2 measured Resident 5's right sacral wound width at the shortest distance side to side. During a concurrent record review and interview, on 10/11/22, at 11:30 a.m., the Nursing Weekly Wound Evaluation Sheet was reviewed with the Director of Nursing (DON). When asked how wounds should be measured, the DON stated wounds should be measured at the widest distance for width, the longest distance for length, and the deepest point for depth. The DON stated any wound tunneling should be documented. During a telephone interview, on 10/13/22, at 1:50 p.m., with the wound doctor (MD-1), MD-1 stated he expected the facility's nursing staff to use the National Pressure Injury Advisory Panel (NPIAP) guidance for pressure wound description, staging, and assessment, including measurements and documentation. MD-1 stated he had examined Resident 5's pressure injuries in the morning and determined there were three wounds on Resident 5's sacrum and sacrococcygeal areas: two were Stage 4 pressure injuries and the third wound had eschar, so was unstageable. MD-1 said staff were expected to document any tunneling or undermining present in the wound. A review of the National Institute of Health National Library of Medicine article, The Prevention and Management of Pressure Ulcers in Primary and Secondary Care, dated April 2014, indicated, The measurement of pressure ulcer size can be used by healthcare professionals for recording and monitoring the progression and healing of a pressure ulcer. Recording this accurately can allow an assessment to be made as to whether a treatment is effective in promoting healing, by reducing the size of the pressure ulcer. It is important for healthcare professionals to understand that a pressure ulcer does not only affect the visible skin but that it also has a cavity underneath it with depth and volume. As well as the visible cavity, a cavity under the skin that cannot be directly observed (undermining) may be present. This would need to be considered in addition to any measurement of visible damage. A review of the National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline. [NAME] Haesler (Ed.). Cambridge Media: [NAME] Park, Western Australia; 2014, indicated, Treatment Assessment and Monitoring: .General signs of healing include decreased length, width, and depth of the ulcer; progressively less exudate; and changes in tissue type from less devitalized tissues (e.g., eschar and slough) to healthy regenerative tissues Assess and document physical characteristics including: location, category/Stage, size, tissue type(s), color, periwound condition, wound edges, sinus tracts, undermining, tunneling, exudate, and odor Select a uniform, consistent method for measuring wound length and width or wound area to facilitate meaningful comparisons of wound measurements across time Select a consistent, uniform method for measuring depth. 555879 Page 3 of 7 555879 10/13/2022 All Saint's Maubert 15731 Maubert Avenue San Leandro, CA 94578

F 0686 Level of Harm - Minimal harm or potential for actual harm 2. A review of Resident 113's Face Sheet indicated Resident 113 was admitted in August 2022 with diagnoses of encephalopathy (brain damage) secondary to bleeding in his brain, respiratory failure requiring a tracheostomy, quadriplegia (impaired movement and sensation in all four extremities), an open skull flap (a portion of the skull is removed to allow for brain swelling) after brain surgery, history of falling and seizure disorder. Residents Affected - Some During a review of the facility's Minimum Data Set (MDS, an assessment tool used to direct resident care), dated 9/1/22, indicated Resident 113 had moderate difficulty hearing, did not speak, sometimes understood what was said to him but could rarely make others understand him. The MDS indicated Resident 113 was totally dependent on at least one person for dressing, toilet use, bed mobility, transfer between surfaces, personal hygiene, and eating. The MDS indicated Resident 113 was at risk of developing pressure ulcers/injuries. A review of Resident 113's physician's Order Summary Report dated 10/12/22, indicated an active order, start date 8/27/22, to apply foam boots at 9 a.m. and remove the boots at 9 p.m., daily, for heel protection. During an observation on 10/10/22 at 11:15 a.m., in Resident 113's room, Resident 113 lay in bed with the head of the bed elevated. Resident 113's feet were bare. A pair of foam boots were on the bedside table adjacent to Resident 113's bed. During an Observation on 10/10/22, at 1:30 p.m., in Resident 113's room, Resident 113 lay in bed with the head of the bed elevated. Resident 113's feet were bare. A pair of foam boots were on the bedside table adjacent to Resident 113's bed. During an observation on 10/11/22, at 12 p.m., in Resident 113's room, Resident 113 lay in bed with the head of the bed elevated. Resident 113's feet were bare. A pair of foam boots were on the bedside table adjacent to Resident 113's bed. During an observation on 10/12/22, at 11:45 a.m., in Resident 113's room, Resident 113 lay in bed with the head of the bed elevated. Resident 113's feet were bare. A pair of foam boots were on Resident 113's clothing cabinet. During an interview and record review on 10/12/22 at 12:15 p.m., with Registered Nurse 3 (RN 3), Resident 113's physician orders were reviewed. RN 3 stated Resident 113 should have the foam boots on from 9 a.m. to 9 p.m. 555879 Page 4 of 7 555879 10/13/2022 All Saint's Maubert 15731 Maubert Avenue San Leandro, CA 94578

F 0732 Post nurse staffing information every day. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to post nurse staffing data to include the total actual hours worked by registered nurses, licensed vocational nurses, and certified nurse assistants directly responsible for resident care. Residents Affected - Few This failure resulted in unavailability of nurse staffing information for residents and visitors. Findings: During a concurrent observation on 10/12/22, at 8:00 a.m., at the Nursing Station, the Scheduler (SCHED) posted the document titled, Census and Direct Care Service Hours Per Patient Day (DHPPD). A review of the document, Census and Direct Care Service Hours Per Patient Day (DHPPD), dated 10/12/22, had data entry boxes for: resident census and adjustments to the census on a shift-by-shift basis; the scheduled estimated total direct care service hours per patient day (DHPPD) both for licensed nurses and certified nursing assistants (CNAs); and the actual total DHPPD for licensed nurses and CNAs. There were no entries in any box except for the resident census boxes. During a concurrent interview and record review on 10/12/22, at 8:30 a.m., with SCHED, the Census and Direct Care Service Hours Per Patient Day (DHPPD), dated 10/12/22, was reviewed. SCHED stated she was responsible for posting the document before 5 p.m., Monday through Friday with the date, license number, facility name, total bed count and current census information completed. The SCHED stated the nurse supervisors should have completed the boxes for the Estimated Direct Care Service Hours and DHPPD for licensed nurses and CNAs. SCHED stated the Human Resources/Payroll (HRP) completed the data boxes for the Actual Direct Care Service Hours and DHPPD for licensed nurses and CNAs. During a concurrent interview and record review on 10/12/22, at 9:30 a.m., with HRP, the Census and Direct Care Service Hours Per Patient Day, dated 10/12/22, was reviewed. HRP stated she was responsible for completing the boxes for the Actual Direct Care Service Hours and DHPPD, as the actual hours were used for payroll. HRP stated SCHED should be completing the boxes for the Estimated Direct Care Service Hours and DHPPD. During a concurrent interview and record review on 10/12/22, at 9:40 AM, with the DON, the Census and Direct Care Service Hours Per Patient Day (DHPPD), dated 10/12/22, were reviewed. The DON stated the form should have all the boxes for the estimated and actual direct care service hours DHPPD boxes completed with the staffing information, as staffing was important for patient care. 555879 Page 5 of 7 555879 10/13/2022 All Saint's Maubert 15731 Maubert Avenue San Leandro, CA 94578

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure two nursing staff followed hand hygiene procedures when Registered Nurse 1 (RN 1) and Certified Nursing Assistant 1 (CNA 1) did not perform hand hygiene between glove changes during wound care for one of thirteen sampled residents (Resident 12). Residents Affected - Few This failure had the potential to result in infection or the spread of infectious organisms. Findings: During an observation on 10/10/22, at 10:48 a.m., in Resident 12's room, was a sign posted on the wall by a box of gloves and a hand sanitizer dispenser which indicated, Sanitize hands before and after wearing gloves. During an observation on 10/10/22, at 11:04 a.m., in Resident 12's room, Registered Nurse 1 (RN 1) prepared to change Resident 12's sacral (tailbone) wound dressing with the assistance of Certified Nursing Assistant 1 (CNA 1) and Certified Nursing Assistant 2 (CNA 2). CNA 2 maintained Resident 12 in a side-lying position while RN 1 and CNA 1 began wound care. CNA 1 donned gloves and stood adjacent to Resident 12's bed. RN 1 donned gloves and removed Resident 12's soiled dressing. RN 1 discarded the soiled dressing, removed her soiled gloves, and without performing hand hygiene, donned a new pair of gloves. RN 1 and CNA 1 used their gloved hands to use cleansing wipes to remove stool from the area near Resident 12's wound. RN 1 and CNA 1 both removed their gloves, and without performing hand hygiene, they each donned a new pair of gloves. RN 1 completed the wound treatment and placed a clean dressing over Resident 12's wound. RN 1 removed her gloves and without performing hand hygiene, donned a new pair of gloves and suctioned Resident 12's tracheostomy tube (a curved tube inserted in the front of the neck into the windpipe to assist with breathing). During an interview on 10/10/22, at 11:34 a.m., with RN 1, RN 1 stated she had tried to complete the wound care as quickly as possible to avoid causing Resident 12 distress, so she had not done hand hygiene between glove changes. RN 1 stated hand hygiene should be performed between glove changes to prevent infection. During an interview on 10/11/22, at 10:35 a.m., with the Director of Nursing (DON), the DON stated hand hygiene should be performed between glove changes, even if the glove changes are performed during the care of the same resident. During an interview on 10/13/22, at 9:15 a.m., with the Infection Preventionist (IP), the IP stated hand hygiene must be performed between doffing and donning gloves to prevent the spread of infection. IP stated there was a potential for infectious organisms to be spread to different areas of a resident's body if hand hygiene was not performed between glove changes, even on the same resident. A review of the facility's Policy and Procedure (P&P) titled, Handwashing/Hand Hygiene, dated 8/2019, indicated, This facility considers hand hygiene the primary means to prevent spread of infections .All personnel shall follow the handwashing/hand hygiene procedures to help prevent spread of infection to other personnel, residents, and visitors .Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: .Before donning gloves; .After removing gloves . The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as 555879 Page 6 of 7 555879 10/13/2022 All Saint's Maubert 15731 Maubert Avenue San Leandro, CA 94578

F 0880 the best practice for preventing healthcare-associated infections . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 555879 Page 7 of 7