Health inspection·April 29, 2024

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. 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 ensure services provided met professional standards of practice when a licensed nurse (LN) did not ensure medications were taken for one of one sampled resident (Resident 1). For Resident 1 LN did not observe medications were taken after giving the medications to the Resident. This finding had the potential to compromise Resident 1's health and safety. Residents Affected - Few Review of Resident 1's Face Sheet (document that contains a summary of personal and demographic information), indicated Resident 1 was admitted to the facility on [DATE] with diagnoses of unspecified fracture (break in a bone) of the upper end of the right humerus (upper end of the arm bone) and superior rim of the right pubis (bone that forms the front of the pelvis), wedge compression fracture of the third lumbar vertebra (bones located in the middle of the spine), Hyperlipidemia (elevated levels of fats in the blood), Hypertensive Heart Disease (changes in the heart as a result of chronic high blood pressure) and Unspecified Atrial Fibrillation (irregular and often very rapid heart rhythm). Review of Resident 1's Minimum Data Set (MDS, as assessment tool), dated 12/24/23, indicated Resident 1 had moderate cognitive impairment (problems with a person's ability to think, learn, remember, use judgement, and make decisions). Review of Resident 1's Physician Orders, dated 12/19/23, indicated to give the following a.m. meds: a. Acetaminophen (Tylenol, pain medication) 500 mg (mg, a metric unit of measurement) 1 tablet every 8 hours for pain management; b. Amlodipine Besylate (used to treat high blood pressure) Oral Tablet 5 mg 1 tablet one time per day for HTN (HTN, hypertension [high blood pressure]); c. Atorvastatin Calcium (used to lower fats in the blood) Oral Tablet 40 mg 1 tablet one time per day for hyperlipidemia (high levels of fat in the blood); d. Dabigatran Etexilate Mesylate (used to decrease the risk of stroke and blood clots) 1 capsule two times per day for Atrial Fibrillation (irregular heartbeat); e. Docusate Sodium (used to manage and treat constipation) 250 mg 1 capsule two times per day for constipation; f. Fluticasone-Salmeterol Inhalation Aerosol (used to prevent asthma attacks) 2230-21 2 puffs inhale two times per (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 3 Event ID: 055750 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 055750 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westwood Post Acute 1601 Petersen Avenue San Jose, CA 95129 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)