Other·February 8, 2017

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following represents the findings of the California Department of Public Health during the investigation of two entity reported incident. Entity reported incident number: CA00502413 and CA00502684. Representing the Department: Health Facilities Evaluator Nurse(s): #34236. The inspection was limited to the specific entity reported incident investigated and does not represent the findings of a full inspection of the facility. No deficiency was issued for CA00502684 One deficiency was issued for the entity reported incident: CA00502413. ------------------------------------------------------------------------------------------------------------------The following represents the findings of the California Department of Public Health during a Complaint Investigation visit. CLASS B CITATION 02-2804-0012945-F Complaint Number: CA00502413 Representing the Department of Public Health: Surveyor ID #2804, HFEN The inspection was limited to the specific facility event investigated and does not represent the findings of a full inspection of the facility. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EBVK11 Facility ID: CA020000275 If continuation sheet 1 of 9 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056121 (X3) DATE SURVEY COMPLETED 12/01/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WASHINGTON CENTER 14766 Washington Avenue San Leandro, CA 94578 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

F333 RESIDENTS FREE OF SIGNIFICANT MED ERRORS CFR(s): 483.25(m)(2)

F333 SS=G PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 12/20/2016 The facility must ensure that residents are free of any significant medication errors. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EBVK11 Facility ID: CA020000275 If continuation sheet 2 of 9 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056121 (X3) DATE SURVEY COMPLETED 12/01/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WASHINGTON CENTER 14766 Washington Avenue San Leandro, CA 94578 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE facility failed to provide an anti-coagulant medication (a blood thinner, a medication used to prevent clot formation in the blood), as ordered for one of three residents (Resident 1). For Resident 1, this failure resulted in a cerebrovascular accident (a stroke) due to formation of a blood clot in the brain (an ischemic stroke). Findings: A review of the Admission Record of Resident 1 indicated she was admitted to the facility on 8/25/16 with diagnoses that included high blood pressure and atrial fibrillation (A-fib, an abnormal heart rhythm that can lead to increased risk of stroke.). The Minimum Data Set (MDS, a resident assessment tool used to guide care) dated 8/31/16, reflected Resident 1 could feed herself, but needed assistance from one person for locomotion and other activities of daily living (hygiene, bathing, etc.). A review of Resident 1's hospital Discharge Summary dated 8/25/16, reflected Resident 1 had paroxysmal atrial fibrillation (a condition where the heart rate suddenly increases, then subsides, in variable time intervals) and needed to continue use of the anticoagulant Pradaxa (dabigatran etexilate, a blood thinner). The Summary indicated the discharge medications included: Pradaxa, 150 milligrams (mg), twice a day. During a telephone interview 12/1/16, at 3:30 p.m., the hospital physician (Phys 1) confirmed she had written the 8/25/16 hospital Discharge Summary with the discharge medication orders. Phys 1 said it was important for Resident 1 to have received the Pradaxa 150 mg twice a day because she had atrial fibrillation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EBVK11 Facility ID: CA020000275 If continuation sheet 3 of 9 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056121 (X3) DATE SURVEY COMPLETED 12/01/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WASHINGTON CENTER 14766 Washington Avenue San Leandro, CA 94578 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During an interview on 9/21/16, at 2:35 p.m., registered nurse 1 (RN 1) said Resident 1 was admitted from acute care hospital with admission orders on the Discharge Summary. RN 1 said she sent a copy of the orders to the pharmacy, and transcribed the orders to the computer. RN 1 said she did not notice she had missed transcribing the order for Pradaxa. A review of the August 2016 transcribed Physician Orders reflected no order for Pradaxa. The Medication Administration Record (MAR) reflected no administration of Pradaxa from 8/25/16 through 8/31/16. A review of Resident 1's care plan, "Resident is at risk for cardiovascular symptoms or complications due to A-fib," dated 8/26/16, reflected, "Administer meds [medications] as ordered and assess for effectiveness and side effects and report abnormalities to physician." A review of the pharmacy Shipment Summary for Resident 1 dated 8/25/16 indicated 30 capsules of Pradaxa had been delivered and signed for by RN 2 at 11:12 p.m. A review of the facility's "Summary of Investigation," dated 9/15/16, indicated the medication was confirmed to be in the medication cart, unopened. The Summary concluded because the nurse did not enter the Pradaxa order into the computer system for Physician Orders and the MAR, the resident never received Pradaxa in the facility: a medication error was substantiated. During an interview 9/21/16 at 2 p.m., the Administrator (Admin) and Director of Nurses (DON) confirmed Resident 1 did not receive Pradaxa during her admission in the facility, despite presence of a physician order and delivery of the medication by the pharmacy. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EBVK11 Facility ID: CA020000275 If continuation sheet 4 of 9 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056121 (X3) DATE SURVEY COMPLETED 12/01/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WASHINGTON CENTER 14766 Washington Avenue San Leandro, CA 94578 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Admin and DON said the order was missed during the transcription of the admission orders, but the omission had not been discovered until after Resident 1 had been discharged to the hospital. During an interview 11/29/16 at 3:20 p.m., LVN 1 said she assessed Resident 1 around 9 a.m. on 8/31/16 and noted increased confusion and facial drooping. LVN 1 said she alerted the DON, called the physician and family, and made arrangements for transfer to the hospital. A review of the Hospital Transfer Form Appendix completed by LVN 1 on 8/31/16 reflected Resident 1 was transferred for stroke treatment. A review of the emergency department Provider Notes dated 8/31/16, at 10:50 a.m., indicated Resident 1 arrived in the emergency room on 8/31/16, at 10:47 a.m., for evaluation of an altered mental state and facial droop. The hospital History and Physical (H & P) dated 8/31/16, indicated Resident 1 was admitted for treatment of an acute cerebrovascular accident (stroke). A review of a hospital imaging test (Magnetic Resonance Angiogram) completed 9/1/16 indicated Resident 1 had significantly decreased blood flow to the right side of her brain from a blood clot. A review of the hospital Discharge Summary dated 9/3/16 indicated Resident 1 had significant brain abnormalities and physical deficits as a result of a "massive" right sided stroke from a blood clot. A review of Resident 1's Certificate of Death issued on 10/5/16 indicated she died on 9/19/16. The immediate cause of death was stroke. A review of the Food and Drug Administration FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EBVK11 Facility ID: CA020000275 If continuation sheet 5 of 9 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056121 (X3) DATE SURVEY COMPLETED 12/01/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WASHINGTON CENTER 14766 Washington Avenue San Leandro, CA 94578 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (FDA) boxed warning (a warning placed on a prescription drug ' s label and is designed to call attention to seri­ous or life­threatening risks) indicated abrupt discontinuation of Pradaxa increases the risk of clot formation. -------------------------------------------------------------------------------------------------------------------------------------------------------------------------Class "B" Citation No. 02-2804-0012945 483.25(m)(2) RESIDENTS FREE OF SIGNIFICANT MED ERRORS The facility must ensure that residents are free of any significant medication errors. A review of the Admission Record of Resident 1 indicated she was admitted to the facility on 8/25/16 with diagnoses that included high blood pressure and atrial fibrillation (A-fib, an abnormal heart rhythm that can lead to increased risk of stroke.). The Minimum Data Set (MDS, a resident assessment tool used to guide care) dated 8/31/16, reflected Resident 1 could feed herself, but needed assistance from one person for locomotion and other activities of daily living (hygiene, bathing, etc.). A review of Resident 1's hospital Discharge Summary dated 8/25/16, reflected Resident 1 had paroxysmal atrial fibrillation (a condition where the heart rate suddenly increases, then subsides, in variable time intervals) and needed to continue use of the anticoagulant Pradaxa (dabigatran etexilate, a blood thinner). The Summary indicated the discharge medications included: Pradaxa, 150 milligrams (mg), twice a day. During a telephone interview 12/1/16, at 3:30 p.m., the hospital physician (Phys 1) confirmed she had written the 8/25/16 hospital Discharge Summary with the discharge medication orders. Phys 1 said it was important for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EBVK11 Facility ID: CA020000275 If continuation sheet 6 of 9 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056121 (X3) DATE SURVEY COMPLETED 12/01/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WASHINGTON CENTER 14766 Washington Avenue San Leandro, CA 94578 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Resident 1 to have received the Pradaxa 150 mg twice a day because she had atrial fibrillation. During an interview on 9/21/16, at 2:35 p.m., registered nurse 1 (RN 1) said Resident 1 was admitted from acute care hospital with admission orders on the Discharge Summary. RN 1 said she sent a copy of the orders to the pharmacy, and transcribed the orders to the computer. RN 1 said she did not notice she had missed transcribing the order for Pradaxa. A review of the August 2016 transcribed Physician Orders reflected no order for Pradaxa. The Medication Administration Record (MAR) reflected no administration of Pradaxa from 8/25/16 through 8/31/16. A review of Resident 1's care plan, "Resident is at risk for cardiovascular symptoms or complications due to A-fib," dated 8/26/16, reflected, "Administer meds [medications] as ordered and assess for effectiveness and side effects and report abnormalities to physician." A review of the pharmacy Shipment Summary for Resident 1 dated 8/25/16 indicated 30 capsules of Pradaxa had been delivered and signed for by RN 2 at 11:12 p.m. A review of the facility's "Summary of Investigation," dated 9/15/16, indicated the medication was confirmed to be in the medication cart, unopened. The Summary concluded because the nurse did not enter the Pradaxa order into the computer system for Physician Orders and the MAR, the resident never received Pradaxa in the facility: a medication error was substantiated. During an interview 9/21/16 at 2 p.m., the Administrator (Admin) and Director of Nurses FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EBVK11 Facility ID: CA020000275 If continuation sheet 7 of 9 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056121 (X3) DATE SURVEY COMPLETED 12/01/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WASHINGTON CENTER 14766 Washington Avenue San Leandro, CA 94578 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (DON) confirmed Resident 1 did not receive Pradaxa during her admission in the facility, despite presence of a physician order and delivery of the medication by the pharmacy. Admin and DON said the order was missed during the transcription of the admission orders, but the omission had not been discovered until after Resident 1 had been discharged to the hospital. During an interview 11/29/16 at 3:20 p.m., LVN 1 said she assessed Resident 1 around 9 a.m. on 8/31/16 and noted increased confusion and facial drooping. LVN 1 said she alerted the DON, called the physician and family, and made arrangements for transfer to the hospital. A review of the Hospital Transfer Form Appendix completed by LVN 1 on 8/31/16 reflected Resident 1 was transferred for stroke treatment. A review of the emergency department Provider Notes dated 8/31/16, at 10:50 a.m., indicated Resident 1 arrived in the emergency room on 8/31/16, at 10:47 a.m., for evaluation of an altered mental state and facial droop. The hospital History and Physical (H & P) dated 8/31/16, indicated Resident 1 was admitted for treatment of an acute cerebrovascular accident (stroke). A review of a hospital imaging test (Magnetic Resonance Angiogram) completed 9/1/16 indicated Resident 1 had significantly decreased blood flow to the right side of her brain from a blood clot. A review of the hospital Discharge Summary dated 9/3/16 indicated Resident 1 had significant brain abnormalities and physical deficits as a result of a "massive" right sided stroke from a blood clot. A review of Resident 1's Certificate of Death issued on 10/5/16 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EBVK11 Facility ID: CA020000275 If continuation sheet 8 of 9 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056121 (X3) DATE SURVEY COMPLETED 12/01/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WASHINGTON CENTER 14766 Washington Avenue San Leandro, CA 94578 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE indicated she died on 9/19/16. The immediate cause of death was stroke. A review of the Food and Drug Administration (FDA) boxed warning (a warning placed on a prescription drug label and is designed to call attention to serious or life-threatening risks) indicated abrupt discontinuation of Pradaxa increases the risk of clot formation. Therefore the facility failed to provide an anticoagulant medication (a blood thinner, a medication used to prevent clot formation in the blood), as ordered for one of three residents (Resident 1). For Resident 1, this failure resulted in a cerebrovascular accident (a stroke) due to formation of a blood clot in the brain (an ischemic stroke). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EBVK11 Facility ID: CA020000275 If continuation sheet 9 of 9