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 Page 1 of 6 056298 056298 09/26/2019 We Care Skilled Nursing - Fremont 2100 Parkside Drive Fremont, CA 94536

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some at 11:15 a.m., SSD stated the Advance Directive should be discussed with the resident/family within 48 hours of admission. If resident indicated they had an Advance Directive, the facility would ask the family to provide a copy for the medical records. If there was no Advance Directive, information was provided with follow up in five to seven days by the SSD to make sure the assessment was completed. If the resident or RP refused the Advance Directive, it was documented in the Interdisciplinary Team (IDT) notes. The SSD was unable to provide documentation of Advance Directives for Residents 23, 54 and 59 or any documentation of follow up with the residents, RP or family. Review of the facility's policy and procedure (P&P) titled Advance Directives, indicated the purpose was to ensure the resident's choice in treatment options should the resident be unable to speak for themselves is honored. 056298 Page 2 of 6 056298 09/26/2019 We Care Skilled Nursing - Fremont 2100 Parkside Drive Fremont, CA 94536

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Based on interviews and record review, the facility failed to follow its theft and loss program policy and procedure to make reasonable efforts to safeguard a resident's property for one (Resident 25) of twenty-four sampled residents when Resident 25's clothing's had bleached patches after a laundry wash. This failure had the potential to cause residents emotional distress. Findings: During a resident council meeting on 9/24/19 at 10:03 a.m., Resident 25 stated her gray pants and clothes had bleach spots after being returned from laundry wash. Resident 25 stated laundry staff threw away her pants and clothes that was bleached and facility did not replace her clothing items. Review of the Minimum Data Set (MDS - an assessment screening tool used to guide care), dated 8/11/19, indicated Resident 25 had good long and short term memory. Resident 25 could identify the correct year. Resident 25 was able to express her ideas and wants, had clear speech, and could understand communication with others. During an interview on 9/25/19 at 11:28 a.m., the Maintenance Supervisor (MS), stated Resident 25's clothes had bleach spots. MS stated the wash cycle smeared the clothing, some clothing came back with blotches. MS stated the social services was informed of the damage to Resident 25's personal clothing. During an interview on 9/25/19 at 1:02 p.m., the Social Service Director (SSD) stated he heard about Resident 25 bleached clothing during standup but had not followed up. The facility's policy and procedure, titled Theft & Loss Program, undated, indicated, It is a policy of this facility to make reasonable efforts to safeguard a resident property. 056298 Page 3 of 6 056298 09/26/2019 We Care Skilled Nursing - Fremont 2100 Parkside Drive Fremont, CA 94536

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to follow its policy and procedure to provide one (Resident 166) of twenty four sampled residents and their representatives with a summary of the baseline care plan. This failure had the potential to cause miscommunication with the care provided to residents. Findings: Review of the admission Record indicated Resident 116 was admitted to the facility on [DATE] with diagnoses that included dyspnea (shortness of breath). Review of the baseline care plan dated 9/19/19, indicated the facility did not review and discuss care instructions with Resident 116 and their representatives. During an interview on 9/23/19 at 10:15 a.m., Resident 116 stated facility had not provided a care plan instructions to him and his representatives. During an interview 9/26/19 at 10:16 a.m., the Director of Nursing (DON), stated facility had not discussed care plan instructions and was not aware a summary of baseline care plan was to be provided to Resident 116 and their representatives. The facility's policy and procedure, titled, Baseline Care Plan, undated, indicated: Ensure that the resident and representative, if applicable, are informed of the initial plan for delivery of care and services by receiving a written summary of the baseline care plan within 48-hour period. 056298 Page 4 of 6 056298 09/26/2019 We Care Skilled Nursing - Fremont 2100 Parkside Drive Fremont, CA 94536

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure one (Resident 17) of twenty four sampled residents was free of unnecessary drugs, when Resident 1 was administered Ativan (anti-anxiety medication) for tremors/seizures without being monitored for its target behavior manifestations. Residents Affected - Few This failure had the potential for residents to receive unnecessary medication and to suffer adverse medication side effects. Definitions: Ativan is anti-anxiety medication taken to reduce tension or anxiety. Its adverse consequences include increased risk of confusion, sedation and falls. Findings: Review of the Annual Minimum Data Set (MDS - an assessment screening tool used to guide care), dated 1/20/19, indicated Resident 17's diagnoses included seizure disorder or epilepsy. Review of the Physician Orders dated 8/17/18 indicated the Resident 17 was prescribed Ativan 0.5 mg one tablets by mouth every 6 hours as needed for tremors/seizures. Review of the Medication Administration Record (MAR), dated 9/1/19 to 9/30/19 indicated Resident 17 was administered Ativan 0.5 mg one tablets by mouth for tremors. Further review indicated there was no monitoring of the target behavior. Review of care plan dated 8/22/19, indicated Resident 17 required the use Ativan medication for seizure. Care plan interventions indicated to document seizures. During clinical record review and concurrent interview on 9/25/19 at 8:52 a.m. the Director of Nursing (DON) stated Resident 17's seizure episodes were not monitored and documented. The facility's policy and procedure, titled, Psychotherapeutic Drug Management dated 7/17/08 did not indicate when and how to monitor and document behaviors manifestations for residents' use of Ativan. 056298 Page 5 of 6 056298 09/26/2019 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 serve food under sanitary conditions when the dry food storage room had a box of brown bananas on a shelf with unexpired food. Residents Affected - Some This deficiency practice has the potential to place residents at risk for foodborne illnesses. Findings: During an initial tour of the kitchen on 9/23/19 at 8:05 a.m., a box of brown bananas dated 9/20/19 was stored on a shelf with unexpired food in the dry food storage area. During interviews at a resident council meeting on 9/24/19 at 10:00 a.m., Resident 23 and Resident 24 stated that they did not like it when they were served brown bananas at meals. During an interview on 9/26/19 at 11:00 a.m., [NAME] 1 stated that all kitchen staff are responsible for checking for expired food. During an interview on 9/26/19 at 11:05 a.m., the Dietary Supervisor (DM) stated that she inspected the dry food storage area each day for expired food items and expected other kitchen staff to do the same thing. Review of the facility's Procedure For Refrigerated Storage policy dated 2018 indicated, Produce will be delivered frequently to assure that a fresh product is used, free of any wilting or spoilage. 056298 Page 6 of 6