Health inspection·October 31, 2023

F 0624 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few insulin that works slowly over about 24 hours to control blood sugar levels) Solution 100 Units/ML Inject 30 units subcutaneously every 12 hours for diabetes. Review of Resident 1's physician orders upon discharge to B&C home on 9/12/2023 indicated, insulin glargine 100 unit/ml solution inject 30 units subcutaneously every 12 hours, Humalog solution 100 units/ml inject subcutaneously as per sliding scale with each meal, at bedtime, and as needed for diabetes. Review of Resident 1's physician orders dated 9/11/2023 indicated, May DC home 9/12/2023 w/PT (physical therapy: a care that aims to ease pain, and help function, move and strengthen muscles) /OT (occupational therapy: helps to learn and regain skills of daily living)/ RN (registered nurse: licensed medical professional who provides hands- on care to residents)/HH (home health: a wide range of health care services that can be given at home for an illness or injury). Resident 1's IDT (interdisciplinary team: a group of dedicated healthcare professionals who work together to provide the care resident needs and when needed) planned Discharge summary dated [DATE] indicated, Resident 1 was discharge with medication list. Further review of this discharge summary indicated, no documented evidence of IDT discussed and implemented the plan to meet Resident 1's blood glucose monitoring, and insulin administration care needs at B&C home after discharged from facility on 9/12/2023. Review of Resident 1's nursing Discharge summary dated [DATE] at 17:26 indicated, Pt discharged to B&C home @ 1600. Pt discharged on w/c (wheelchair: a chair on wheels that people who are unable to walk use for moving around), picked up by the driver of the receiving facility. Review of Resident 1's clinical record indicated, there was no documented evidence of facility planned, implemented, and confirmed to meet Resident 1's blood glucose monitoring, and insulin administration care at the B&C home after his discharge from facility. Further review of Resident 1's clinical record indicated, there was no documented evidence of B&C home staff evaluated Resident 1's blood glucose monitoring, and insulin administration care needs to meet at the B&C home before accepted Resident 1 from facility. During an interview with primary care physician (PCP) for Resident 1 on 10/12/2023 at 12:30 p.m., PCP stated she (PCP) was not involved with discharge plan for Resident 1. PCP confirmed Resident 1 needed to continue monitoring for blood glucose and insulin administration for diabetes at B&C home. PCP also stated facility did not verify whether B&C home was capable to continue Resident 1's insulin administration, and blood glucose monitoring care at B&C home before discharged Resident 1. PCP further stated facility unsafely discharged Resident 1 to B&C home without evaluated and confirmed the B&C home's capabilities to meet Resident 1's need for on-going diabetes management. During a concurrent interview and record review with licensed vocational nurse/unit manager A (LVN/UM A) on 10/12/2023 at 2:05 p.m., LVN/UM A confirmed she attended IDT discharge meeting for Resident 1 on 9/11/2023. LVN/UM A also confirmed Resident 1 was discharged to B&C home with physician orders including blood glucose monitoring and insulin administration on 9/12/2023. LVN/UM A stated IDT did not discuss the plan for Resident 1 ' s blood glucose monitoring, and insulin administration care needs at B&C home upon discharge from facility to B&C home. LVN/UM A further stated facility should have discussed and planned safe discharge to meet Resident 1's blood glucose management at the B&C home before discharged from facility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055866 If continuation sheet Page 2 of 3 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 10/31/2023 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 0624 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview with social service director (SSD) on 10/12/2023 at 2:15 p.m., SSD confirmed Resident 1 had physician orders for blood glucose monitoring and insulin administration at B&C home. SSD also confirmed IDT did not discuss Resident 1's blood glucose monitoring, and insulin administration care needs at the B&C home after discharge from facility. SSD stated staff from B&C home did not evaluate Resident 1's care needs to meet for blood glucose monitoring and insulin administration at B&C home upon the discharge from facility. SSD also stated facility failed to verify and confirm whether B&C home had the capacity to monitor blood glucose, and administer insulin as ordered by physician before discharged to B&C home on 9/12/2023. SSD further stated facility should have discharged Resident 1 with a safe discharge plan to meet blood glucose monitoring and insulin administration arrangements at B&C home as required for Resident 1 before discharged him to B&C home from facility. During a concurrent interview and record review with director of nursing (DON) on 10/12/2023 at 3:45 p.m., DON confirmed IDT did not discuss the plan to meet Resident 1's blood glucose monitoring, and insulin administration orders at the B&C home after discharged from facility. DON stated IDT should have discussed, planned, and arranged to meet diabetic care needs at B&C home for a safe discharge plan for Resident 1. DON also stated SSD should have verified and confirmed with B&C home to meet Resident 1's on-going diabetic management care before Resident 1 discharge to the B&C home. DON further stated Resident 1 had unsafe discharge to B&C home. Review of facility's policy and procedure (P&P) titled, Discharging the Resident, dated 7/1/2020, the P&P indicated, If the resident is being discharged home, ensure that resident and/or responsible party (RP: who is given authority to act on behalf of the resident for daily decision making) receive teaching and discharge instructions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055866 If continuation sheet Page 3 of 3