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. Page 1 of 3 055866 055866 05/31/2024 Plum Tree Care Center 2580 Samaritan Drive San Jose, CA 95124

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a concurrent interview and record review on 5/13/24, at 11:58 a.m., with DON, indicated Resident 1's Physician Orders undated was reviewed. DON confirmed there was no physcian order for transfer to acute care hospital. DON stated she did not see an order to transfer Resident 1 to acute care hospital. During a review of the facility's policy and procedure (P&P) titled, Documentation of Medication Administration, dated 2022, the P&P indicated, 1. A nurse. documents all medications administered to each resident on the resident's medication administration record. During a review of the facility's policy and procedure (P&P) titled, Oxygen administration dated 2020, the P&P indicated, After completing oxygen setup, or adjustment, administration of oxygen will be recorded in the resident's medical. [sic]. During a review of the facility's policy and procedure (P&P) titled, Change in a Resident's Condition or Status dated 2007, the P&P indicated, Our facility shall promptly notify the resident, his or her attending Physician and representative (sponsor) of changes in the resident's medical/mental condition. 055866 Page 2 of 3 055866 05/31/2024 Plum Tree Care Center 2580 Samaritan Drive San Jose, CA 95124

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to implement proper infection control practices for 1 of 2 sampled residents (Resident 2) when Resident 2 ' s oxygen tubing and humidifier was not replaced and labeled according to facility policy. Residents Affected - Few This failure had the potential for Resident 2 to develop an infectious disease from old oxygen tubing. Findings: During a concurrent observation and interview on 5/13/24, at 11:22 a.m., with Registered Nurse (RN) A, in Resident 2 ' s room, Resident 2 was receiving oxygen via oxygen tubing through a nasal cannula (tube that provides oxygen directly to the nose). The oxygen tubing did not have a date when it was last replaced. The humidifier container on the oxygen machine did not have a date on it when it was last replaced. RN A confirmed there was no date on the tubing and no date on the humidifier. She stated licensed nurses should have change and label the date every week. I have no way of knowing how old the tubing is. During a review of Resident 2 ' s Order Summary Report May 2024, report indicated, an order for O2[oxygen] at 2lit/min[liters per minute] via NC [nasal cannula] to keep SPO2 [oxygen saturation] above 90%, active 4/11/24. During an interview on 5/13/24, at 11:55 a.m., with Director of Nursing (DON), DON confirmed the nurses should have change the tubing and humidifier every week and put their initial and the date the tubing was replaced on a label or tape. During a review of the facility ' s policy and procedure titled, Oxygen Administration, dated 2020 indicated, 2. Oxygen tubing and humidifier will be changed and labeled every 7 days and as needed. 055866 Page 3 of 3