Health inspection·May 13, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to promote respect and dignity for one of one resident (Resident 1) when Social Services (SS) A told Resident 1 she would call 911 (a telephone number for emergencies) for a 5150 (the number of the section of the Welfare and Institutions Code, which allows an adult who is experiencing a mental health crisis to be involuntarily detained for a 72- hour psychiatric hospitalization when evaluated to be a danger to others, or to himself or herself, or gravely disabled) assessment when the resident was trying to advocate for her roommate. This failure had the potential to negatively affect the resident's dignity and psychosocial well-being. Findings: Review of Resident 1's face sheet (a document that gives a resident's information at a quick glance) indicated Resident 1 was admitted to the facility on [DATE] with diagnoses of type 1 diabetes (a lifelong condition where the pancreas makes little or no insulin, which leads to high blood sugar levels), major depression disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), pancreatic cancer (cancer that begins in the organ lying behind the lower part of the stomach pancreas), absence of both upper limbs below elbows and both legs above knees. Review of Resident 1's Minimum Data Set (MDS, a clinical assessment tool), dated 3/19/24, indicated Resident 1 had a brief interview for mental status [BIMS, a tool used to assess cognition (knowing, learning, and understanding things)] score of 15 [a score of 0 to 7 indicates severe cognitive impairment, 8-12 moderate impairment, 13-15 patient is cognitively intact]. During an interview on 4/22/24 at 12:00 p.m. with Resident 1, Resident 1 stated she was trying to advocate for her roommate who was having a fever on 4/14/24, however [SS A's name] came to the room and told Resident 1 that she was going to call 911 and tell them Resident 1 was 5150, and they were going to take her away. She also stated [SS A's name]'s statement made her feeling threatened. So she called the police herself because she did not think she should be treated that way. She further stated nobody came to her to clarify anything after the incident, and the management did not address the issue. During an interview on 4/22/24 at 2:04 p.m. with Licensed Vocational Nurse (LVN) B, LVN B stated (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 2 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 05/13/2024 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)