Health inspection·January 21, 2025

F 0624 Prepare residents for a safe transfer or discharge from the nursing home. 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 safe and orderly discharge for one (Resident 1) out of 2 residents when Resident 1 was discharged without established home health as ordered by the physician. Residents Affected - Few This failure had the potential to put Resident 1 in danger upon returning to his home without a proper care and treatment. Findings: A review of Resident 1's medical records indicated, admission date of 1/7/24 and discharged date of 1/1/25. A review of Resident 1's diagnoses included hearing loss, gastrostomy (a surgical procedure where a tube is inserted through a small opening in the abdomen directly into the stomach) and malignant neoplasm of larynx (a cancerous tumor that forms in the voice box). A review of Resident 1's Interdisciplinary Discharge summary dated [DATE] indicated, .Transportation: Private, pick up by friend .Diet Order and Texture: three times a day enteral bolus feeding via GT [gastrostomy tube] . A review of Resident 1's Physician Orders indicated, May D/C [discharge] home on [DATE] with HH [home health], PT [physical therapy], OT [occupational therapy], ST [speech therapy], RN [registered nurse] with DME [durable medical equipment such as, wheelchair, walker, oxygen tanks, etc.] and feeding supplies. A review of Resident 1's face sheet (document that summarizes a patient's personal and medical information) indicated Resident 1's address was located away in another county very far from the county where the facility is located. During a concurrent interview and record review of Resident 1's medical records with the Social Services Assistant (SSA) on 1/3/25 at 3:13 p.m., the SSA stated Resident 1 was discharged without an approved IHSS (In-Home Supportive Services, a state program that helps low-income, elderly, blind, or disabled people pay for in-home care). The SSA also stated, Resident 1 was picked by her (SSA's) friend (SSAF) via private car on 1/1/25 and SSAF was a certified nurse aide who will look after Resident 1. The SSA verified that Resident 1 had no companion at home. The SSA also stated, Resident 1 cannot talk and used his phone to communicate via text messaging. The SSA provided the contact number for the home health agency (HHA) for Resident 1. (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 01/21/2025 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)