Health inspection·March 28, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure respect and dignity was maintained for one of four sampled residents (Residents 39) when staff failed to provide privacy bag for above residents' nephrostomy (a surgery to make an opening from the outside of the body to the renal pelvis [part of the kidney that collects urine]) collection bag. This failure had the potential to affect the emotional and psychosocial well-being of the residents. Findings: Review of Resident 39's clinical record indicated, she was admitted on [DATE] with diagnoses that include malignant neoplasm (an abnormal growth of tissue that can be benign or malignant) of cervix(the lower , narrow end of the uterus that connects the uterus to the vagina), unspecified; cystitis (inflammation of the bladder [hollow organ that stores urine before it leaves the body]), unspecified without hematuria (presence of blood in urine); urinary tract infection (occur when bacteria enter the urinary tract through the urethra and begin to spread in the bladder) site not specified. During an observation on 3/24/25 at 11:19 a.m., Resident 39 was lying in bed, with nephrostomy collection bag was laying in the floor. The nephrostomy collection bag was not covered, and the contents were visible. During a concurrent observation and interview on 3/24/25 at 11:23 a.m., with the Infection Preventionist (IP), the IP confirmed Resident 39's nephrostomy collection bag was not covered and visible. The IP stated the nephrostomy collection bag should have been covered. During an interview with Director of Staff Development (DSD) on 3/26/25 at 3:24 p.m., the DSD stated the nephrostomy collection bag should have been with privacy bag. During a review of the facility's policy and procedure (P&P) titled, Dignity , revised 2/2021, the P&P indicated, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem.12. Demeaning practice and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist resident; for example: a. helping the resident to keep urinary catheter bags covered. Page 1 of 15 055866 055866 03/28/2025 Plum Tree Care Center 2580 Samaritan Drive San Jose, CA 95124

F 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure one (Resident 58) out of 15 sampled residents was free from physical restraint not required to treat medical symptoms when Resident 58 was restrained to a wheelchair. Residents Affected - Few This failure resulted in Resident 58 being restricted from moving out of the wheelchair which had the potential for distress and physical injury. Findings: A review of Resident 58's medical record included diagnoses of Hemiplegia and Hemiparesis following cerebral infarction (paralysis and weakness on one side of the body, on one side, both resulting from impaired communication between the brain and muscles), and other abnormalities of gait and mobility, mood disorder due to known physiological condition with depressive features. A review of Resident 58's Minimum Data Set (MDS, an assessment tool), dated 12/24/24, indicated a brief interview for mental status score of 8 [BIMS, a tool used to assess cognition (knowing, learning, and understanding), a score of 0 to 7 indicates severe cognitive impairment, 8-12 moderate impairment, 13-15 patient is cognitively intact]. A review of Resident 58's Occupational Therapy and Plan of Treatment dated 12/18/24 indicated, Reason for Therapy: .pt [patient] has severe L [left] neglect [an attention disorder that causes difficulty paying attention to, or is unaware of, things on the left side] along with L hemiparesis [weakness on one side of the body] ,pt is also Chinese speaking only During an interview on 3/27/25 at 8:48 a.m. with Licensed Vocational Nurse (LVN) A, LVN A stated, it was not okay to put a resident in restraints on a wheelchair. During an interview on 3/27/25 at 9:05 a.m. with LVN B, LVN B stated, restraints were not used in the facility. During an interview on 3/27/25 at 10:16 a.m. with Certified Nurse Aide (CNA) D, CNA D stated, before 7 a.m. on 3/3/25, Resident 58 was in his wheelchair inside his room pointing at his abdomen. CNA D stated she did not check on Resident 58 and she proceeded to clock in for her shift. CNA D stated that Resident 58 did not speak English. During an interview on 3/27/25 at 10:41 a.m. with Director of Staff Development (DSD), DSD stated, CNAs were not allowed to use restraints on residents. During an interview on 3/27/25 at 10:51 a.m. with Social Services Director (SSD), SSD stated, I don't know if there is a policy that says we can restrain a resident. During a concurrent observation and interview on 3/28/25 at 10:50 a.m. with CNA D, CNA D demonstrated how to lock and unlock a gait belt (an assistive device which can be used to help safely transfer a person from a bed to a wheelchair and assist with sitting and standing) with metal buckle and stated it was not easy to unlock a gait belt. 055866 Page 2 of 15 055866 03/28/2025 Plum Tree Care Center 2580 Samaritan Drive San Jose, CA 95124

F 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a concurrent observation and interview on 3/28/25 at 11:14 a.m. with the Director of Nursing (DON), the DON stated that gait belts were used for transfers and ambulation (walking). The DON stated it was not right to restrain a resident in a wheelchair for safety. The DON demonstrated how to lock and unlock a gait belt with a plastic clip buckle and another with a metal clasp. The DON stated that CNA F used a gait belt with a plastic clip buckle to restrain Resident 58. The DON also stated, a confused resident would not be able to unlock a gait belt with a clip buckle. During a telephone interview on 3/28/25 at 11:49 a.m. with CNA F, CNA F stated that on 3/3/25 around 5:45 a.m., while Resident 58 was on a wheelchair, she put a gait belt around him and the wheelchair because Resident 58 goes around. CNA F stated she was new in the facility. CNA F also stated she did not remove the gait belt on Resident 58. During a telephone interview on 3/28/25 at 1:53 p.m. with CNA G, CNA G stated she found Resident 58 restrained to a wheelchair on the morning of 3/3/25. CNA G stated Resident 58 was in his room in a wheelchair asking his roommate for help and there was a language barrier. CNA G stated, I gave him my hand to try and get up and I noticed he cannot move up from the wheelchair. He was wearing a blue jacket, and when I opened the jacket, I found he was restrained. The restraint was covered by his jacket. I removed the restraint. A review of facility's undated Policy and Procedure (P&P) entitled, Use of Restraints, the P&P indicated, Restraints shall only be used for the safety and well-being of the resident and only after alternatives have been tried unsuccessfully. Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline and staff convenience, and that are not required to treat the resident's medical symptoms .'Physical restraint is defined as any manual method, physical or mechanical device, equipment, or material that meets all of the following criteria: attached or adjacent to the resident's body; Cannot be removed easily by the resident; and Restricts the resident's freedom of movement or normal access to his/her body .2. Prior to placing a resident in restraints, there shall be a pre-restraining assessment and review to determine the need for restraints .5. Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative (sponsor). The order shall include the following: a. The specific reason for the restraint .b. How the restraint will be used to benefit the resident's medical symptom, and c. The type of restraint and period of time for the use of the restraint 8. The following safety guidelines shall be implemented and documented while a resident is in restraints: b. Physical restraints shall be applied in such a manner that they can be speedily removed in case of fire or other emergency. Restraints with locking devices shall not be used. A review of facility's undated document entitled Resident Rights indicated, Employees shall treat all residents with kindness, respect, and dignity. 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: .d. be free from corporal punishment or involuntary seclusion, and physical or chemical restraints not required to treat resident's symptoms; A review of facility's Policy and Procedure (P&P) entitled Dignity revised February 2021, the P&P indicated, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. 1. Residents are treated with dignity and respect at all times . 3. Residents may exercise their rights without interference, coercion, discrimination or reprisal from any person or entity associated with this facility. 055866 Page 3 of 15 055866 03/28/2025 Plum Tree Care Center 2580 Samaritan Drive San Jose, CA 95124

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to follow their policy and procedure (P&P) for pre-admission screening and resident review (PASRR- screening for residents with mental disorder and residents with intellectual disability) screening was completed and submitted for one of two sample resident (Resident 24) with significant change in mental illness (MI-a wide range of conditions that affect resident's mood, thinking, and behavior). This failure had the potential for mentally ill sample resident not to receive benefit from specialized health care and services. Findings: Review of Resident 24 face sheet (FS- a document that gives a resident's information at a quick glance) indicated Resident 24 was initially admitted to facility on 5/21/2023 and re-admitted on [DATE]. Resident 24's FS also indicated diagnoses including anxiety disorder (excessive, persistent worry and fear of everyday situations) dated 1/8/2025, and delusional disorders (a serious mental illness that causes resident can not tell what's real from what's imagined), dated 2/24/2025. Review of Resident 24's physician's order form dated 3/13/2025 indicated Resident 24's hospice (a program that gives special care to residents who are near the end of life) MD (medical doctor) ordered risperidone (a class of antipsychotic medication used to treat mental illnesses) 1 milligram (mg-a unit of mass in metric system equal to a thousandth of a gram) daily PM (every afternoon or evening)for delusional disorder m/b (manifested by- as evidenced by) auditory hallucinations (hearing voices or noises that aren't there) started on 3/13/2025. Further review of his order form also indicated medication order for risperidone 1 mg daily PM for Schizophrenia (a serious mental illness that affects how a resident think, feels and behaves) started on 2/28/2025 and discontinued on 3/14/2025. Review of Resident 24's minimum data set significant change in status (MDS SCIS- comprehensive assessment tool when resident's status changed significantly, either for the better or worse) assessment dated [DATE] indicated section N for medications indicated Resident 24 received antipsychotic medication during last 7 days. Section I for active diagnoses indicated anxiety and psychotic disorder (other than schizophrenia) under psychiatric/mood disorder for Resident 24. Review of documented PASRR dated 5/21/2023 copy provided by facility for Resident 24 indicated no serious mental illness, and no prescribed psychotropic medications for mental illness. Review of clinical documentation for Resident 24 indicated there was no documented PASRR assessment and submitted to state agency (an agency responsible for financing, providing physical and mental health services and support for low-income individuals and families in California) until 3/28/2025 with Resident 24's significant change in mental condition. Review of this PASRR indicated date completed on 3/28/2025, after this health facility evaluator nurse (HFEN-a registered nurse who conducts inspections, investigations, and surveys of health facilities to ensure compliance with state and federal laws and regulations related to resident's care) started investigation and requested facility for copy of PASRR with Resident 24's significant change in mental condition. During an interview with facility's director of nursing (DON) on 3/27/2025 at 10:14 a.m., DON confirmed documented PASRR assessment completed on 5/21/2023. DON also confirmed Resident 24 received new diagnoses of anxiety on 1/8/2025, delusional disorder on 3/13/2025, and started new order for 055866 Page 4 of 15 055866 03/28/2025 Plum Tree Care Center 2580 Samaritan Drive San Jose, CA 95124

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few antipsychotic medication risperidone on 2/28/2025 and there was no documented PASRR assessment completed after Resident 24's newly diagnosed MI and newly started antipsychotic medication. DON stated significant change in mental condition with new diagnoses of MI and newly started antipsychotic medication warranted for facility to do a new PASRR assessment and submit to the stae agency as per facility's policy. DON also stated facility should have followed P&P for completion of PASRR assessment and submitted to the state agency to receive healthcare and services as needed for Resident 24. During an interview with DON on 3/28/2025 at 2:04 p.m., DON confirmed facility completed PASRR on 3/28/2025 for Resident 24. DON stated facility should have completed and submitted new PASRR after Resident 24's significant change in mental condition on 2/28/2025 not after HFEN started investigation. Review of facility's P&P titled, Preadmission Screening Resident Review (PASRR) revised August 2007, the P&P indicated, This facility promptly notify the state mental health and /or mental retardation (MR-disorder characterized by significant intellectual impairment) or developmental disability authority, as applicable, if there is a significant change in the physical or mental condition of a recipient who is mentally ill or mentally retarded. This would warrant re-evaluation . A readmission is not subject to another PASRR Level 1 screening unless there is a change in his or her medical condition that may indicate a change in his or her MI (Mental illness)/ MR status. 055866 Page 5 of 15 055866 03/28/2025 Plum Tree Care Center 2580 Samaritan Drive San Jose, CA 95124

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure professional standards of practice were followed for three out of six sampled residents (Resident 5, 11, and 39) when: Residents Affected - Some 1. [NAME] color particles (solid particles settle out of urine), and cloudy color urine (urine appears hazy or white color particles) in urinary catheter (U/C-a thin, flexible tube inserted into urethra [urinary opening] to drain urine from bladder [body organ that stores urine] into a collection bag) in U/C drain tube were not assessed and reported to medical doctor (MD) for Resident 5; 2. Controlled drug record (CDR-record of every transaction involving a controlled drug [CD-medication that can be easily abused and under strict government control] purchasing, receiving, dispensing, or disposal) was not signed, dated, and documented amount of controlled drug received from pharmacy for Resident 11, and 39. Above failures had the potential for infection, health and well-being for Resident 5, and accountability of CD record for Resident 11 and 39. Findings: 1. During an observation on [DATE] at 9:15 a.m., noted Resident 5's U/C drain tube with white color particles, and cloudy urine. During review of Resident 5's face sheet (FS-a document that gives a resident's information at a quick glance) indicated Resident was admitted to facility on [DATE]. Resident 5's FS also indicated Resident 5's diagnoses including history of urinary tract infections (an illness of the system of organs that makes urine), presence of urogenital implants (implantation of artificial devices in the urinary system), and neuromuscular dysfunction of bladder (condition where bladder control problems due to dysfunction of muscles that control bladder leading to difficulty emptying or controlling urine). Review of Resident 5's physician order dated [DATE] indicated suprapubic urinary catheter (SUC-a medical device inserted through a small incision in the lower abdomen into the bladder to drain urine from bladder into a collection bag) size FR#16/30 (catheter tube outer diameter, I FR equal to 1/3 millimeter) for neuromuscular dysfunction of bladder. Review of Resident 5's another physician order dated [DATE] indicated catheter: monitor/record/report to MD for signs and symptoms of urinary tract infection . Review of clinical documentation indicated there was no documentation for assessment and notification to MD for white color particles and cloudy urine in urinary catheter drain tube for Resident 5. Review of care plan for Resident 5 SUC dated [DATE] indicated with intervention to observe output for color, odor, threads, & sedimentation. During an interview with certified nursing assistant L (CNA L) on [DATE] at 9:22 a.m., CNA L confirmed white color and cloudy urine in U/C drain tube for Resident 5. CNA L stated she did not notice before, will report to charge nurse now. 055866 Page 6 of 15 055866 03/28/2025 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 - Some During an interview with licensed vocational nurse H (LVN H) on [DATE] at 9:34 a.m., LVN H confirmed white sedimentation, and cloudy urine for Resident 5's U/C drain tube. LVN H stated abnormal to have sedimentation and cloudy urine, did not notice before. LVN H also stated urine should be clear and amber color not cloudy with sedimentation, will notify MD. During an interview with facility's director of nursing (DON) on [DATE] at 10:45 a.m., DON stated nursing staff should have monitored, assessed white sedimentation with cloudy urine and notified MD to prevent and control urinary infection for Resident 5. 2. Review of Resident 11's FS indicated Resident 11 was admitted to facility on [DATE] and expired on [DATE]. Resident 11's FS also indicated diagnoses including malignant neoplasm of ovary (ovary- small glands produce and release eggs for female reproductive system, ovarian cancer). Review of Resident 11's physician orders dated [DATE] indicated morphine sulfate (MS-schedule 11 controlled drug, used to treat pain) oral solution 20 mg/5 ml (mg-milligram, unit of mass equal to one thousandth of a gram/ ml-milliliter, unit of volume equal to one thousandth of a liter). Give 20 ml by mouth every 3 hours as needed for pain Review of Resident 11's CDR for MS medication dated [DATE] indicated no license nurse signature, not dated, and not documented number of doses when received MS medication from pharmacy. Review of Resident 39's FS indicated Resident 39 was admitted to facility on [DATE]. Resident 39's FS also indicated diagnoses including pain, and neoplasm of cervix (cervix-a small canal that connects uterus, cervical cancer). Review of Resident 39's physician orders dated [DATE] indicated oxycodone (schedule 11 controlled drug used to treat pain). Review of Resident 39's CDR dated [DATE] indicated no signature by license nurse, not dated, and not documented of number of doses when received oxycodone medication from pharmacy. During an interview with registered nurse I (RN I) on [DATE] at 5:02 p.m., RN I reviewed CDR documents for Resident 11 for medication MS, and Resident 39 for oxycodone. RN I confirmed both CDR documents for both residents not signed by license staff, not dated, and not documented amount of medication received for Resident 11 and 39. RN I stated license staff should have signed, dated and documented amount of medication received from pharmacy for both residents. During an interview with RN J on [DATE] at 5:20 p.m., RN J reviewed CDR forms for Resident 11 and 39. RN J confirmed license nurse did not sign, not dated and written number doses received for Resident 11 for MS and Resident 39 for oxycodone. RN J stated license nurse should have signed, dated, and documented number of doses received for both residents when received from pharmacy. During an interview with facility's director of nursing (DON) on [DATE] at 10:33 a.m., DON reviewed CDR document for Resident 11 for medication MS, and Resident 39 for oxycodone. DON confirmed missing license nurse signature, date, and number of doses of medication received pharmacy for above both residents. DON stated license nurse should have signed, dated and documented number of doses received pharmacy for accountability for controlled medications and as per facility's policy. Review of facility's policy and procedure (P&P) titled, Catheter Care, Urinary, revision date 055866 Page 7 of 15 055866 03/28/2025 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 - Some [DATE], the P&P indicated, Observe the resident for complications associated with urinary catheters. Report unusual findings to the physician or supervisor immediately. If urine has an unusual appearance (i.e., color, blood, etc.). Review of facility's P&P titled, Controlled Medication Storage, undated, the P&P indicated, A controlled medication accountability record is prepared when receiving inventory of a Schedule 11 medication .The following information is completed: a. Name of resident b. Prescription number c. Name, strength (if designated), and dosage form of medication d. Date received e. Quantity received f. Name of person receiving medication. 055866 Page 8 of 15 055866 03/28/2025 Plum Tree Care Center 2580 Samaritan Drive San Jose, CA 95124

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure to provide proper oxygen (a colorless, odorless gas) care and treatment services for three of 15 sampled residents (Residents 16, 20, and 53) when: Residents Affected - Some 1. Resident 16 had room air concentrator (RAC- a medical device take in air from room and filter out nitrogen [a colorless, odorless and nontoxic gas, humans do not breath directly] to provide enriched oxygen [O2-a colorless, odorless, and tasteless gas essential to living organisms])and there was no oxygen signage posted on the door; 2. Residents 20 had an oxygen concentrator (a portable device that provides oxygen) at the bedside, but there was no oxygen signage posted on the door. 3. Residents 53 had an oxygen concentrator at the bedside, but there was no oxygen signage posted on the door. This deficient practice had the potential for accidents and hazards that could pose harm to residents in the facility. Findings: 1. During an observation on 3/24/2025 at 9:55 a.m., noted RAC not in use, placed next to Resident 16's bed. There was no sign posted for no smoking/oxygen in use for this room. Review of Resident 16's face sheet (FS-a document that gives a resident's information at a quick glance) indicated Resident 16 was admitted to facility on 5/28/2019. Resident 16's FS also indicated Resident 16's diagnoses including cerebral ischemic attack (caused by a brief disruption of blood flow to brain), and hypertension (pressure in blood vessels too high). Review of Resident 16's physician orders indicated oxygen: at 2liters/min via nasal cannula (NC, a thin, flexible tube to deliver supplemental O2) every shift for hypoxia (low levels of O2)/shortness of breath (SOB-feeling of can't get enough air into lungs). Goal was to maintain oxygen saturation above 90% dated 3/26/2025. During an interview with license vocational nurse H on 3/24/2025 at 10:50 a.m., LVN H confirmed there was no sign for oxygen in use posted for Resident 16's room. LVN H also confirmed Resident 16 uses O2 on and off for SOB. LVN H stated oxygen in use sign should have been posted for Resident 16's room. LVN H also stated nursing staff should have posted oxygen in use sign outside Resident 16's room. During an interview with facility's director of nursing (DON) on 3/27/2025 at 10:04 a.m., DON stated nursing staff should have posted O2 in use sign for Resident 16's room when Resident 16 uses O2 on and off. 2 .During an observation on 3/24/25, at 10:08 a.m., Resident 20 was lying in bed, asleep, with oxygen concentrator at the bedside, nasal cannula delivering oxygen inside the plastic bag not in used. There was no Oxygen in use/No smoking signage posted on Resident 20's door. 055866 Page 9 of 15 055866 03/28/2025 Plum Tree Care Center 2580 Samaritan Drive San Jose, CA 95124

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of Resident 20's order summary report dated 2/18/25 indicated Resident 20's has order for Oxygen at 2 liters (L, metric unit of volume) /minutes via nasal cannula for history of obstructive sleep apnea (OSA, a condition where sleep is interrupted by abnormal breathing) every evening and night shift. During a concurrent observation and interview on 3/24/25 at 10:18 a.m., with the Infection Preventionist (IP), the IP confirmed there was no Oxygen in use/No smoking sign posted by Resident 20's door. The IP stated there should have been a sign posted by the door for precautionary that resident in oxygen in use for safety. 3. During an observation on 3/24/25, at 10:24 a.m., Resident 53 was lying in bed, with oxygen concentrator at the bedside, nasal cannula delivering oxygen inside the plastic bag not in used. There was no Oxygen in use/No smoking signage posted on Resident 53's door. Review of Resident 20's order summary report dated 11/20/24 indicated Resident 53's has order for Oxygen at 2 L/Min via NC PRN (pro re nata, means when required) to keep 02 saturation > 90 percent as needed. On hold from 03/25/25 17:36 to 03/30/25 17:35. During a concurrent observation and interview on 3/24/25 at 10:26 a.m., with the IP, the IP confirmed there was no Oxygen in use/No smoking sign posted by Resident 53's door. During an interview on 3/28/25 at 10:23 a.m., with the IP , the IP further stated there should have been signage in the room for safety hazard to remind staff there was oxygen in use. During an interview with DON on 3/28/25 at 11:36 a.m., the DON stated there should have been oxygen signage to alert the staff in case of emergency when admitted and with order of oxygen. During a review of the facility's policy and procedure (P&P) titled, Oxygen Administration , dated 2001, the P&P indicated, The purpose of this procedure is to provide guidelines for safe oxygen administration. Equipment and supplies: The following equipment . 4. No Smoking /Oxygen in Use signs .Steps in procedure1. Place an Oxygen in Use sign on the outside of the room entrance room. During a review of the facility's policy and procedure (P&P) titled, Signage and Posting, undated, the P&P indicated, The facility will maintain mandatory posting on facility grounds in compliance with State and Federal regulations as well as posting that are helpful for guidance for staff, resident and visitors.1. The maintenance department is responsible for maintaining signage in good repair on facility grounds. Periodic observations will be made to assure the signage is legible and within regulatory guidance. 055866 Page 10 of 15 055866 03/28/2025 Plum Tree Care Center 2580 Samaritan Drive San Jose, CA 95124

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure proper medication storage and labeling of medications and supplies when: 1. An opened multi use eye drop medication with no opened date for Resident 175; 2. Expired over the counter (OTC- medication that can be purchased without a prescription) laxative (medication that helps to promote bowel movement) stored in supply cabinet in medication room [ROOM NUMBER]; 3. Expired suction machine (a medical device that is used for removing obstructions from resident's airway [the path that air follows to get into and out of the lungs]) tubing stored in supply area in medication room [ROOM NUMBER]. Above deficient practices had the potential for resident to receive medications and care equipment supplies with reduced potency from expired medications, and expired equipment supplies and/or medication errors due to medications not being labeled. Findings: 1. During concurrent observation of medication cart 1 and interview with licensed vocational nurse K (LVN K) on 3/27/2025 at 3:38 p.m., noted opened, multi dose rocklatan (used to treat high pressure in the eye) eye medication without opened date written on bottle or bottle stored packet in medication cart for Resident 175. Further review of manufacturer's directions for this medication indicated this medication may be kept at 36-to-77-degree Fahrenheit (F-temperature scale, 36-77, room temperature) for up to 6 weeks. LVN K confirmed multi dose eye medication bottle was opened and currently licensed staff are using this medication for Resident 175. LVN K confirmed opened date not documented on medication bottle or bottle stored packet. LVN K stated license staff should have labeled opened date to stop using this medication 6 weeks after opened. LVN K also stated without opened date labeled unable to know when to stop using this medication. 2. During concurrent observation of medication room [ROOM NUMBER] and interview with facility's director of nursing (DON) on 3/27/2025 at 10:24 a.m., observed OTC miralax (brand name laxative medication) single use packets x3 with 2/2025 expiration date stored in OTC supply cabinet. DON confirmed this expiration date for all 3 packets. DON stated licensed staff should have verified and removed expired OTC medications weekly while checking supplies in medication room [ROOM NUMBER]. 3. During concurrent observation of medication room [ROOM NUMBER] and interview with DON on 3/27/2025 at 10:35 a.m., noted suction machine tubing in sealed package with expiration date of 12/1/2024 placed in a supply's storage area. DON confirmed this observation. DON stated licensed staff should have removed and discarded expired suction machine tubing from supplies storage area in medication room [ROOM NUMBER]. During an interview with DON on 3/27/2025 at 10:43 a.m., DON stated license staff should have labeled with opened date on bottle or bottle stored packet for multi dose eye drop medication when 055866 Page 11 of 15 055866 03/28/2025 Plum Tree Care Center 2580 Samaritan Drive San Jose, CA 95124

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some opened. DON also stated without opened date label, licensed staff would not know when to stop using this medication for Resident 175 as recommended by manufacturer to avoid using expired medication. Review of facility's policy and procedure (P&P) titled, Medication Administration General Guidelines, dated 09/18, the P&P indicated, b. The nurse shall place a 'date opened' sticker on the medication if one is not provided by the dispensing pharmacy and enter the date opened. Manufacturer recommendations for beyond use dating should take precedence, taking into consideration 'not to exceed' limitations. The beyond use dating, which only lists month/year, falls to the last day of that month. 055866 Page 12 of 15 055866 03/28/2025 Plum Tree Care Center 2580 Samaritan Drive San Jose, CA 95124

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and document review, the facility failed to ensure food was stored and/or prepared under sanitary conditions when an opened bag of hamburger buns past their used-by date was found in the kitchen pantry. This failure had the potential to cause food borne illness. Findings: During an initial kitchen observation and interview on 3/24/25 at 9:12 a.m. with the Dietary Director (DD), an opened bag of hamburger buns containing six buns dated 3/6/25 was found in the dry storage room/pantry. The DD stated, bread could have been stored seven days from the labeled date. The DD also stated, the hamburger buns dated 3/6/25 must be discarded. A loaf of bread with a labeled date of 3/23/25 was also found beside the hamburger buns. The DD pointed at the sticker on the shelf underneath the loaf of bread which indicated Item: Bread Date: 3/23/25 Use By: 3/30/25. The DD verified there was no sticker for use by date for the hamburger buns dated 3/6/25. A review of facility's Policy and Procedure (P&P) entitled, Food Receiving and Storage dated 2001, the P&P indicated, Foods shall be received and stored in a manner that complies with safe food handling practices . A review of Duties and Responsibilities for Dietary Supervisor indicated, .Administrative Functions: Inspect food storage rooms, utility/janitorial closets, etc., for upkeep and supply control . A review of facility's Policy and procedure (P&P) entitled Refrigerators and Freezers revised November 2022, the P&P indicated, .9. Supervisors are responsible for ensuring food items in pantry, refrigerators, and freezers are not past 'use by' or expiration dates 055866 Page 13 of 15 055866 03/28/2025 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 ensure staff implemented proper infection control practices when: Residents Affected - Some 1. Uncovered feeding tube (a thin, flexible tube one end attached to feeding formula bottle and other end attached to gastrostomy tube [GT-a thin, flexible tube inserted into the stomach to provide nutrition and medications to resident who cannot eat or drink by mouth]) when feeding was not in use; 2. Resident 39's nephrostomy (a surgery to make an opening from the outside of the body to the renal pelvis [part of the kidney that collects urine]) collection bag was laying in the floor; 3. Nebulizer (a small machine that turns liquid medicine into a mist, allowing you to breathe it in directly into your lungs through a mouthpiece or mask) kit was not properly stored after use for Resident 32. These failures had the potential for development and transmission of communicable diseases and infections in the facility. Findings: 1. During an observation on 3/25/2025 at 9:45 a.m., noted Resident 29's GT feeding machine was turned off. Further observation noted end of feeding tube which was disconnected from Resident 29's GT, left on GT machine, and uncovered feeding tube. Other end of feeding tube was connected to ready to use ¾ th full feeding formula bottle hanging on a pole next to Resident 29's bed. Handwritten documentation on feeding formula bottle noted started on 3/25/2025 at 4:30 am, rate 65 cc/hr. Review of Resident 29's face sheet (FS-a document that gives a resident's information at a quick glance) indicated Resident 29 was admitted to facility on 6/1/2022. Resident 29's FS also indicated Resident 29's diagnoses including cerebral infarction (happens when blood supply to brain disrupted), gastrostomy status (surgically inserted tube into stomach to provide nutrition and medications for resident who can not eat or drink my mouth due to medical reasons), and diabetes type 2 (a disease in which high levels of sugar in blood). Review of Resident 29's orders indicated enteral feed order every shift enteral: Tube feeding Glucerna 1.2 (brand name ready to use nutritional formula) at 65cc/hrx20 hours to provide 1560 kcal (a unit of energy measurement used to quantify the calorie content of food) /day. Start feeding via pump at 12 noon stop feeding at 8 am or until volume was met dated 11/6/2024. During an interview with license vocational nurse H (LVN H) on 3/25/2025 at 9:50 a.m., LVN H confirmed end of GT feeding tube left uncovered when Gt feeding was not in use for Resident 29. LVN also confirmed using same feeding formula bottle and feeding tube to restart feeding at 12 noon for Resident 29. LVN also stated feeding tube should have been covered when not in use, nursing staff should have not leave uncovered. During an interview with facility infection preventionist (IP) on 3/25/2025 at 9:55 a.m., IP confirmed GT feeding tube left uncovered. IP discarded feeding formula bottle along with feeding tube. IP stated nursing staff should have placed feeding tube in a plastic bag when not in use for infection control. 055866 Page 14 of 15 055866 03/28/2025 Plum Tree Care Center 2580 Samaritan Drive San Jose, CA 95124

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During on telephone interview with director of sales (DS) from a medical supply company that supplies GT feeding supplies to facility on 3/28/2025 at 1:18 p.m., DS stated manufacturer for GT feeding tube recommending covering the GT feeding tube when not in use and when re-using same supplies later on for infection control. 2.During an observation on 3/24/25 at 11:19 a.m., Resident 39 was lying in bed, where in a nephrostomy tube connected to a nephrostomy collection bag was laying in the floor. During a concurrent observation and interview on 3/24/25 at 11:23 a.m., with the Infection Preventionist (IP), the IP confirmed Resident 39's nephrostomy collection bag was laying in the floor. During an interview with Director of Staff Development (DSD) on 3/26/25 at 3:24 p.m., DSD confirmed the nephrostomy collection was bag was laying in the floor and stated it should have been hanging to drain correctly and prevent infection. During a review of the facility's policy and procedure (P&P) titled, Infection Prevention and Control Program , revised 8/2022, the P&P indicated, An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infections. 3. A review of Resident 32's medical record included a diagnosis of chronic obstructive pulmonary disease with (acute) exacerbation (COPD, a common lung disease causing restricted airflow and breathing problems). A review of Resident 32's Physician Order started on 2/24/25 indicated, Ipratropium-Albuterol Solution [used to treat symptoms of COPD] 0.5/2.5 (3)mg [milligram, unit of measurement]/3 ml [milliliter, unit of measurement] inhale orally every 4 hours as needed for SOB [shortness of breath] or wheezing [a high-pitched, whistling sound that occurs during breathing, often when airways in the lungs are narrowed or blocked, signaling potential breathing difficulties] via nebulizer During a concurrent observation and interview on 3/25/25 at 9:41 a.m. in Resident 32's bedside with the DON, the DON verified the nebulizer mask hanging by its string on the nebulizer machine. The nebulizer mask was still attached to the medication cup and was connected via its tubing to a nebulizer. The DON stated it should have been placed in a plastic bag. The DON proceeded to put the nebulizer mask in an unlabeled plastic bag. Resident 32 stated he turned off the nebulizer because the nurse had not come back yet. During an interview on 3/28/25 at 8:57 a.m. with the Infection Preventionist Nurse (IP), the IP stated that nebulizer masks must be rinsed after use and then put in a plastic bag. A review of facility's Policy and Procedure (P&P) entitled Medication Administration Nebulizers indicated, .18. When treatment is complete, turn off nebulizer and disconnect T-Piece, mouthpiece and medication cup .20. Rinse and disinfect the nebulizer equipment according to manufacturer's recommendations and facility policy .22. When equipment is completely dry, store in a plastic bag with the resident's name and date on it. 055866 Page 15 of 15