Health inspection·July 5, 2023

F 0742 pinching/scratching/spitting, gabbing, biting, and pushing. Level of Harm - Minimal harm or potential for actual harm Review of Resident 2's Skilled Charting note dated 9/9/2022 at 3:41 p.m., showed he did not exhibit any signs/symptoms of delirium, or physical/verbal behaviors. Residents Affected - Few Review of Resident 2's Behavior Notes indicated: 1. On 9/9/2022 at 5:41 p.m.: attempted to exit out the side door of the facility. When the Licensed Vocational Nurse (LVN) attempted to calm the resident down and redirect him into his room, the resident became verbally aggressive and agitated. 2. On 9/9/2022 at 9:23 p.m.: yelling slurs, cursing, and was agitated with the staff. 3. On 9/22/2022 at 10:22 p.m.: continuously kicking the door at 9 p.m., refusing medications, difficult to redirect, other residents were complaining of the noise, 4. On 9/27/2022 at 7 a.m. (late entry): DON and ADON notified of inappropriate behavior, behavior has been ongoing but progressively worsening since COVID isolation, yelling, cursing at staff, throwing items in room, writing on walls and furniture, scratched both sides of the face and bit Certified Nursing Assistant (CNA) C on his forearm. 5. On 9/28/2022 at 6:41 a.m. (late entry): kicking, biting, and yelling at staff, defacing furniture. 6. On 9/29/2022 at 7:09 a.m.: combative, screaming and cursing at the staff, unable to redirect and console, started throwing items in the room (chairs, tables, trash bins), kicking bathroom door, writing on the walls, used furniture to block the door, and refused care. 7. On 9/30/2022 at 5:41 a.m. (late entry): barricade himself in room blocking entrance, yelling obscenities, and banging on the walls. 8. On 9/30/2022 at 6:42 a.m.: locked himself in the room, barricading entrance door, yelling, calling names, and writing on furniture. 9. On 9/30/2022 (3 days after DON notified of behaviors) at 10:47 a.m.: refused help, combative, tried to leave the facility several times, screaming profanities at staff, barricaded door, DON notified and 911 was called. Review of Resident 2's Incident Note dated 9/30/2022 at 2 p.m., showed the DON documented this morning it was reported Resident 2 was exhibiting behaviors putting the staff and resident at risk for harm. The DON, the Assistant Director of Nurses (ADON) and the Director of Social Service (DSS) approached Resident 2's room and when the resident was asked if they may enter, he slammed the door, was calling out profanities and barricaded the door shut. The DON, ADON and DSS noted profanities written on the walls in Resident 2's room and on the door frame. In addition, the staff heard noises of furniture being thrown around in Resident 2's room. The staff then called 911 (emergency number) and three police officers attempted to enter Resident 2's room for about 10 minutes before they were able to open the door and enter Resident 2's room. Resident 2 was then placed on a 5150 hold. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055866 If continuation sheet Page 2 of 4 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 055866 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Plum Tree Care Center 2580 Samaritan Drive San Jose, CA 95124 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 0742 The Administrator's Interview Records showed: Level of Harm - Minimal harm or potential for actual harm a. On 9/30/2022, CNA C: Resident 2's behaviors became worse when he got COVID (per admission Record: COVID 9/21/2022). The resident was trying to exit the building and as he was changing his clothes, Resident 2 scratched CNA C's face and bit his right forearm. In addition, Resident 2 continued to hit and kick CNA C and was yelling. Residents Affected - Few b. On 9/30/2022, Licensed Vocational Nurse (LVN) F: Resident 2 is very volatile, very angry, throws a fit, pounds on the wall. Resident 2 would barricade himself in his room, kick and throw stuff. c. On 9/30/2022, CNA D: he (Resident 2) was horrible, he was very angry and agitated, he would throw things and bang on the wall. His neighbor (another resident) would respond and bang on the wall as well. I was not able to take care of him because of his agitation. d. On 10/4/2022, Resident 3 (next door from Resident 2) stated Resident 2 would yell at the staff using profanity, bang on the wall, and moving furniture inside his room. He stated at 2-3 a.m., Resident 2 would be playing his keyboard (musical instrument). I am glad he (Resident 2) is gone from the facility. Review of Resident 2's Emergency Department Provider Report dated 9/30/2023 at 11:39 a.m., showed the resident was sent to the emergency room for altered mentation. The skilled nursing facility staff stated Resident 2 was getting progressively more confused and, in the ER, was placed on a hold given his agitation and concerns for grave disability. The resident was on day 9 of 10 for COVID isolation. Review of Resident 2's Emergency Department Module/Management (EDM) Note dated 9/30/2022 at 12:07 p.m., showed the resident was very confused, aggressive, somewhat combative at times and very hard to redirect. Review of Resident 2's hospital's Admission/Shift assessment dated [DATE] at 6:30 p.m., showed he had slurred, disorganized speech and short- and long-term memory impairment. On 6/27/2023 at 2:45 p.m., an interview was conducted with the Administrator. When she was asked the reason Resident 2 was not evaluated for his change in behaviors until he was sent to the emergency room on 9/30/2022, she stated the resident was redirectable. A follow-up email from the Administrator was received on 6/28/2023 at 4:37 p.m. The Administrator stated Resident (2) was stable at the hospital for several days with routine medications that we could manage. Resident was admitted on [DATE]. First week was without incident. On 9/9/22 there was some verbal aggression, however the patient was redirected and able to be calm after that. Resident 2 contracted COVID on 9/21/22 and struggled with isolation requirements. On 9/22/23 resident had kicking the door behaviors and we were able to get him to calm down. On 9/27 resident had an incident with a CNA and scratched the CNA. On 9/28 defacing furniture. Neither the 9/27 or 9/28 would qualify for a 5150. The police will only 5150 a patient if they witness the behavior and must be a danger to self or others, and only if they cannot get them to calm down. On 7/3/2023 at 3:10 p.m., a telephone interview was conducted with CNA D. She stated Resident 2 had behavior episodes of verbal and physical aggression. CNA D stated the resident would block his entrance door with overbed tables and isolation bins. He would swear and curse at the staff, and you could hear him (the resident) banging on the walls and throwing things in his room. CNA D stated other (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055866 If continuation sheet Page 3 of 4 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 055866 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Plum Tree Care Center 2580 Samaritan Drive San Jose, CA 95124 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 0742 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few residents would hear Resident 2 banging all night and Resident 3 complained about the noise. When CNA D was asked how often Resident 2 would bang on the walls and throw things, she stated definitely every night, more than a week and the facility did nothing about it. She stated she knew Resident 2 had scratched CNA C's eye. On 7/4/2023 at 7:55 a.m., a telephone interview was conducted with CNA C. He stated Resident 2 was confused intermittently and his behaviors became worse a few days after he developed COVID (9/21/2022) and was placed in isolation. CNA C stated Resident 2 got resistive to care, became aggressive with exit seeking, and would throw things (furniture) inside his room. He stated Resident 2 scratched his face (CNA C), knocked my eyeglasses off and clawed me from the hairline to my chin. In addition, he stated Resident 2 also bit my left forearm through the isolation gown and broke the skin, hit me a couple of times and punched me. CNA C stated Resident 2 would barricade himself inside his room, would throw things and played his piano at night at a maximum volume. CNA C stated other residents, including Resident 3, constantly complained about Resident 2's behaviors and he reported these incidents to the nurse who notified the management team. When CNA C was asked about Resident 2 writing on the walls, he stated he witnessed Resident 2 writing profanities and racial slurs on the wall and on the bed, trash cans, at least a dozen different locations. He stated two days later, Resident 2 was transferred out of the facility. Clinical record review for Resident 3 was conducted on 7/5/2023. His MDS dated [DATE] showed he was cognitively intact and had no behavior problems. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055866 If continuation sheet Page 4 of 4