Health inspection·May 31, 2024

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to provide services according to professional standards of practice for 1 of 2 sampled residents (Resident 1). When staff failed to: Residents Affected - Few 1. Document to keep Resident 1's oxygen saturation (a measure of how much hemoglobin: protein responsible for transporting oxygen, is currently bound to oxygen) greater 90% as prescribed by the physician; 2. Notify the physician regarding Resident 1's change of condition and there was no physician order for transfer to the acute care hospital. These failures had the potential to affect his medical condition and address the residents needs during the transfer to the acute care hospital. Findings: 1. During a review of Resident 1's Order Summary Report dated, 4/24/24, Report indicated, Oxygen: At 3 L/min [liters per minute] via NC [nasal cannula] qs [every shift] to keep 0xygen sats [oxygen saturation] >90%. every shift for sob [shortness of breath]. During a concurrent interview and record review on 5/13/24, at 11:51 a.m., with Director of Nursing (DON), Resident 1's Treatment Administration Record (TAR) dated 4/26/24 was reviewed. The TAR indicated, Resident 1's oxygen saturation was not marked as checked for the evening shift. DON stated, it was not charted that it was completed, and the nurse should have charted that they checked the oxygen. 2. During a review of Resident 1's Progress notes dated 4/28/24 indicated, Patient back from [acute care hospital] ER [emergency room] via ambulance as per report from paramedic, and there was nothing wrong with the patient findings negative of blood clot. Patient and family aware. During a concurrent interview and record review on 5/13/24, at 11:58 a.m., with DON, Resident 1's Change in Condition Evaluation dated 4/28/24 was reviewed. The evaluation indicated, swelling on lateral border of left forearm. 3 Review Findings and Provider Notifications this section was left blank with no Physician notification documented. DON stated, the Evaluation was not completed by the nurse. Licensed nurses should have notified the physician during the change of condition and to get an order to transfer Resident 1 to the acute care hospital. During a review of Resident 1's Progress notes dated 4/28/24 indicated there was no documentation the physician was notified during Resident 1's change in condition. (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 3 Event ID: 055866 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 05/31/2024 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)