Health inspection·November 8, 2024

F 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to timely complete and submit a Discharge Minimum Data Set federal healthcare programs) for three of three residents (1, 2, and 3). This failure resulted in non-compliance with CMS regulatory requirements. Residents Affected - Many Findings: Review of Resident 1's clinical record indicated he was admitted to the facility on [DATE] and discharged from the facility on 9/14/24. Review of Resident 2's clinical record indicated she was admitted to the facility on [DATE] and discharged from the facility on 9/13/24. Review of Resident 3's clinical record indicated she was admitted to the facility on [DATE] and discharged from the facility on 9/17/24. On 11/6/24, review of Resident 1's, Resident 2's, and Resident 3's clinical records indicated their Discharge MDS were overdue, still in progress, not completed, and not submitted to the CMS. During an interview with MDS coordinator A (MDSCO A) on 11/6/24, at 3:45 p.m., she reviewed Resident 1's, Resident 2's, and Resident 3's clinical records and confirmed that their discharge MDS were overdue and showing still in progress. MDSCO A stated the residents' Discharge MDS should be completed within 14 days and submitted to the CMS within 28 days after the residents were discharged . MDSCO A stated the discharge MDS of Resident 1, Resident 2, and Resident 3 should have already been completed and submitted to the CMS. Review of the facility's policy, MDS Completion and Submission Timeframes, dated 7/2017, indicated The assessment coordinator or designee is responsible for ensuring that resident assessments are submitted to CMS' QIES Assessment Submission and Processing (ASAP) system in accordance with current federal and state guidelines. Review of the CMS's Resident Assessment Instrument (RAI) Version 3.0 Manual, dated 10/2024, indicated Page 1 of 3 055884 055884 11/08/2024 Creekside Post-Acute 3580 Payne Avenue San Jose, CA 95117

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of three residents (1) received the necessary care and services when Resident 1's wounds did not have the weekly wound assessments completed consistently as required. This failure resulted in undetermined wound status and could negatively affect the progress of wound healing for Resident 1. Residents Affected - Some Findings: Review of Resident 1's admission Record indicated he was admitted to the facility on [DATE] with diagnoses including sepsis (a life-threatening condition that occurs when the body has an extreme response to an infection), atelectasis (a collapsed lung), and diabetes (a disease that occurs when the blood sugar is too high). Review of Resident 1's clinical record indicated he had wounds on his left toes, right toes, left knee, mid spine, and perianal area. Review of Resident 1's Skin Assessments indicated that his left and right toes wounds were not assessed from 4/30/24 to 6/9/24, from 6/18/24 to 6/30/24, and from 7/2/24 to 8/11/24; his left knee wound was not assessed from 4/30/24 to 6/3/24, from 6/18/24 to 6/30/24, and from 7/2/24 to 8/11/24; his mid spine wound was not assessed from 4/30/24 to 6/3/24, from 6/18/24 to 6/30/24, and from 7/2/24 to 8/11/24. Review of Resident 1's physician order indicated that he had an order for the licensed nurse to cleanse the wound on his perianal area with soap and water, gently wash skin, pat dry, and apply thin layer of Triad (a wound care product that combines the benefits of a protective ointment and a moisture barrier cream) every day and as needed, started on 9/12/23. However, review of Resident 1's Skin Assessments indicated that the wound on his perianal area was not assessed until 8/20/24. During an interview with the director of nursing (DON) on 11/8/24, at 3 p.m., she reviewed Resident 1's clinical record and confirmed that his left and right toes wounds were not assessed from 4/30/24 to 6/9/24, from 6/18/24 to 6/30/24, and from 7/2/24 to 8/11/24; his left knee wound was not assessed from 4/30/24 to 6/3/24, from 6/18/24 to 6/30/24, and from 7/2/24 to 8/11/24; his mid spine wound was not assessed from 4/30/24 to 6/3/24, from 6/18/24 to 6/30/24, and from 7/2/24 to 8/11/24; and the wound on his perianal area was not assessed until 8/20/24. The DON stated the residents' wounds should be assessed every week. The Skin Assessment (for Non-Pressure Injury) Form indicates that the Skin Assessment for each wound should be completed by the LIcensed Nurse weekly. Review of the facility's policy, Pressure Injury Risk Assessment, dated 3/2020, indicated . Step in the Procedure: . 4. Conduct a comprehensive skin assessment with every risk assessment: . b. Once inspection of skin is completed, document the findings on a facility-approved skin assessment tool. c. If a new skin alteration is noted, initiate a (pressure or non-pressure) form related to the type of alteration in skin. 055884 Page 2 of 3 055884 11/08/2024 Creekside Post-Acute 3580 Payne Avenue San Jose, CA 95117

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation, interview, and policy review, the facility failed to provide a safe, functional, and comfortable environment for the residents and staff when the facility's floor had multiple holes. This failure placed the residents, staff and visitors at risk for accident and/or injury. Findings: During an observation with maintenance staff B (MTNS B) on 11/7/24, at 2:20 p.m., the floor in the hallway in front of nursing station 3 had a hole below the handrail which was measured 6 x 3 x 0.5 inches, and the floor in the rehabilitation area had 8 holes which each hole was measured 5¾ x ¾ x 0.5 inches. During a concurrent interview with MTNS B, he stated the floor with these holes was not good and not safe. MTNS B stated he would fix them. Review of the facility's policy, Floors, dated 12/2009, indicated Floors shall be maintained in a clean, safe, and sanitary manner. 055884 Page 3 of 3