Health inspection·August 9, 2018

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to notify the physician of a need to alter the treatment for one (Resident 19) of 22 sampled residents when the facility did not notify the physician of Resident 19's refusal of weights. This failure could result in delay of initiation of life saving treatment. Findings: Review of the admission Record indicated Resident 19 was readmitted to the facility on [DATE] with multiple medical diagnoses that included unspecified atrial fibrillation (an irregular and often rapid heart rate that can increase risk of stroke, heart failure, and other heart-related complications), Hypothyroidism (abnormally low activity of the thyroid gland and congestive heart failure (CHF-occurs when heart cannot pump blood to provide what the body demands). During an observation of Resident 19 and interview with Licensed Vocational (LVN) 3 on 8/6/18 at 1: 48 p.m., Resident 19 was sitting in her wheelchair outside room [ROOM NUMBER] with both legs resting in each of the footrest. LVN 3 stated Resident 19's legs were swelling. Review of the Physician Orders dated 5/29/18 indicated Bumex (used to reduce extra fluid in the body) 1 milligram, by mouth, daily for CHF. Further review of Physician Orders dated 6/28/18 indicated an order to fax Resident 19's weight records every two weeks to the physician. Rewiew of the Medication Administration Record for June 2018 and July 2018 revealed no weight was obtained from 6/28/18 through 7/31/18. During an interview and concurrent record review with LVN 1 on 8/7/18 at 12:35 p.m., LVN 1 stated refused to be weighed and that the physician was not notified of Resident 19's refusal to take weights on 7/2/18 and 7/16/18. LVN 1 added We should notify the physician when she refuses to be weighed. During an interview and concurrent record review with the Director of Nursing (DON) on 8/7/18 at 1:35 p.m., the DON confirmed there were no weights done for 7/2/18 and 7/16/18 for Resident 19. Review of undated policy and procedure titled Refusal of Treatment indicated Should the resident refuse to accept treatment, detailed information relating to the refusal must be entered into the resident's medical record. The attending physician must be notified of such refusal without delay. Page 1 of 6 056298 056298 08/09/2018 We Care Skilled Nursing - Fremont 2100 Parkside Drive Fremont, CA 94536

F 0661 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure there was physician discharge summary in the clinical record for one (Resident 100) of 22 sampled residents. This failure could result in lack of treatment received and coordination of continued treatment needs in the community. Findings: Review of the admission Record indicated Resident 100 was admitted to the facility on [DATE] with multiple diagnoses that included high blood pressure and Hypothyroidism (a disorder of the endocrine system in which the thyroid gland does not produce enough thyroid hormone). Further review indicated Resident 100 was discharge home on 5/22/18. Review of the clinical record indicated there was no discharge summary in the clinical record that provided discharge justification or coordination of care after discharge. In an interview and concurrent record review with the Assistant Medical Record (AMR), on 8/8/18 at 11:52 a.m., the AMR stated there was no discharge summary in Resident 100's clinical record. In a follow up interview with Medical Record Director (MRD) on 8/9/18 at 11:20 a.m., MRD stated after residents' discharge they faxed the discharge summary form to the physician and they have 30 days to follow up. Review of undated policy and procedure titled discharged Summary indicated A discharge summary will be prepared for each resident discharged from the facility. An explanation of the care will be provided to the resident and/or family or surrogate decision maker and discharge summary will be signed indicating that the information was explained to the resident and/ or family surrogate decision maker. The original Discharge Summary will be provided to the resident or surrogate decision maker and a copy filed in the resident's medical record. 056298 Page 2 of 6 056298 08/09/2018 We Care Skilled Nursing - Fremont 2100 Parkside Drive Fremont, CA 94536

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the pharmacist's medication regimen review (MRR) was promptly acted upon for one (Resident 19) of 22 sampled residents. This failure had the potential to delay Resident 19's treatment and placed Resident 19 at risk for serious side effects. Findings: Review of the admission Record indicated Resident 19 was readmitted to the facility on [DATE] with multiple medical diagnoses that included unspecified atrial fibrillation (an irregular and often rapid heart rate that can increase risk of stroke, heart failure, and other heart-related complications) Hypothyroidism (abnormally low activity of the thyroid gland), and Congestive Heart Failure (CHF,occurs when heart cannot pump blood to provide what the body demands). Review of the facility's Consultant Pharmacist (CP) Medication Regimen Review (MRR) dated 7/9/18, indicated Resident 19 was currently receiving warfarin [used to treat or prevent clots] and amiodarone [used to treat and prevent a number of types of irregular heartbeats], which may increase INR's [International Normalized Ratio, a test used to determine the clotting tendency of blood] and risk for bleeding related adverse effects. Since this combination can affect proper control of the INR, do the benefits of using these medications with Coumadin outweigh the risk? . Further review revealed no response from the physician. Review of another Consultant Pharmacist (CP) Medication Regimen Review (MRR) dated 7/9/18, indicated Resident 19 was on Ativan 0.5 mg three times a day as need. It further indicated Please specify a 14-day duration of the therapy and reevaluate the continued need. Further review revealed no response from the physician. During an interview with Licensed Vocational Nurse (LVN) 1 on 8/7/18 at 10:15 a.m., he stated that the MRR was faxed to the attending physician on 7/27/18, but LVN 1 did not follow up on the issues. During an interview with Director of Nursing (DON) on 08/08/18 at 9:38 a.m., the DON stated the MRR was received on 7/20/18. Usually the MRR was divided between her Assistant Director of Nursing (ADON) and and her LVN to report to the physician any recommendations made by the Consultant Pharmacist. DON added that on 7/27/18 the MRR was given to her ADON and LVN 1. The DON further stated pharmacy recommendation should be followed up within 72 hours from the day it was received. In a telephone interview with the CP on 8/09/18 at 9:21 a.m., CP stated the facility has 72 hours to complete the MRR after the date facility received the recommendations. 056298 Page 3 of 6 056298 08/09/2018 We Care Skilled Nursing - Fremont 2100 Parkside Drive Fremont, CA 94536

F 0777 Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to promptly provide diagnostic services for one (Resident 19) of 22 sampled residents when the facility did not provide four laboratory test as ordered by the physician. Residents Affected - Few This failure had the potential to delay identification of worsening medical condition and delay initiation of appropriate treatment. Findings: Review of the admission Record indicated Resident 19 was admitted to the facility on [DATE] with multiple medical diagnoses that included unspecified atrial fibrillation (an irregular and often rapid heart rate), congestive heart failure (CHF, occurs when heart cannot pump blood to provide what the body demands) and Hypothyroidism (abnormally low activity of the thyroid gland). Review of Physician orders dated 5/29/18 indicated Resident 19 had an order for Chem 7 (blood tests that provides information about metabolism) and B-type natriuretic peptide test (BNP, used to help detect, diagnose, and evaluate the severity of heart failure) to be done every month and Complete Blood Count (CBC, a blood test used to evaluate overall health) and Thyroid Stimulating Hormone (TSH, used to check the level of thyroid-stimulating hormone) to be done every two months. During an interview and concurrent record review with Licensed Vocational Nurse (LVN) 1 on 8/7/18 at 12:45 p.m., LVN 1 was unable to find the results of Chem-7 and BNP for June and July 2018 and CBC and TSH for the month of August 2018. During an interview with the Director of Nursing (DON) on 8/7/18 at 1:15 p.m., the DON stated they missed the physician orders for Resident 19's monthly and every two months blood draw. 056298 Page 4 of 6 056298 08/09/2018 We Care Skilled Nursing - Fremont 2100 Parkside Drive Fremont, CA 94536

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store food under sanitary conditions when multiple outdated food items were stored in the reach in and walk in refrigerator. Residents Affected - Some These failures had the potential to cause food-borne illness. Findings: During the initial kitchen tour observation on 08/06/18 at 7:10 a.m., the following was observed inside walk in refrigerator and the reach-in refrigerator: a. 1/2 a jar of pudding with used by date 8/5/18 b. 1/2 a jar of jelly with used by date 8/2/18 c. 1/2 a jar of cottage cheese with use by date 8/4/18 . d. 1/2 a pitcher of nepro drink (a therapeutic nutrition drink that is specifically designed to help meet the nutritional needs of patients on dialysis ) with used by date 8/2/18 e. 1/2 a cartoon lactose free milk used by date 8/5/18. and; f. 1/2 a cartoon thickened liquid drink with a used by date on 8/5/18. During an interview with Dietary Aide 1(DA 1) on 8/6/18 at 7:30 a.m., she stated that leftover food or drinks should be kept for two days only. Review of the facility undated policy and procedure titled Food Preparation Leftover Foods indicated Leftover foods will be stored and served in a safe manner. Storage of leftovers. Label and date. Use refrigerated leftovers within 72 hours. 056298 Page 5 of 6 056298 08/09/2018 We Care Skilled Nursing - Fremont 2100 Parkside Drive Fremont, CA 94536

F 0838 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. Based on observation, interview and record review, the facility failed to ensure adequate emergency food supply was available for one (Resident 17) of 22 sampled residents when multiple food items were not readily available as specified in the facility's emergency menu. This failure had the potential to result in inadequate food supplies for residents in the event of an emergency or disaster. Findings: During an inspection of emergency food supply in the dry food storage area with Dietary Supervisor(DS) on 8/7/18 at 8:30 a.m., the DS confirmed the following food items were missing from the emergency food supply storage section as indicated in the facility's list of emergency food supply. a. eight cans of Canned chicken b. one can pork and beans c. one cans beef stew d. one can peas /beets e. one can tuna f. one three bean salad g. two one-gallon container of mayonnaise h. one box of sugar cookies i. 39 8-ounces ready to serve apple juice During a concurrent interview, DS stated he checked the emergency food supplies few months ago and used some of the food supplies but forgot to replace the used items. Review of facility's undated policy and procedure titled Emergency and Disaster Procedures indicated facilities will have a written plan of action which includes emergency menus to be in the event of an emergency or disaster (i.e. fire, earthquake, explosion, flood or strike). Facilities will maintain an emergency food supply on the premises to last for a three -day period. 056298 Page 6 of 6