Health inspection·September 1, 2023

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Based on interview and record review, the facility failed to ensure if safe skilled nursing care was provided to all 62 residents residing at the facility when Licensed Nurses (LNs) including, three of three sampled Registered Nurses (RNs) and 12 of 12 sampled Licensed Vocational Nurses (LVNs) who had been working at the facility for more than one year, did not receive an annual competency assessment (a measure of an employee's knowledge, skills and behaviors used in performing specific job tasks) since their date of hire. This failure had the potential to cause compromised skilled nursing care to all 63 residents residing in the facility. Findings: During a review of facility's untitled, undated, document for current nursing employee list, the employee list indicated, the facility employed 17 direct care LNs including 12 LVNs and three (3) RNs whose hire dates ranged from 4/26/2002 till 8/18/2023. During a concurrent interview and record review on 8/31/23 at 10:30 a.m. with Director of Staff Development (DSD), LVN 2 and LVN 3's personnel files were reviewed. DSD stated, LVN 2 was hired on 8/31/2004 and LVN 3 was hired on 5/29/2009. DSD stated, there were no competency skills check found on both files since their date of hire. During a concurrent interview and record review on 8/31/23 at 10:45 a.m. with DSD, personnel files for sampled three RNs and 12 LVNs were reviewed. The DSD stated, RN 1, RN 2 and IP were hired on 8/16/21, 10/17/15 and 10/16/18 respectively. The DSD stated, LVN 1, LVN 4, LVN 5, LVN 6, LVN 7, LVN 9, LVN 10, LVN 11, LVN 12 and LVN 14 were hired on 11/14/05, 7/1/03, 12/03/13, 2/17/22, 6/16/10, 10/07/15, 6/1/22, 10/21/16, 4/26/02 and 2/27/08 respectively. The personnel files indicated, all 15 sampled nurses were working at the facility for more than a year. The DSD stated, there were no competency skills check found on all the files. The DSD stated, the Director of Nursing (DON) was responsible for LNs annual competency evaluation. During an interview on 8/31/23 at 1:50 p.m., the DON stated, she checked LNs skills during her rounds/observations. The DON stated, most LNs worked in the facility for number of years and were familiar with resident's needs. The DON stated, she did not complete competency assessment/evaluation for any LNs on an annual basis. During an interview on 9/1/23 at 11:15 a.m. with Administrator (Admin), the Admin stated, he expected the DON to conduct the required annual competency assessment for LNs and he was not aware that Page 1 of 16 056298 056298 09/01/2023 We Care Skilled Nursing - Fremont 2100 Parkside Drive Fremont, CA 94536

F 0726 LNs competency assessments weren't done since their date of hire. Level of Harm - Minimal harm or potential for actual harm During a review of the facility's undated Policy and Procedure (P&P) titled, Knowledge and Skills Competency Evaluation, the P&P indicated, In an effort to provide optimal clinical care, direct care nursing staff are required to meet minimum standards before caring for residents. Knowledge and skill competencies are evaluated upon hire, annually thereafter and as needed, as indicated by job performance, newly introduced procedures, specific techniques required for an individual resident or new products and equipment .Employees will be evaluated as part of their annual performance review. They will also be evaluated on an ongoing basis by senior staff members and/or external consultants to ensure that their skills and knowledge are still sharp. Residents Affected - Many 056298 Page 2 of 16 056298 09/01/2023 We Care Skilled Nursing - Fremont 2100 Parkside Drive Fremont, CA 94536

F 0727 Level of Harm - Minimal harm or potential for actual harm Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on interview and record review, the facility failed to have a Registered Nurse (RN) on duty for at least eight consecutive hours for nine weekends during the month of June, July and August of 2023. Residents Affected - Some This failure had the potential to place residents residing at the facility at risk to receive limited nursing assessment and compromised health and safety. Findings: During an interview on 8/30/23 at 11:49 a.m. with Licensed Vocational Nurse (LVN 14), LVN 14 stated, there were no RN on duty on some weekends but she was unable to remember the exact dates with no RN coverage. During an interview on 8/30/23 at 12:02 p.m. with Certified Nursing Assistant (CNA 3), CNA 3 stated, facility had only LVNs working during weekends. During a review of Licensed Nurses (LNs) monthly schedule, dated June 2023, July 2023 and August 2023, the schedule indicated, weekends with respective dates of 6/4/23, 6/18/23, 6/25/23, 7/9/23, 7/22/23, 7/23/23, 7/29/23, 7/30/23, 8/5/23, 8/6/23, 8/12/23, 8/13/23 and 8/20/23, no RN who was scheduled to work. During a concurrent interview and record review on 8/30/23, at 1:18 p.m., with Payroll/Human Resource (P/HR), the facility's document titled, Nursing Staffing Assignment and Sign-In Sheet, dated 6/4/23, 6/18/23, 6/25/23, 7/9/23, 7/22/23, 7/23/23, 7/29/23, 7/30/23, 8/5/23, 8/6/23, 8/12/23, 8/13/23 and 8/20/23 were reviewed. The P/HR stated, staff on duty signed the assignment sheet every time they came to work. P/HR stated, there were no RNs who signed the assignment sheet for the dates reviewed. During an interview on 9/1/23 at 7:52 a.m., LVN 2 stated, lack of RN coverage was difficult for the LVNs to handle residents' emergencies such as falls, bleeding, intense pain and difficulty breathing, she had to phone/call an RN for advice on assessment/intervention. LVN 2 also stated, the time spent in calling an RN and the Doctor caused delayed treatment that could further worsen the resident's condition. LVN 2 stated, an RN coverage was essential daily including the weekends, due to their advanced assessment skills and decision-making process. During an interview on 9/1/23 at 8:39 a.m., the DON stated, an absence of RN in the facility would potentially decrease the excellence of care and health of residents living at the facility. 056298 Page 3 of 16 056298 09/01/2023 We Care Skilled Nursing - Fremont 2100 Parkside Drive Fremont, CA 94536

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure three (Resident 12, 28 and 40) of five sampled residents were free from unnecessary drugs when; Resident 12, 28 and 40 with Alzheimer Dementia were administered antipsychotic medications without adequate clinical indication for use: Resident 12 was administered Olanzapin (Zyprexa) an antipsychotic medication for fighting and resisting care. Resident 28 was administered Risperdal an antipsychotic for people conspiring against her. Resident 40 was administered Seroquel an antipsychotic for combativeness and hitting staff for no reasons. {Alzheimer's Dementia-is a progressive disease that destroys memory and other important mental functions}. {Antipsychotic medication are drugs used to treat schizophrenia and bipolar serious mental health conditions, capable of affecting the mind, emotions, and behavior}. According to the manufacturer, elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Risperidal, Seroquel and Zyprexa can increase the risk of death in elderly people who have memory loss and is not approved for use in psychotic conditions related to dementia. [Reference: https://www.[NAME].com]. These failures had the potential for residents to receive unnecessary drugs and to suffer adverse medication side effects. Findings: Review of Minimum Data Set (MDS), Resident Assessment and care guide tool, dated 7/17/23, MDS indicated, Resident 12 had short-term and long-term memory problems. Resident 12 was incoherent with rambling conversation was not able to express herself and could not understand others. Resident 12 exhibited no physical or verbal behavioral symptoms towards others such as hitting or scratching and screaming. Resident 12's diagnoses included Non-Alzheimer's Dementia (a group of diseases characterized by progressive deficits in behavior, executive function or language), Review of alteration in behavior care plan initiated 4/12/19, care plan indicated, Resident 12 had behavior manifested by calling out continuously, refuses care/ restlessness, refuses to wear armband and climb out of bed. Review of order summary report dated 6/30/23, summary report indicated, physician prescribed 056298 Page 4 of 16 056298 09/01/2023 We Care Skilled Nursing - Fremont 2100 Parkside Drive Fremont, CA 94536

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident 12 Olanzapine (Zyprexa) 10 mg give one tablet via G-Tube (tube inserted through the belly that brings nutrition directly to the stomach) at bedtime for psychotic disorder manifested by disorganized behavior, fighting and resisting care. Review of the Medication Administration Record (MAR), dated June, July and August 2023, MAR indicated, Resident 12 was administered Zyprexa 10 mg by via G-tube at bedtime for fighting and resisting care. During an interview on 8/29/23 at 8:51am, with Resident 12, in bed in her room. Resident 12 was verbal with incomprehensible sounds. During an interview on 8/29/23 at 8:55 am, with Certified Nursing Assistant (CNA1), CNA1 stated, she was Resident 12's care giver during the morning shift. CNA1 stated, Resident 12 had no behavioral problems, no kicking or fighting. CNA 1 said Resident 12 only screams and talks aloud sometimes. During an interview on 8/31/23 at 10:23 am, Licensed Vocational Nurse/Nurse Supervisor (LVN1) in the presence of Director of Nursing (DON), LVN1 stated, Resident 12 was referred to the psychiatrist and was prescribed Zyprexa for fighting and kicking staff. Review of Consultant Pharmacist note to attending physician, dated 10/19/22, the pharmacist note indicated, Resident 12 has been receiving the antipsychotic medication Zyprexa 10 mg every hour of sleep since 7/2022 for behavioral and psychological symptoms of psychosis/dementia. Please evaluate for possible discontinuation or gradual dose reduction. Further review indicated, the attending physician/Physician Assistant ordered no change to current order. Review of Minimum Data Set (MDS), Resident Assessment and care guide tool, dated 7/29/23, MDS indicated, Resident 28 had clear speech, able to express herself and could understand what others said to her. Resident 28 exhibited no physical or verbal behavioral symptoms towards others such as hitting, kicking, scratching and screaming. Resident 28's diagnoses included Non-Alzheimer's Dementia and psychotic disorder (a mental disorder characterized by a disconnection from reality) Review of alteration in behavior care plan initiated 8/2/21, behavior care plan indicated, Resident 28 behavior manifestation included agitation causing distress and paranoia related to diagnosis of dementia, depression, anxiety and psychosis. Review of order summary report dated 9/10/22, the order summary report indicated, physician prescribed Resident 28 Risperidone tablet 0.25 mg give one tablet by mouth at bedtime for paranoid thoughts. Review of the Medication Administration Record (MAR), dated June, July and August 2023, the MAR indicated, Resident 28 was administered Risperidone tablet 0.25 mg give one tablet by mouth at bedtime for paranoid thoughts. During an interview on 8/29/23 at 10:38 am, with CNA2, CNA2 stated, Resident 28 was pleasant and had no aggressive behavior. CNA2 stated, she was a regular' care giver for Resident 28 during morning shift. During an interview on 8/29/23 at 10:42 am, withLicensed Vocational Nurse (LVN3), LVN3 stated, Resident 28 behavioral symptoms for use of risperdal included refusing medication 056298 Page 5 of 16 056298 09/01/2023 We Care Skilled Nursing - Fremont 2100 Parkside Drive Fremont, CA 94536

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 8/31/23 at 10:23 am, with LVN1 in the presence of DON, LVN1 stated, Resident 28 diagnosis was dementia. After psychiatrist consultation Resident 28 was prescribed Risperdal and diagnosed with psychosis for paranoid thought, people conspiring against her. Review of Consultant Pharmacist note to attending physician, dated 11/28/22, the consultant pharmacist note indicated, Resident 28 had been receiving the antipsychotic medication Risperdal 0.25 mg every hour of sleep since 8/2022 for behavioral and psychological symptoms of psychosis/dementia. Please evaluate for possible discontinuation or gradual dose reduction. During an interview on 9/1/23 at 9:46 a.m., in the presence of DON, with Resident 28's physician (MD 1), MD1stated, Resident 28 felt her family did not frequently visit and support her. MD1 stated, low dose Risperdal was prescribed to make Resident 28's life comfortable. Review of Minimum Data Set (MDS), Resident Assessment and care guide tool, dated 6/18/23, MDS indicated, Resident 40 had a clear speech, sometimes understood and respond adequately to simple direct communication only. Resident 40 exhibited no physical or verbal behavioral symptoms towards others such as hitting, kicking, pushing, screaming at others, scratching or grabbing. Resident 40's diagnoses included Non-Alzheimer's Dementia. Review of alteration in behavior care plan initiated 8/12/21, the care plan indicated, Resident 40 had behavior manifested by striking out, angry outburst, kicking and continuous yelling and screaming. Review of order summary report dated 4/3/23, the order summary report indicated, physician prescribed Resident 40 Seroquel tablet 25 mg give one tablet by mouth at bedtime for dementia with behavior disturbances manifested by combativeness, hitting staff for no reason. Review of the Medication Administration Record (MAR), date June, July and August 2023, the MAR indicated, Resident 40 was administered Seroquel tablet 25 mg one tablet by mouth at bedtime for dementia with behavior disturbances. During an observation on 8/29/23 at 8:59 am, Resident 40 was awake in bed in her room. Resident 40 was pleasant, smiled and whispered during conversation. Resident 40 stated, she was okay. During an interview on 8/29/23 at 9:00 am, with CNA 1, CNA1 stated, Resident 40 was pleasant and no behaviors. During an interview on 8/29/23 at 9:03 a.m., with LVN2, LVN2 stated, Resident 40's behavioral symptoms included throwing object, combativeness, agitation and restlessness. Review of Consultant Pharmacist note to attending physician, dated 10/19/22, Pharmacist note indicated, Resident 40 has been receiving the antipsychotic medication Seroque 12.5 mg every morning since 7/2022 for behavioral and psychological symptoms of psychosis/dementia. Please evaluate for possible discontinuation or gradual dose reduction. Further review indicated the attending physician/Physician Assistant ordered no change to current order. Review of the facility's policy and procedure, titled, Antipsychotic Medication Use revised December 2016, policy and procedure indicated, Diagnosis of a specific condition for which antipsychotic medications are necessary to treat will be based on a comprehensive assessment of the resident. 056298 Page 6 of 16 056298 09/01/2023 We Care Skilled Nursing - Fremont 2100 Parkside Drive Fremont, CA 94536

F 0758 Diagnoses alone do not warrant the use of antipsychotic medication. Level of Harm - Minimal harm or potential for actual harm Antipsychotic medications will not be used if the only symptoms are one or more of the followings: a. Wandering; Residents Affected - Few b. Poor self-care; c. Restlessness; d. Impaired memory; e. Mild anxiety; f. Insomnia; g. Inattention or indifference to surroundings; h. Sadness; i. Fidgeting; j. Nervousness; or k. Uncooperativeness. 056298 Page 7 of 16 056298 09/01/2023 We Care Skilled Nursing - Fremont 2100 Parkside Drive Fremont, CA 94536

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to label according to accepted professional principle and did not safely store drugs and biologicals under proper temperature controls when: 1. Temperature of medication refrigerator on Stations 1 & 2's Medication Room were not within the recommended temperature range. 2. Expired pharmaceutical products were stored in Medication Cart #2. 3. Pharmaceutical products stored in Med Cart# 2 were opened and not dated. 4. Non-pharmaceutical products were stored in the Medication Cart #2. This failure had the potential for residents to receive ineffective medications and treatments. Findings: 1. During a concurrent observation and interview on 8/28/23 at 11:22 a.m. with Licensed Vocational Nurse (LVN) 1 in the medication room [ROOM NUMBER], LVN 1 stated, the temperature of the medication refrigerator containing pharmaceutical products, was 32-33 degrees Fahrenheit (unit of measurement). LVN 1 stated, the recommended temperature is 36-46 °F. During a concurrent observation and interview on 8/29/23 at 9:37 a.m. with LVN 1 in the medication room [ROOM NUMBER], LVN 1 stated, the temperature of the medication refrigerator was 32°F- out of acceptable range. During an interview on 8/29/2023 at 11:02 a.m. with Director of Nursing (DON), the DON stated, the medications in the refrigerator would not be effective, if stored outside the recommended temperature range of 36°F - 46 °F. During a review of facility's document titled Temperature Log, dated August 2023, the document indicated the medication refrigerator acceptable range: 36°F - 46 °F. 2. During an inspection on 8/28/23 at 11:27 a.m. of medication cart 2 in nursing Station 2, LVN 14 verified, two insulin pens (medication used to lower high blood sugar levels) and one insulin bottle was out of date. During an interview on 8/29/23 at 11:05 a.m. with the DON, the DON stated expired medications should have been pulled out of the medication cart as the expired medications will not be effective. During a review of the facility's policy and procedure (P&P) titled, Storage of Medications, dated April 2007, the P&P indicated, All medications maintained in the facility shall be properly labeled in accordance with current state and federal regulations .the facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. 056298 Page 8 of 16 056298 09/01/2023 We Care Skilled Nursing - Fremont 2100 Parkside Drive Fremont, CA 94536

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 3. During an inspection on 8/28/23 at 11:29 a.m. of medication cart 2 in nursing Station 2, LVN 14 verified two bottles of blood glucose strips (test strips used to measure the blood sugar level in the blood) had no open date. During an inspection on 8/28/23 at 11:31 a.m. of medication cart 2 in nursing Station 2, LVN 14 verified three bottles of latanoprost eyedrop (used to treat eye condition) had no open date and a bottle of brimonidine tartrate eyedrop (also used to treat a certain eye condition) had an unreadable black marking. During an interview on 8/29/23 at 11:35 a.m. with LVN 14, LVN 14 was unable to determine the proper expiration date for the pharmaceutical products. During an interview on 8/29/23 at 11:37 a.m. with DON, she stated eyedrops and blood glucose strips were to be labeled with open date once opened. DON stated, eyedrops expires within 28 days and blood glucose strips were according to manufacturer's expiration date. During a review of the facility's policy and procedure (P&P) titled, Labeling of Medication Containers, dated April 2007, the P&P indicated, All medications maintained in the facility shall be properly labeled in accordance with current state and federal regulations .Medication labels must be legible at all times .Any medication packaging or containers that are inadequately or improperly labeled shall be returned to the issuing pharmacy .Labels for each floor's stock medications shall include all necessary information, such as: the expiration date when applicable. 4. During an inspection on 8/28/23 at 11:33 a.m. of medication cart 2 locked box for controlled drugs, LVN 14 verified items of: jewelry on a zip lock bag, keys on a plastic container, an opened box of wander guard (device worn by resident to alert staff when resident wanders out of the facility) wander guard testing device, and envelope with a black paper clip. During an interview on 8/29/23 at 11:35 a.m. with LVN 14, LVN 14 acknowledged that the non-pharmaceutical products should not have been stored in the medication cart. During an interview on 8/29/2023 at 11:39 a.m. with DON, DON she stated, medications only should be on the medication carts. The DON also acknowledged that having random non-pharmaceutical items in the medication cart could potentially contaminate the medications stored in the cart. During a review of the facility's policy and procedure (P&P) titled, Storage of Medications, dated April 2007, the P&P indicated, The facility shall store all drugs and biologicals in a safe, secure, and orderly manner .The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe and sanitary manner. 056298 Page 9 of 16 056298 09/01/2023 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, interviews and record review, the facility failed to ensure food are stored under sanitary conditions when; Residents Affected - Many The following food items in refrigerator were not labeled and no use by date: One bottle of jalapeno peppers opened 8/8/23 with no use by date One container of garlic in water opened, unlabeled with no use by date One container of beef base opened with no use by date Walk in freezer was cluttered with several boxes of food items. These failures had the potential to result in food borne illnesses. Findings: During the initial tour of the kitchen on 8/28/23 at 10:30 a.m., accompanied by Dietary Supervisor (DS) the followings were observed in the walk-in refrigerator; one bottle of jalapeno peppers opened 8/8/23 with no use by date; one container of garlic in water opened and unlabeled with no use by date; one container of beef base opened with no use by date. Walk-in freezer was cluttered with several boxes of food items over each other and tightly packed with no space to check food items. During an interview on 8/28/23 at 10:43 a.m. with DS, DS stated, food items must be labeled and dated when opened and placed in the refrigerator with use by date. DS stated, the walk-in freezer was cluttered since when she was hired 10 months ago. Review of the facility's policy and procedure, titled Labeling and Dating of Foods dated 2020, indicated ; All food items in the storeroom, refrigerator, and freezer need to be labeled and dated. 056298 Page 10 of 16 056298 09/01/2023 We Care Skilled Nursing - Fremont 2100 Parkside Drive Fremont, CA 94536

F 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to follow food safety requirements when following was noted: Residents Affected - Many 1. Food items kept in the refrigerator designated for food brought from outside the facility were not labeled and not separated from staff's food. 2. Facility did not allow heating/ reheating cold food leftovers for residents brought from outside. These failures had the potential to cause foodborne illness for residents in the facility. Findings: During a concurrent observation and interview on 8/31/23 at 12:04 p.m. with the Assistant Director of Nursing (ADON), at nursing station one's medication room, the ADON opened a 3.7 cubic foot refrigerator located inside nursing station one's medication room. A small, circular, clear, plastic container that contained small, chopped pieces of yellow food labeled with Resident 16's name, dated 8/29/23; and a small, clear, unlabeled and undated container with a blue lid that contained white pasta was in the refrigerator. The ADON stated, facility policy was to label food with the item and use by date. The ADON stated, she was unable to find who the unlabeled food belonged to. Licensed Vocational Nurse 1 (LVN 1) then walked in the medication room and stated, the unlabeled and undated container with the blue lid belonged to them. LVN 1 stated, staff food should not be stored in the refrigerator designated for residents' food brought from outside the facility. During an interview with LVN 14 on 8/31/23 at 12:16 p.m., LVN 14 stated, she was unable to reheat food for residents because staff did not have food thermometer available to check the temperature of the food. During an interview with Certified Nursing Assistant (CNA) 4 on 8/31/23 at 12:18 p.m., CNA 4 stated she was unaware that staff was to label the date on residents' food/ leftovers brought from outside prior to keeping them in the refrigerator. CNA 4 stated, she labels leftover food items only with residents' name. During an interview with Family Member 1 (FM 1- family of a resident who was identified as eating food from home) on 9/1/23 at 9:42 a.m., FM 1 stated, they never received a copy of the facility's foods brought by family/visitors policy. FM 1 stated, facility staff told them that they would not warm food brought from home and to only bring enough food for that specific mealtime. During a review of the facility's Policy and Procedure (P&P) titled Foods Brought by Family/Visitors revised 10/ 2017, the P&P showed, .Facility staff will strive to balance resident choice and a homelike environment .2. Nursing staff will provide family/visitors who wish to bring foods to the 056298 Page 11 of 16 056298 09/01/2023 We Care Skilled Nursing - Fremont 2100 Parkside Drive Fremont, CA 94536

F 0813 Level of Harm - Minimal harm or potential for actual harm facility with a copy of this policy. Residents will also be provided a copy in a language and format he or she can understand .7b. Perishable foods must be stored in re-sealable containers with tightly fitting lids in a refrigerator. Containers will be labeled with the resident's name, the item and the [use by] date . Residents Affected - Many 056298 Page 12 of 16 056298 09/01/2023 We Care Skilled Nursing - Fremont 2100 Parkside Drive Fremont, CA 94536

F 0849 Level of Harm - Minimal harm or potential for actual harm Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. Based on interviews and record review, the facility failed to coordinate care planning in collaboration with resident, family and hospice care provider for one (Resident 2) of two sampled residents. Residents Affected - Few This failure had the potential to result in residents to not received person centered care. Findings: Review of Resident 2's Minimum Data Set, Resident Assessment and Care Screening, dated 6/11/23, indicated Resident 2 diagnoses included Non-Alzheimer's Dementia (a group of diseases characterized by progressive deficits in behavior, executive function or language), schizophrenia ( a disorder that affects a person's ability to think, feel and behave clearly) and encounter for palliative care and on hospice care ( a type of care that focuses on interdisciplinary approach to specialized nursing care for people with life limiting illnesses, available to people with a life expectancy of six months or less, does not focus on treatments to cure the cause of the terminal illness. It seeks to keep the individual comfortable and make their remaining time as meaningfully as possible). Review of order summary report, dated 12/5/2020, the summary report indicated, Resident 2 was admitted to hospice care. Review of hospice care plan initiated 12/6/2020, the care plan indicated, Resident 2's was on routine level of hospice care with terminal diagnosis of COPD ( a group of lung disease that block airflow and make it difficult to breathe). Further review of Resident 2's care plans on 8/30/23 at 8:57 a.m., with Registered Nurse/Assistant Director of Nursing (ADON) in the presence of Director of Nursing (DON), the care plan indicated, hospice representatives did not participate in Resident 2's care planning. During an interview on 8/29/23 at 9:50 a.m., with the Social Service Designee (SSD), SSD stated, facility had invited hospice provider for care plan conferences. SSD stated, hospice staff had not attended and participated in Resident 2's care plan conferences because hospice case manager said they cannot attend because they are short of staff. SSD could not provide documentation of communication with Resident 2's hospice provider regarding coordination of care plan conferences. During an interview on 8/30/23 at 8:57 a.m., with ADON in the presence of DON, ADON stated, she and Social Services Director (SSD) were assigned as contact with hospice provider. ADON stated, facility's Interdisciplinary Team (IDT -group of healthcare professionals with various areas of expertise who work together toward the goals of their clients ) had not met with hospice representatives to coordinate care planning conference with Resident 2, family and hospice provider. ADON stated, hospice provider did not participate in Resident 2's care plan conferences. The facility's policy and procedure, titled, Hospice Program, revised July 2017, policy and procedure indicated, Collaborating with hospice representatives and coordinating facility staff participation in the hospice care planning process for residents receiving these services. Coordinated care plans for residents receiving hospice services will include the most recent hospice plan of care as well as the care and services provided by our facility including the responsible 056298 Page 13 of 16 056298 09/01/2023 We Care Skilled Nursing - Fremont 2100 Parkside Drive Fremont, CA 94536

F 0849 provider and discipline assigned to specific tasks in order to maintain the resident's highest practicable physical, mental, and psychosocial well-being. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 056298 Page 14 of 16 056298 09/01/2023 We Care Skilled Nursing - Fremont 2100 Parkside Drive Fremont, CA 94536

F 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation, interviews and record review the facility failed to maintain ice machine in a safe and proper working condition when ice machine located in the kitchen was not sanitized per manufacturers instructions. Residents Affected - Many This failures had the potential to result in food borne illnesses. Findings: During an observation and concurrent interview on 8/28/23 at 11:12 a.m., the ice machine located in the kitchen was filled with water and small tiny ice floating in the ice bin. DS stated, the ice machine was not harvesting ice properly, freezes from time to time and had to be unplugged to dispense ice. DS said she had complained about the ice machine not making proper ice for several months. During an interview on 8/29/23 at 9:33 a.m., with [NAME] (CK), CK stated, ice machine freezes up ice and had to be un plug from time to time. Ck stated, the ice from ice machine are used in the kitchen, distributed to ice chest placed outside the nurses station for residents use. CK stated, she had worked in the Kitchen for 20 years. During an interview on 8/29/23 at 9:35 a.m., with Dietary Aide (DA 2), D2 stated, ice from ice machine are distributed to ice chest cooler, place at the nurses station and hall ways for residents' use. During an interview on 8/31/23 at 9:52 a.m., with Administrator (Admin), Admin stated, ice machine started having problem with harvesting ice from time to time in June 2023. Admin stated, the ice machine problem progressing got worse. Admin stated, Ice machine was last sanitized in June 2023. Admin stated, routine ice machine sanitation was not included in the preventative maintenance contract. During an interview on 8/31/23 at 1:22 a.m., with Registered Dietician (RD), RD stated, she visited facility weekly on Thursdays. RD stated she checked kitchen for sanitation practices. RD stated, she was aware the ice machine was having trouble making ice from time to time. RD stated, she had not looked for the ice machine sanitation log. During an interview on 9/1/23 at 10:39 a.m., with DS, DS stated, she was told by Maintenance Supervisor (MS) that the ice machine was to be sanitized annually by an outside contractor. DS stated ice machine could incubate bacteria when not sanitized per manufacturer instruction. Review of the Maintenance Manual-Ice Series Cubers date 02/2020, indicated; General Maintenance Procedure; Cleaning Instruction for Ice-O-Matic CIM Series Ice Machines: Note: Proper cleaning of an ice machine requires two parts: descaling and sanitizing. Sanitizing should be performed after each descaling but no more than once per month. Sanitizing disinfects the machine and removes microbial growth including mold and slime. Ice-O-Matic requires anickel-safe sanitizer such as Nu-Calgon ImS-III or equivalent diluted per manufacturer instructions. To insure economical, trouble free operation of your machine, it is recommended that the following maintenance be performed every 6 months. Clean the ice-making section per the instructions below: 056298 Page 15 of 16 056298 09/01/2023 We Care Skilled Nursing - Fremont 2100 Parkside Drive Fremont, CA 94536

F 0908 Level of Harm - Minimal harm or potential for actual harm Routine cleaning with Cleaning should be performed a minimum of every 6 months. Local water conditions may require that cleaning be performed more often. (Reference: www.iceomatic.com) Residents Affected - Many 056298 Page 16 of 16