Health inspection·July 16, 2025

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 document reason to withheld medications and failed to notify primary care physician (PCP) when withheld medications for one of three sampled resident (Resident 2) to meet professional standards. This failure had the potential to affect Resident 2's medical condition and well-being. Review of Resident 2's face sheet (FS: a documenta that gives resident's information at a quick glance) indicated Resident 2 was admitted to facility on 4/30/2025 and discharged home on 5/21/2025. Resident 2 was self-responsible for daily decision making.Review of Resident 2's diagnoses included tachycardia (a rapid heartbeat that may be regular or irregular), depression (a mood disorder that causes persistent feeling of sadness and loss of interest in day to day activities), anxiety (persistent worry and fear about everyday situations), and headache (a painful sensation in any part of the head ranging from sharp to dull).Review of Resident 2's minimum data set (MDS, clinical and functional assessment tool) dated 5/21/2025 indicated Resident 2's brief interview for mental status (BIMS) score of 15/15 (score of 0-7: severely impaired cognition, 8-12: moderately impaired cognition and 13-15: intact cognition), intact cognition.Review of Resident 2's order summary report indicated medication auvelity (used to treat depression) 45-105 MG (mg-milligram, a unit of mass or weight equal to one thousandth of a gram) two times a day for depression, dated 4/30/2025.Review of Resident 2's order summary report also indicated medication ivabradine (used to treat certain heart conditions) 5 MG one time a day for angina (a type of chest pain caused by reduced blood flow to the heart, dated 5/1/2025.Review of Resident 2's order summary report further indicated medication emgality (used to treat headache in adults) 120 mg inject subcutaneously (inject into fatty tissue just underneath the skin) every 30 day (s) for migraine (a health condition that is more just a bad headache with nausea, vomiting or sensitivity to light and sound), dated 5/13/2025.Review of Resident 2's electronic medical record (EMAR, a digital system used to document medication administration to residents) for May 2025 indicated medication auvelity was documented as 3 at 0900 on 5/3/2025, 1 dose. Medication ivabradine was documented as 3 at 0900 on 5/8/2025, 5/17/2025, 5/18/2025 and at 2100 on 5/8/2025, 5/16/2025, and 5/17/2025, total 6 doses. Medication emgality was documented as 3 at 0900 on 5/13/2025, one dose.Review of Resident 2's EMAR chart codes/follow up codes for 3, indicated Hold/Progress notes MD (medical doctor) Notification. Further review of nursing progress notes indicated there was no documented evidence for the reason to withheld above medications and no documented evidence of notification to Resident 2's PCP when withheld above medications.During a telephone interview with Resident 2 on 6/3/2025 at 3:51 p.m., Resident 2 stated did not receive multiple medications for several days when Resident 2 was in facility. Resident 2 was told by nursing staff some of medications not available to give as ordered for several days during Resident 2's stay in facility. During a concurrent record review of Resident 2's EMAR for May/2025 and interview with license vocational nurse A(LVN A) on 7/16/2025 at 11:23 a.m., LVN A confirmed above medications during those days and timings were held, not administered to Resident 2 as indicated in EMAR. LVN A Residents Affected - Few (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 07/16/2025 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)