Inspection·October 11, 2023

F 0684 Level of Harm - Actual harm Residents Affected - Few 1. During an observation and interview with Resident 2 in his room on 9/21/2023 at 1:07 p.m., Resident 2 was up in a wheelchair. Resident 2 stated he (Resident 2) felt sad, and repeatedly asked staff when the mortuary will be coming to pick up the body. Resident 2 also stated he (Resident 2) was bothered by the smell seemed like came from the body. Resident 2 further stated he (Resident 2) does not want to deal with that smell again in the facility. Resident 2's minimum data set (MDS: clinical and functional assessment tool) assessment dated [DATE] indicated, Resident 2's brief interview for mental status (BIMS) score of 13 of 15 (13-15: Intact cognition). Resident 2's assigned room was located opposite to Resident 1's room. 2. During an observation and interview with Resident 3 in his room on 9/21/2023 at 1:20 p.m., Resident 3 was observed sitting in a wheelchair next to his bed. Resident 3 stated felt sorry for the resident who died in facility and staff unable to send the body to mortuary till next day. Resident 3 also stated he (Resident 3) was sad worried and hoped facility would not keep his body in the facility long time when he dies. Resident 3 stated he kept on asking staff when the mortuary would be coming to pick up the body. Resident 3 further stated he could smell in his room most likely that smell came from the body, and he (Resident 3) wished no one could have to smell that kind of smell in their life. Review of Resident 3's face sheet indicated Resident 3 was admitted to facility on 5/14/2021 with current diagnoses including depressive, adjustment disorder (an emotional or behavioral reaction to a stressful event or change in resident's life), and transient cerebral ischemic attack (a temporary blockage of blood flow to the brain). Review of Resident 3's MDS assessment dated [DATE] indicated, Resident 3's BIMS score of 15 of 15, intact cognition. Resident 3's assigned room was located opposite to Resident 1's room. 3. During an observation and interview with Resident 4 in her room on 9/21/2023 at 1:40 p.m., Resident 4 was observed sitting in a chair in her room. Resident 4 stated she (Resident 4) felt sad and emotionally heartbroken when she (Resident 4) heard about facility was not able to release the body till next day. Resident 4 further stated she (Resident 4) remembered the smell from the body and not able to forget. Review of Resident 4's face sheet indicated Resident 4 was admitted to facility on 9/23/2022, with current diagnoses including psychotic disturbance (a mental disorder characterized by a disconnection from reality), mood disturbance (a mood disorder is a mental health condition that primarily affects person's emotional state), and anxiety (a disorder involves more than temporary worry or fear). Review of Resident 4's MDS assessment dated [DATE] indicated Resident 4's BIMS score of 15 of 15, intact cognition. Resident 4's assigned room was located opposite to Resident 1's room. During an interview with certified nursing assistant B (CNA B) on 9/21/2023 at 2:15 p.m., CNA B said she (CNA B) could smell strong odor from Resident 1's dead body. CNA B said she (CNA B) observed some kind of fluid came out of Resident 1's mouth when mortuary staff came to pick up the body on 8/9/2023. CNA B also stated Resident 2, and Resident 3 were looked sad, worried and did not eat breakfast on 8/9/2023. CNA B stated both Resident 2 and 3 were kept on asking CNA B when the Resident 1's body would be removed from the facility. CNA B further stated Resident 4 was quiet, appeared sad, and did not speak much on 8/9/2023. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055388 If continuation sheet Page 2 of 3 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 055388 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Jose Healthcare & Wellness Center 75 N. 13th Street San Jose, CA 95112 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)

F 0684 Level of Harm - Actual harm Residents Affected - Few During an interview with facility's administrator (ADMN) on 9/21/2023 at 3:30 p.m., the ADMN confirmed Resident 1's body was released to mortuary on 8/9/2023 at 9 a.m. The ADMN stated miscommunication between nursing staff and previous DON in handling the mortuary situation for Resident 1 has potentially caused in delay to release the body. ADMN stated nursing staff should have released Resident 1's body to mortuary within 4 hours after Resident 1's death. During a telephone interview with LVN C on 9/25/2023 at 3:38 p.m., LVN C stated she spent time to find a mortuary to release the Resident 1's body affected her work that night. LVN C stated she was told by public administrator (PA: this office gets involved when there is no one else with higher authority to act when resident has no next of kin)'s office staff, they cannot send mortician to pick up the body. LVN C stated she made telephone calls during that night to several mortuaries in the area with no success and no help from DON, or ADMN till the next morning. LVN C also stated Resident 2, and Resident 3 did not sleep during night on 8/8/2023. LVN C stated Resident 2 and Resident 3 seemed worried and kept on asking LVN C for when Resident 1's body would be removed from facility. LVN C further stated Resident 2, Resident 3, and Resident 4 had verbalized feeling sad about facility not able to release the body to mortuary. During an interview with Resident 2 on 9/28/2023 at 7:44 a.m., Resident 2 stated he (Resident 2) did not sleep during the night on 8/8/2023. Resident 2 also stated he missed the sleep and felt sad that night. Resident 2 further stated he lost interest in food due to the smell from the body, he stated he ate very little breakfast on 8/9/2023. During an interview with Resident 3 on 9/28/2023 at 7:50 a.m., Resident 3 stated did not sleep whole night on 8/8/2023. Resident 3 stated he could not sleep by knowing a body was near to his room. Resident 3 also stated he lost his appetite and did not eat breakfast on 8/9/2023. Resident 3 stated he was scared and worried about what would happen to his body when he dies in facility. Resident 3 further stated he desperately waited that night for Resident 1's body to be removed from the facility. During an interview with Resident 4 on 9/28/2023 at 8:00 a.m., Resident 4 stated she felt emotionally sad and did not want to talk to anyone. Resident 4 also stated she was emotionally scarred from the fact that the facility kept the body until it started smelling bad. During a telephone interview with the DON on 10/3/2023 at 2:20 p.m., the DON stated, definitely could have caused emotional distress for other residents in the facility when body was kept more than 12 hours. Review of facility's policy and procedure (P&P) titled, Identifying a Mortuary, revied, dated 7/14/2017, the P&P indicated, The facility will obtain information regarding the resident's preferred mortuary to ensure a timely transfer of the body following a resident's death. If the resident/resident representative has not informed the facility of their choice of mortuary, and the resident expires, efforts will be made to contact the representative. If the resident representative cannot be contacted within 4 hours, the body will be released to a mortuary on the facility referral list. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055388 If continuation sheet Page 3 of 3