Health inspection·September 26, 2019

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. Based on interview and record review, for four (Residents 23, 34, 54 and 59) of 73 sampled residents the facility had no process in place to ensure residents had an Advance Directive (a written instruction relating to the provision of health care when the individual is incapacitated) on file. This failure had the potential for the residents' preference for treatment not to be implemented, in the event the resident was incapacitated. Findings: During a review of the medical record, on 9/24/29 at 11 am, the POLST (Physician Orders for Life Sustaining Treatment) dated 2/10/18, showed Resident 34 did not have an Advance Directive. In an interview, on 9/24/19 at 12:15 p.m., the admission Director (AD) stated when a resident was admitted , the resident or the responsible party (RP=person making decisions for resident) was given information on Advance Directives as a part of the admission packet. The resident or RP was asked if they had an Advance Directive. If the response was no, the POLST was checked, No Advance Directive. The AD stated she would make a note to follow up with the resident or RP. The AD was unable to provide any documentation of follow up with Resident 34 or a record of an Advance Directive for Resident 34. During an interview, on 9/26/19 at 10:15 a.m., Resident 34 stated she was given information on Advance Directives during her admission but did not want to make a decision at that time. Resident 34 stated no one had spoken to her since that time but she would be interested in doing an Advance Directive. During a review of the medical record, on 9/24/29 at 1:10 p.m., the POLST dated 2/27/17, showed Resident 54 did not have an Advance Directive. During a review of the medical records, on 9/26/29 at 11:45 a.m., the POLST dated 8/4/16, for Resident 23 and the POLST dated 7/4/16, for Resident 59 did not indicate any choices for an Advance Directive. Review of the POLST form showed, POLST does not replace the Advance Directive. When available, review the Advance Directive and POLST form to ensure consistency, and update forms appropriately to resolve any conflicts. During a concurrent interview and record review with the Social Services Director (SSD) on 9/27/19 (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 6 Event ID: 056298 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 056298 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE We Care Skilled Nursing - Fremont 2100 Parkside Drive Fremont, CA 94536 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)