Health inspection·June 11, 2024

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the physician promptly for one of one resident (Resident 1) when Physical Therapist (PT, who promote, maintain, or restore health through patient education, physical intervention, disease prevention, and health promotion) A did not communicate with Resident 1's charge nurse when the resident fell during her physical therapy session and sustained minor injuries. This failure had the potential to result in a delay of assessment and possible treatment to Resident 1. Findings: Review of Resident 1's face sheet (a document that gives a resident's information at a quick glance) dated 6/11/24 indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses of oral surgical aftercare, cancer, reduced mobility. Review of Resident 1's SBAR & INITIAL COC/ALERT CHARTING & SKILLED DOCUMENTATION (a documentation for change of a resident's conditions) dated 4/24/24 at 3:53 p.m. indicated, Date & Time Problem or Symptom Started: 04/24/2024 12:00 [p.m.], Resident's son informed writer and ADON [Assisted Director of Nursing] that resident fell during therapy outside of the facility. Resident noted with a small excoriation on bilateral knees. Resident denies pain. MD [Medical Doctor] and RR [responsible representative] notified. During an interview on 6/11/24 at 1:02 p.m. with the Director of Rehab (DOR), the DOR stated rehab staff would report to the DOR and let the charge nurse know if a resident fell during a therapy session, a change in condition for fall would be completed, the therapist would complete a rehab post fall assessment. IDT (interdisciplinary team, a group of healthcare professionals) would meet to discuss new interventions, such as rehab recommendations. The DOR further stated the therapist did not reported to the nursing staff because Resident 1's son reported the incident before him. During an interview on 6/11/24 at 1:57 p.m. with ADON B, ADON B stated on 4/24/24, Resident 1 went out with PT A around noon, but Resident 1's fall was reported by a family member a little before 3, it was almost change of shift. The charge nurse and ADON B went to assess the resident for injury right away after they found out the fall, no major injury was noted, they notified the MD and performed treatment to Resident 1's knees. PT A should have informed the nursing department for any changes of a resident right away, not sure why it was not reported timely. ADON B further stated due to the delay of reporting, there could potentially cause a delay of assessment and treatment. (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 06/11/2024 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)