Health inspection·September 24, 2024

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide assistance to prevent an accident for one of three sampled residents (Resident 1). Resident 1's functional ability for bending and picking up objects on the floor was not assessed to determine the ability to bend and Rehab Aide A (RAA) did not provide assistance by holding the gait belt (a device that helps caregivers safely move and support patients who have mobility issues) during therapy exercise. This failure resulted in Resident 1 having a fall and was sent to the hospital with a forehead laceration (a cut in the skin or underlying tissue that's usually caused by blunt trauma). Findings: During a review of Resident 1's undated Facesheet (document used to reference a resident's medical and contact information), indicated Resident 1 was admitted to the facility on [DATE], with diagnoses of need for assistance with personal care, other abnormalities of gait [pattern of limb movement when walking] and mobility. During a review of Resident 1's Fall Risk Evaluation, dated 7/19/24, evaluation indicated, Resident 1 was assessed to be at a Moderate Risk of fall (Scored 15). Fall risk evaluation also indicated, to evaluate residents balance while standing, sitting and during transitions. Resident 1 was not able to attempt the transfer without physical help. Resident 1 has impaired balance. On problem: Resident 1 was at risk for fall r/t[related to] generalized weakness. Resident 1 approach r/t impaired gait/balance was to use gait belt and physical therapy (PT) recommended devices. During a review of Resident 1's Fall Risk Care Plan dated 7/20/24 indicated, At risk for falls r/t generalized weakness, hx [history] of falls, DX [diagnosis of] Renal Cancer. The care plan tasks indicated to anticipate and meet resident's needs r/t impaired gait/balance. During a review of Resident 1's MDS (Minimum Data Set- an assessment tool) Section GG, dated 7/25/24, MDS indicated, for eating, toileting, bathing self, dressing upper and lower body, putting on footwear and personal hygiene, as Dependent-Helper does ALL of the effort. The MDS also indicated, P. Picking up object for ability to bend/stoop from a standing position to pick up a small object, such as a spoon, from the floor, it was indicated 88 which means Resident 1 was not attempted due to medical condition or safety concerns. During a review of Resident 1's MDS Section C dated 7/25/24, the MDS indicated, Resident 1's BIMS (Brief Interview for Mentals Status: assessment used to determine cognitive status: ability to reason (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 09/24/2024 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)