Inspection·October 15, 2021

F 0842 Level of Harm - Potential for minimal harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on interview and record review the facility failed to ensure one of three sampled residents (Resident 10) with a gastrostomy tube (GT, a tube inserted through the wall of the abdomen directly into the stomach) had documentation of provision of ordered nursing care related to the GT. This failure resulted in impaired communication across shifts and had the potential to result in inaccurate assessments of needed care, and unnecessary duplication of care. Findings: A review of Resident 10's face sheet indicated Resident 10 admitted to the facility with a diagnosis of dysphagia (difficulty or discomfort in swallowing). A review of Resident 10 ' s Medication Administration Record (MAR) dated 9/2021, indicated the following physician orders were not signed/initialed to indicate task completion by the night shift (the shift starting at 11 p.m. and ending 7:30 a.m. the following morning) nurse on 9/17/21, 9/18/21, 9/24/21, 9/28/21: every shift, check stomach contents before beginning a tube feeding, and delay feeding for one hour if the contents were more than 100 milliliters; elevate the head of the bed 30-45 degrees during feedings; flush the GT with 30ml of water before and after each medication. During a review of Resident 10 ' s Treatment Administration Record (TAR) dated 9/21, indicated the following physician orders were not signed/initialed to indicated task completion by the night shift nurse on 9/17/21, 9/24/21, 9/28/21, and 9/30/21: change the syringe that contained the tube feeding every night shift; monitor GT site for any redness or discharge every shift. During an interview and concurrent review of Resident 10 ' s September 2021 MAR and TAR on 10/13/21 at 12:50 p.m., with Licensed Vocational Nurse 1 (LVN1), LVN 1 stated she had been the assigned nurse on the night shifts of 9/17/21, 9/24/21, 9/28/21, and 9/30/21. LVN 1 stated she had forgotten to document completion of the tasks on those dates. LVN 1 stated if the tasks were not documented, the assumption was the tasks were not performed. During an interview and concurrent review of Resident 10 ' s September 2021 MAR and TAR on 10/12/21, at 11:13 a.m., with the Director of Nursing (DON), the DON stated the ordered tasks without initials on the MAR and TAR indicated those tasks had not been completed. The DON stated nurses should document completion of all resident care tasks. A review of the facility policy and procedure, Center's Nursing Policies revised 6/1/21, indicated, Documentation includes information about the patient's status, nursing assessment and interventions (continued on next page) 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. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 056121 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056121 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/15/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Washington Center 14766 Washington Avenue San Leandro, CA 94578 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)