Health inspection·September 2, 2022

F 0637 Assess the resident when there is a significant change in condition Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on an observation, interview and record review, the facility failed to complete a significant change in status assessment (SCSA) in minimum data set (MDS, an assessment tool) for one of 12 sampled residents (Resident 48). When Resident 48 had significant weight loss, had declined in activities of daily living (ADL, daily self-care tasks, e.g., bathing, toileting, and transferring), incontinency and communication. This failure had the potential to result in Resident 48 unable to achieve or maintain optimal status of health, function and quality of life. Residents Affected - Few Findings: 1.Review of Resident 48's face sheet (summary page of a patient's important information) indicated she was admitted to the facility on [DATE] with diagnoses including muscle weakness, bipolar disorder (mental disorder characterized by periods of elevated mood and depression (mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily functioning, often with poor decision-making) and schizoaffective disorder (a mental illness that can affect your thoughts, mood and behavior). Review of Resident 48's MDS, dated [DATE], indicated her cognition (mental, thought processes) was severely impaired with Brief Interview for Mental Status (BIMS, cognition level) score of five. She required limited assistance with one person assist in walk in room and corridor, extensive assistance with one person with activities of daily living (ADL), bed mobility, personal hygiene, dressing, toilet use, transfer and supervision with set up help with eating, locomotion on and off unit. She can make self-understood and understand others, continent of bowel and frequently incontinent of urine. Her weight was 123 Lbs. During a concurrent interview and record review, on 8/31/22 at 11:42 a.m., with registered nurse K (RN K), she reviewed Resident 48's MDS, dated [DATE], and stated Resident 48's had BIMS score of three which means severely impaired. She required total assistance with one-person assistance for toilet use, activity did not occur for walk in room, corridor, locomotion on unit and off unit. She usually understood and usually understand others, frequently incontinent of bowel and bladder. Her weight was 111 Lbs. During an interview and concurrent record review on 8/31/22 at 11:55 a.m., with minimum data set nurse (MDSN), she reviewed the MDS, dated [DATE], RD notes, care plan and confirmed that Resident 48 had weight loss of 5% or more within 30 days, had two or more activities of daily living (ADL) declined, incontinency and communication. The comprehensive assessment should have been done within 14 days from the determination of the significant change status together with the five-day Medicare assessment that was done on 6/17/22. MDSN confirmed there was no evidence a SCSA comprehensive assessment was done and no interdisciplinary team (IDT- a group of health care professionals from diverse fields who work toward a common goal for residents) discussion about criteria of SCSA. Review of Resident Assessment Instrument Version Manual 3.0 Manual, dated 10/2019, indicated, .a significant change in status assessment must be completed on the fourteenth calendar day after determination that a significant change in the resident's status occurred. The manual further indicated a SCSA MDS is appropriate when a resident declined in two or more areas or the emergence of an unplanned weight loss problem . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056026 If continuation sheet Page 2 of 29 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 056026 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Empress Care Center, LLC 1299 S. Bascom Avenue San Jose, CA 95128 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)

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 ensure the Minimum Data Set (MDS, an assessment tool) quarterly assessments was transmitted (sent electronically) to the Centers of Medicare and Medicaid Services (CMS, a government agency) for one of 12 residents (Resident 44). This failure could potentially affect the provision of care or services to the resident. Residents Affected - Few Findings: Review of Resident 44's clinical record indicated he was re- admitted to the facility on [DATE] and MDS quarterly assessments, dated 3/15/22, 6/15/22 and 8/15/22, were completed, but were not submitted to CMS. During an interview on 9/2/22 at 2:09 p.m., with registered nurse K (RN K) she confirmed the above record review and stated that the assessment for Resident 44 should have been transmitted within 14 days after they were complete. During a concurrent interview and record review on 9/2/22 at 3:52 p.m., RN K reviewed resident 44's MDS 3.0 final validation report from CMS and confirmed the assessments, dated 3/15/2022, 5/13/2022, and 5/29/2022 were not transmitted within 14 days after they were completed. Review of the RAI Manual Version 3.0 dated October 2019 indicated the MDS completion date must be no later than 14 days after the completion date plus 14 calendar days for transmission. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056026 If continuation sheet Page 3 of 29 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 056026 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Empress Care Center, LLC 1299 S. Bascom Avenue San Jose, CA 95128 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)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. b. A review of Resident 26's medical record indicated she was admitted with diagnoses including atrial fibrillation (an irregular and often very rapid heart rhythm that can lead to blood clots in the heart). She had a physician's order, dated 7/14/22, for rivaroxaban 15 milligrams (mg, unit of measurement) once daily for atrial fibrillation. A review of the Prescribing Information (detailed description of a drug's uses, dosage range, side effects, drug-drug interactions, and contraindications that is available to clinicians) for rivaroxaban indicated to monitor the resident closely for signs and symptoms of bleeding (nose bleeds, bleeding gums, blood in urine, abdominal pain, etc) and neurological (related to the nervous system) impairment. A review of Resident 26's medical record indicated there was no care plan developed for the bleeding precautions related to the rivaroxaban use, such as monitoring for signs and symptoms of bleeding and neurological impairment. During a concurrent interview and record review with RN A on 8/31/22 at 2:52 PM, he confirmed there was no care plan developed for the use of rivaroxaban. He stated, There should be one. 3. During a concurrent interview and record review on 9/2/22 at 10:24 a.m., with NS, he reviewed Resident 30's clinical record and confirmed there was a physician order, dated 4/4/22, for Haloperidol (Haldol used to treat certain mental/mood disorders e.g., schizophrenia, schizoaffective disorders) for aggressive behavior related to schizophrenia (chronic and severe mental disorder that affects how a person thinks, feels, and behaves). The NS stated there was no care plan and stated there should have been a care plan. During a concurrent interview and record review, on 9/2/22 at 10:30 a.m., with social service director (SSD), she reviewed Resident 30's clinical record and stated Resident 30 was taking Haldol for schizophrenia. SSD further stated she forgot to care plan for use of Haldol for aggressive behavior. The facility policy and procedure titled Care Planning, dated 7/22, indicated our facility's Care Planning/Interdisciplinary Team is responsible to provide resident centric comprehensive and interdisciplinary care that reflects best practice standard for meeting the health, safety, psychosocial, behavioral, environmental needs of residents in order to obtain or maintain the highest physical, mental and psychosocial wellbeing of each individual .All goals, objectives, interventions, etc. from the current baseline care plan will be included in the resident's comprehensive care plan. Based on interview and record review, the facility failed to develop and implement comprehensive person-centered care plans for three of 15 sampled residents (Residents 21, 26, and 30) when: 1. Resident 21's anxiety and antipsychotic care plan was incomplete and not person-centered; 2. For Resident 26, there was no care plan developed for the hearing difficulty and the bleeding precautions related to the use of Rivaroxaban (an anticoagulant or blood thinning medication); and, 3. For Resident 30, there was no care plan for use of antipsychotic medication (Haldol). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056026 If continuation sheet Page 4 of 29 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 056026 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Empress Care Center, LLC 1299 S. Bascom Avenue San Jose, CA 95128 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)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some These failures had the potential for inaccurate development and implementation of personalized and resident-centered care plans that would address the residents' identified concerns and needs. Findings: 1. Review of Resident 21's clinical records indicated she was admitted to the facility on [DATE] with diagnoses of bipolar disorder (mental disorder characterized by periods of elevated mood and depression (mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily functioning, often with poor decision-making). During a concurrent interview and record review on 9/2/22 at 11:03 a.m., with the nursing supervisor (NS), he reviewed Resident 21's care plans and stated a care plan for anxiety (medical condition includes symptoms of intense anxiety or panic that are directly caused by a physical health problem.) was initiated on 7/5/22 and did not indicate the behavior manifestation for anxiety. The NS also stated the care plan initiated on 7/5/22, focused on psychotropic medications for bipolar disorder and did not indicate Resident 21's behavior manifestations to monitor for bipolar disorder. NS stated the care plan was incomplete and not person-centered care planning. 2. a. Review of Resident 26's clinical record indicated she was admitted on [DATE], and had diagnoses of dementia, history of falling, hypertension (high blood pressure), and type 2 diabetes mellitus (high blood sugar). During an interview with Resident 26 on 9/02/22 at 11:36 a.m., she shook her head and pointed her right ear when asked if she could hear. Review of Resident 26's admission Nursing Assessment, dated 7/13/22, indicated she had poor hearing on her right ear. Review of Resident 26's minimum data set (MDS, an assessment tool), dated 7/20/22, indicated the resident had minimal hearing difficulty in Section B (an assessment section for hearing, speech, and vision). Review of Resident 26's care plans indicated there was no care plan for the hearing difficulty. During an interview and concurrent record review with the MDS nurse (MDSN) on 9/02/22 at 8:45 a.m., she reviewed Resident 26's admission Nursing Assessment, dated 7/13/22, and MDS section B, dated 7/20/22. The MDSN confirmed there was no care plan developed for the hearing difficulty. The MDSN stated the care plan for the hearing difficulty should have been developed. Review of the facility policy and procedure Care plan, revised 9/2009, indicated The resident care plan is developed within 7 days upon resident's admission, reviewed quarterly, annually or as often as needed as there is a change of condition. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056026 If continuation sheet Page 5 of 29 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 056026 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Empress Care Center, LLC 1299 S. Bascom Avenue San Jose, CA 95128 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)

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 Based on observation, interview and record review, the facility failed to assess the skin of one of three residents (Resident 22) when the resident's skin abrasion (surface of the skin has been broken) was not monitored. The failure resulted in progression of skin blisters (skin condition where fluid fills a space between layers of skin) and potential for skin infection. Residents Affected - Few Findings:one resident Review of Resident 22's clinical record indicated he was admitted with multiple diagnosis including peripheral venous insufficiency (a blood circulation disorder that causes the blood vessels outside of the heart and brain to narrow, block, or spasm), muscle weakness. Review of Resident 22's Minimum Data Set (MDS, a standardized assessment tool), dated 7/9/22, indicated his cognition was intact. During an observation on 8/29/22/ at 9:01 a.m. inside Resident 22's room, his lower left leg was noted to be dark in appearance and had abrasions. During a concurrent interview with Resident 22, he stated he had spoken to the staff about his leg and was waiting for treatment. Review of Resident 22's nursing weekly summary (comprehensive nursing assessment done for a resident every seven days), dated 8/26/22, indicated superficial abrasion left lower leg (front) Review of Resident 22's nursing skin care plan, dated 6/28/21, indicated Monitor/observe for redness, swelling, discharges, refer to physician. There was no documented evidence Resident 22's skin was monitored. During a follow up observation and interview with Registered Nurse A (RN A), on 8/31/22 at 10:42 a.m., Resident 22's left leg was noted to be red in color and had skin blisters with fluid coming out. RN A stated the monitoring of Resident 22's skin related to status and changes were not monitored and documented. RN A reviewed the treatment administration record (TAR) and there should have been a monitoring for checking skin status and changes for Resident 22. During an interview with director of nursing (DON) on 9/1/22 at 1:11 p.m., he stated skin assessment should be done every shift by the nursing staff and changes should be documented, monitored, and reported to a physician for appropriate treatment. Review of the facility's policy titled Skin check and Prevention of Skin breakdown for Resident, dated 7/12, indicated Comprehensive assessment of resident upon admission, quarterly, annually or often as needed. Licensed nurse immediately follows up concerns FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056026 If continuation sheet Page 6 of 29 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 056026 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Empress Care Center, LLC 1299 S. Bascom Avenue San Jose, CA 95128 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)

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. 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 prescribed treatment for pressure ulcer (an area of the skin that breaks down when something keeps rubbing or pressing against the skin) was followed for two of three residents (Residents 43 and 44). This failure had the potential for decreased healing and further injury to the residents' wounds. Residents Affected - Few Findings: 1. Review of Resident 43's admission Record indicated she was admitted to the facility on [DATE] with diagnoses including hemiplegia (a condition caused by brain damage or spinal cord injury that leads to severe or complete loss of strength on one side of the body), pressure ulcer on left buttock, pressure ulcer on right buttock, and dependence on supplemental oxygen. Review of Resident 43's physician order, dated 8/12/22, indicated she had a treatment order for her left and right buttock pressure ulcers to be cleansed with Dakin's solution (used to prevent and treat skin and tissue infections that could result from cuts, scrapes and pressure sores), then applied with lantiseptic (skin protectant cream) and covered with dry dressing every day and evening shift. During an observation on 8/31/22 at 11:06 a.m., licensed vocational nurse D (LVN D) prepared to do the treatment for Resident 43's left and right buttock pressure ulcers, but she was unable to locate Resident 43's Dakin's solution. During a treatment observation on 8/31/22 at 11:21 a.m., LVN D cleansed Resident 43's left and right buttock pressure ulcers with normal saline (NS, a mixture of salt and water and contains 0.9 % of salt) instead of Dakin's solution as ordered by the physician. During an interview with LVN D on 8/31/22 at 11:33 a.m., LVN D reviewed Resident 43's Treatment Administration Record (TAR) and confirmed she provided treatment to Resident 43's left and right buttock pressure ulcers on 8/13/22, 8/14/22, 8/17/22 - 8/19/22, 8/21/22, 8/24/22 - 8/28/22, and she had been cleansing the wounds with NS instead of Dakin's solution. LVN D stated she ordered Dakin's solution for Resident 43, but it was not delivered; she did follow up once, but she did not follow up after then. 2. Review of Resident 44's admission Record indicated she was admitted to the facility on [DATE] with diagnoses including hemiplegia, hemiparesis (weakness on one side of the body), and pressure ulcer of sacral region. Review of Resident 44's physician order, dated 6/23/22, indicated she had a treatment order for her coccyx pressure ulcer to be cleansed and irrigated with Dakin's solution, patted dry, packed with iodoform strip (an antiseptic dressing), and covered with dry dressing every day and evening shift and as needed. During a treatment observation on 8/31/22 at 10:37 a.m., LVN D cleansed Resident 44's coccyx pressure ulcer with Dakin's solution, but she did not irrigate the wound as ordered. During an interview on 8/31/22 at 11:36 a.m., LVN D confirmed she did not irrigate Resident 44's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056026 If continuation sheet Page 7 of 29 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 056026 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Empress Care Center, LLC 1299 S. Bascom Avenue San Jose, CA 95128 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)

F 0686 coccyx pressure ulcer. LVN D stated she should follow the physician order. Level of Harm - Minimal harm or potential for actual harm Review of the facility's undated policy, Job Description and Performance Standards - Treatment Nurse, indicated The primary functions and responsibilities of this position are as follows: . 17. Administer treatments according to the physician's order . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056026 If continuation sheet Page 8 of 29 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 056026 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Empress Care Center, LLC 1299 S. Bascom Avenue San Jose, CA 95128 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)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, interview, and record review, the facility failed to follow a fall prevention order for one of four sampled residents (Resident 20) when the pad alarm (device that makes a loud noise to alert caregivers if a resident is getting up from bed) was not placed in bed. This failure had the potential for falls and injury to the resident. Findings: Review of Resident 20's clinical record indicated the resident had a diagnosis including dementia (the loss of cognitive functioning) and abnormalities of gait and mobility. Review of Resident 20's Minimum Data Set (MDS, an assessment tool), dated 7/7/22, indicated the resident's Brief Interview for Mental Status score (BIMS score, a test to get a quick snapshot of how well the resident is functioning cognitively at the moment) was seven, which means severely impaired cognition. Review of Resident 20's Fall assessment, dated 7/7/22, indicated 13, high risk. Review of Resident 20's physician order, dated 7/30/21, indicated. Pad alarm while on bed for poor safety awareness every shift. During a concurrent observation and interview on 8/31/22 at 1:27 p.m. in Resident 20's room, Certified Nursing Assistant B (CNA B) confirmed there was no pad alarm placed on the resident's bed and stated he was unaware of Resident 20's pad alarm. During an interview with Registered Nurse A (RN A) on 8/31/22 at 1:50 p.m., he stated Resident 20 was at risk for falls and the order of the pad alarm should have been implemented. During an interview with Director of Nursing (DON) on 9/2/22 at 1:27 p.m. the physician orders should be implemented. A review of the facility's policy, Falls Management, dated 12/14/20, indicated Interventions in preventing falls should be continued until resident's risks have resolved. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056026 If continuation sheet Page 9 of 29 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 056026 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Empress Care Center, LLC 1299 S. Bascom Avenue San Jose, CA 95128 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)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. 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 administer oxygen (02) according to professional standards of practice for one of one resident (Resident 3). This failure could affect the resident's health and safety. Residents Affected - Few Findings: Review of Resident 3's clinical record indicated the resident was admitted to the facility on [DATE] and was readmitted on 5/1/ 22 with diagnoses including COPD (Chronic Obstructive Pulmonary Disease, a group of diseases that cause airflow blockage and breathing-related problems) and acute respiratory failure. Review of Resident 3's physician order, dated 8/11/21, indicated to administer oxygen at 2 LPM (liters per minute, the flow of oxygen) via nasal cannula (NC, a device used to deliver supplemental oxygen. The device consists of a lightweight tube which on one end splits into two prongs which are placed in the nostrils). During an observation on 8/29/22 at 8:39 a.m., Resident 3 was sleeping in the bed with oxygen at 2.5 LPM via NC. There was an oxygen concentrator (a machine that supplies oxygen) and the humidifier bottle was empty with whitish sediments inside the bottle. During a concurrent observation and interview, on 8/29/22 at 8:54 a.m., Infection Preventionist (IP) verified the oxygen humidifier bottle was empty and unclean. IP stated it needed to be filled with distilled water to keep the nasal moist and avoid dryness of the nostrils. During an interview with Director of Nursing (DON), on 9/1/22 at 11:02 a.m., the license nurses should ensure that the humidifier bottle should be cleaned and filled with distilled water. Review of facility's policy titled Oxygen Therapy, dated 3/05/22, indicated that oxygen humidifier must be always clean and distilled water replaced every 24 hours. Refill non -disposable humidifier with distilled water as needed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056026 If continuation sheet Page 10 of 29 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 056026 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Empress Care Center, LLC 1299 S. Bascom Avenue San Jose, CA 95128 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)

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident 37's admission Record indicated he was originally admitted to the facility on [DATE] and was re-admitted on [DATE]. Review of Resident 37's physician order dated 5/3/20, indicated he had an order for Escitalopram oxalate (Lexapro) (an antidepressant medication that works in the brain and for the treatment of major depressive disorder (MDD) tablet10 milligrams (mg, a unit of measurement) by mouth (PO) one time a day for depression manifested by self-isolation related to major depressive disorder. Review of Resident 37's Note to Attending Physician/Prescriber, dated 7/15/22, indicated the pharmacist recommended the physician to evaluate the current dose of Lexapro 10 mg. daily to consider a dose reduction to 5 mg. daily since Resident 37 has not been manifested any behaviors. Further reviewed of the note there was no response from the physician on the recommendation. During an interview with the director of nursing (DON) on 9/2/22 at 1:48 p.m., he confirmed the pharmacist's recommendation was not presented to the physician. DON stated the recommendation should have been faxed to the physician and should have been followed up by the facility staff. 3. Review of Resident 44's admission Record indicated she was originally admitted to the facility on [DATE]. Review of Resident 44's physician order indicated she had an order for guaifenesin (used to treat coughs and congestion caused by the common cold and other breathing illnesses) 10 milliliters (ml, a metric unit of volume) every 4 hours as needed for cough, started on 1/17/20. Review of Resident 44's Note to Attending Physician/Prescriber, dated 3/15/22, indicated the pharmacist recommended the physician to evaluate the continued need or discontinuation of guaifenesin since it had not been used for Resident 44 recently. However, there was no response from the physician on the recommendation. During an interview with the director of nursing (DON) on 9/2/22 at 12:53 p.m., he confirmed the pharmacist's recommendation was not presented to the physician. DON stated the recommendation should have been faxed to the physician and guaifenesin should have been discontinued. Review of the facility's policy, Medication Monitoring - Medication Regimen Review (MRR) and Reporting, dated 9/2018, indicated Resident-specific MRR recommendations and findings are documented and acted upon by the nursing care center and/or physician. Based on interview and record review, the facility failed to ensure the consultant pharmacist's (CP) medication regimen review (MRR) recommendations were acted upon for three out of 15 sampled residents (Residents 7, 37, and 44). This failure resulted in unnecessary medications due to inadequate monitoring, prolonged medication use, etc. and had the potential for adverse side effects that could negatively impact the residents' physical, mental, and psychosocial well-being. Findings: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056026 If continuation sheet Page 11 of 29 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 056026 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Empress Care Center, LLC 1299 S. Bascom Avenue San Jose, CA 95128 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)

F 0756 Level of Harm - Minimal harm or potential for actual harm 1. Resident 7 was admitted to the facility with diagnoses including moderate calorie malnutrition, chronic heart disease, and hypothyroidism (a condition in which the thyroid gland does not produce enough thyroid hormone). A review of Resident 7's medical record indicated the resident was receiving: Residents Affected - Some - Furosemide (Lasix, a diuretic) 40 milligrams (mg, unit of measurement), 1 tablet twice daily from 2/19/21 to 8/25/22; and 40 mg daily for high blood pressure since 8/15/22. - Levothyroxine (a thyroid medication) 88 micrograms (unit of measurement) 1 tablet once daily related to hypothyroidism, dated 2/19/21. A review of the Prescribing Information (PI, detailed description of a drug's uses, dosage range, side effects, drug-drug interactions, and contraindications that is available to clinicians) for furosemide indicated it is a diuretic that can lead to a profound diuresis with water (removal of water through the urine) and electrolyte depletion. The PI indicated serum electrolytes should be checked periodically (https://dailymed.nlm.nih.gov/dailymed/index.cfm; accessed 9/7/22) A review of the PI for levothyroxine indicated to monitor serum TSH [thyroid stimulating hormone] levels after an interval of 6 to 8 weeks after any change in dose. In patients on a stable and appropriate replacement dose, evaluate clinical and biochemical response every 6 to 12 months and whenever there is a change in the patient's clinical status. (https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm; accessed 9/7/22) A review of Resident 7's clinical record showed the latest laboratory test for electrolytes was conducted on 2/23/21; and the latest TSH was obtained on 2/22/21, one and a half years ago. During a telephone interview with the facility's CP on 9/1/22 at 1:35 p.m., she stated she would normally recommend getting the complete metabolic panel (CMP, blood test that includes electrolytes and kidney functions) and TSH every 6 months for residents receiving diuretics and levothyroxine, respectively. She stated she made the recommendations for getting those tests for Resident 7 in February and April 2022 but she did not know what happened to those recommendations. A review of the CP's two MRR recommendations, dated 2/14/22 and 4/8/22, addressed to Resident 7's physician, as follows: This resident is receiving medications which need routine lab work. Please check all that you would like ordered . ( ) CMP for the use of lasix ( ) TSH for the use of levothyroxine ( ) Please list below any additional labs or monitoring parameters not listed During a concurrent interview and record review on with the nurse supervisor (NS) on 9/1/22 at 3:06 p.m., he stated there were no other laboratory tests for electrolytes and TSH for Resident 7 besides those done in February 2021. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056026 If continuation sheet Page 12 of 29 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 056026 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Empress Care Center, LLC 1299 S. Bascom Avenue San Jose, CA 95128 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)

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview with the director of nursing (DON) and the NS on 9/1/22 at 3:10 p.m., the DON stated there had been changes in the facility DONs, and he just became the DON 4 to 5 months ago. He stated he and the NS had been trying to catch up on the CP's recommendations but had not been able to work on all of them yet. The DON verified the facility received the above MRR recommendations for Resident 7, but they had not been able to carry them out yet. He stated the expectation was for the facility to respond to them as soon as possible or within a month. A review of the facility's 5/2016 policy and procedures titled Medication Monitoring Medication Regiment Review and Reporting indicated, The consultant pharmacist reviews the medication regimen of each resident at least monthly. Findings and recommendations are communicated to those with authority and/or responsibility to implement the recommendations, and responded to in an appropriate and timely fashion and Resident-specific MRR recommendations and findings are . acted upon by the nursing care center and/or physician. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056026 If continuation sheet Page 13 of 29 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 056026 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Empress Care Center, LLC 1299 S. Bascom Avenue San Jose, CA 95128 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)

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure 1 of 15 sampled residents (Resident 7) was free from unnecessary medications when Resident 7 received long-term diuretic (medication that remove water from the body which can affect the electrolyte levels in the body) without routine electrolyte (such as potassium, calcium, magnesium) monitoring; and levothyroxine (thyroid medication) without periodic lab work for its use. The failure had the potential to result in electrolyte imbalance and inadequate thyroid response, that can cause serious medical conditions such as irregular heartbeats, fatigue, confusion, etc. for the resident. Residents Affected - Few Findings: Resident 7 was admitted to the facility with diagnoses including moderate calorie malnutrition, chronic heart disease, and hypothyroidism (a condition in which the thyroid gland doesn't produce enough thyroid hormone). A review of Resident 7's medical record indicated the resident was receiving: - Furosemide (a diuretic) 40 milligrams (mg, unit of measurement), 1 tablet twice daily from 2/19/21 to 8/25/22; and 40 mg daily for high blood pressure since 8/15/22. - Levothyroxine 88 micrograms (unit of measurement) 1 tablet once daily related to hypothyroidism, dated 2/19/21. A review of the Prescribing Information (PI, detailed description of a drug's uses, dosage range, side effects, drug-drug interactions, and contraindications that is available to clinicians) for furosemide indicated it is a diuretic that can lead to a profound diuresis with water (removal of water through the urine) and electrolyte depletion. The PI indicated serum electrolytes should be checked periodically (https://dailymed.nlm.nih.gov/dailymed/index.cfm; accessed 9/7/22) A review of the PI for levothyroxine indicated tomonitor serum TSH [thyroid stimulating hormone] levels after an interval of 6 to 8 weeks after any change in dose. In patients on a stable and appropriate replacement dose, evaluate clinical and biochemical response every 6 to 12 months and whenever there is a change in the patient's clinical status. (https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm; accessed 9/7/22) A review of Resident 7's clinical record showed the latest laboratory test for electrolytes was conducted on 2/23/21; and the latest TSH was obtained on 2/22/21, one and a half years ago. During a telephone interview with the facility's consultant pharmacist (CP) on 9/1/22 at 1:35 PM, she stated she would normally recommend getting the complete metabolic panel (blood test that includes electrolytes and kidney functions) and TSH every 6 months for residents receiving diuretics and levothyroxine, respectively. She stated she made the recommendations for getting those tests for Resident 7 in February and April 2022, but she did not know what happened to those recommendations. During a concurrent interview and record review on with the nurse supervisor (NS) on 9/01/22 at 3:06 PM, he stated there were no other laboratory tests for electrolytes and TSH for Resident 7 besides those done in February 2021. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056026 If continuation sheet Page 14 of 29 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 056026 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Empress Care Center, LLC 1299 S. Bascom Avenue San Jose, CA 95128 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)

F 0757 Level of Harm - Minimal harm or potential for actual harm A review of the facility's policy and procedures titled Medication Monitoring Medication Management, dated 11/2017, indicated: In order to optimize the therapeutic benefit of medication therapy and minimize or prevent potential adverse consequences, facility staff, the attending physician/prescriber, and the consultant pharmacist perform ongoing monitoring for appropriate, effective, and safe medication use. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056026 If continuation sheet Page 15 of 29 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 056026 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Empress Care Center, LLC 1299 S. Bascom Avenue San Jose, CA 95128 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)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure two of 9 residents (36 and 44) were free from unnecessary psychotropic medications (drugs that affects brain activities associated with mental processes and behaviors) when: 1. Resident 36 received Abilify for schizoaffective disorder (a mental disorder characterized by abnormal thought processes and an unstable mood), and the electrocardiogram (ECG, a test that measures the electrical activity of the heartbeat) was not done as ordered; and 2. Resident 44 received Latuda for schizoaffective disorder and haloperidol for schizophrenia (a mental disorder in which people interpret reality abnormally), and the liver function tests (LFTs, blood tests used to help diagnose and monitor liver disease or damage) was not done as ordered. These failures resulted in unnecessary medications for the residents, which had the potential for increased risks associated with psychotropic medication use that include, but not limited to, sedation, respiratory depression, falls, constipation, anxiety, agitation, abnormal involuntary movements, and memory loss. Findings: 1. Review of Resident 36's admission Record indicated she was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). Review of Resident 36's physician orders indicated she had orders for Abilify 5 milligrams (mg, a metric unit of mass) every day related to schizoaffective disorder, started on 11/7/19, and check ECG annually in May, dated 3/31/21. However, there was no ECG result found for Resident 36. During an interview with the director of nursing (DON) on 9/2/22 at 1:48 p.m., the DON reviewed Resident 36's clinical record and confirmed Resident 36 had not had the ECG done since 2021. 2. Review of Resident 44's admission Record indicated she was originally admitted to the facility on [DATE] with diagnoses including schizoaffective disorder and depression. Review of Resident 44's physician orders indicated she had orders for haloperidol 5 mg three times a day related to schizophrenia, started on 1/17/20, Latuda 100 mg one time a day related to schizoaffective disorder, started on 4/12/20, and LFTs every December, dated 1/6/18. However, there was no LFTs result found for Resident 44. During an interview with the DON on 9/2/22 at 2:37 p.m., the DON reviewed Resident 44's clinical record and confirmed LFTs had not been done for Resident 44 as ordered. Review of the facility's policy, Medication Monitoring - Medication Management, dated 11/2017, indicated Each resident's drug regimen is reviewed to ensure it is free from unnecessary drugs. This includes any drug without adequate monitoring; . The facility's medication management supports and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056026 If continuation sheet Page 16 of 29 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 056026 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Empress Care Center, LLC 1299 S. Bascom Avenue San Jose, CA 95128 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)

F 0758 promotes: . The monitoring of medications for efficacy and adverse consequences. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056026 If continuation sheet Page 17 of 29 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 056026 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Empress Care Center, LLC 1299 S. Bascom Avenue San Jose, CA 95128 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)

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility had a medication error rate of 10.71% when three medication errors occurred out of 28 opportunities during the medication administration for three residents (Residents 30, 37, and 40). The failure resulted in medications not given according to manufacturer's specifications, and had the potential for residents not receiving the full therapeutic effects of medications. Residents Affected - Some Findings: 1. During a medication pass observation on 8/29/22 at 9:05 AM, the nurse supervisor (NS) was observed preparing 3 medications for Resident 40. The medications included the phenytoin (brand name: Dilantin, a medication for seizures) 125 milligrams (mg) per 5 milliliters (mL) oral liquid. He removed the phenytoin bottle from the medication cart and poured 4 mL into a small medication cup without shaking the bottle first. On 8/29/22 at 9:10 AM, the NS was observed administering the phenytoin liquid, along with the other two medications, via the resident's gastrostomy tube (G-tube, a tube inserted through the abdomen that delivers nutrition and medications directly to the stomach). Then, on 8/29/22 at 9:15 AM, the NS was observed attaching a bag of Isosource HN (an enteral feeding preparation) to the resident's enteral feeding pump (machine) and running it at 45 mL per hour. During an interview with the NS on 8/29/22 at 9:55 AM, he confirmed he did not shake the phenytoin liquid bottle before pouring into the cup. He acknowledged the medication settled on the bottom after sitting in the medication cart. A review of the pharmacy label on the bottle with the NS at this time read, Shake Well Before Using. A review of Resident 40's medical record indicated a physician's order, dated 9/5/19, for Dilantin Suspension 125 mg/5 mL (Phenytoin), give 4 mL via G-tube every 12 hours related to UNSPECIFIED CONVULSIONS. On 8/29/22 at 11:28 AM, a review of the facility's current Nursing Drug Handbook was conducted with the NS. It indicated, Tube feedings decrease phenytoin absorption The manufacturer recommends not to administer concomitantly with an enteral feeding preparation. The NS acknowledged he administered phenytoin at the same time with an enteral feeding formula. A review of Lexi-comp, a nationally recognized drug information resource, indicated the following for phenytoin liquid administration: Shake well prior to use and Enteral feeding tube: Administration of phenytoin with enteral nutrition and/or related nutritional supplements may decrease phenytoin absorption. If possible, hold feedings for 1 to 2 hours prior to and 1 to 2 hours after phenytoin administration. A review of the facility's policy and procedures (P&P) titled POLICY AND PROCEDURE IN MEDICATION ADMINISTRATION, revised 7/2013, indicated, Holding one hour before and one hour after administration of Dilantin with a tube feeding resident is a must, unless M.D. orders specified otherwise. 2. During a medication pass observation on 8/29/22 at 10:43 AM, the NS was observed preparing 4 units of Admelog (insulin Lispro, a rapid-acting insulin, medication to lower blood sugar [BS]) 100 units/mL for Resident 30. He stated the resident's BS was 271. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056026 If continuation sheet Page 18 of 29 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 056026 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Empress Care Center, LLC 1299 S. Bascom Avenue San Jose, CA 95128 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)

F 0759 On 8/29/22 at 10:45 AM, the NS injected the insulin into the fatty area under the resident's left upper arm. Level of Harm - Minimal harm or potential for actual harm A review of Resident 30's medical record indicated a physician's order, dated 5/14/22, for Admelog 100 units/mL, inject as per sliding scale (a set of instructions for administering insulin dosages based on specific BS readings) subcutaneously (under the skin) three times a day for diabetes. Residents Affected - Some A review of the facility's current Nursing Drug Handbook indicated, Insulin Lispro should be administered within 15 minutes before or immediately after a meal. 3. During another medication pass observation with the NS on 8/29/22 at 10:50 AM, he was observed performing a BS check by pricking Resident 37's finger using a lancet. The BS reading was 155. In response to the BS reading, on 8/29/22 at 10:52 AM, the NS was observed preparing 2 units of Novolog (a rapid-acting insulin) for Resident 37. On 8/29/22 at 10:53 AM, the NS injected Novolog into the fatty area on the resident's left waist. During an interview on 8/29/22 at 10:54 AM, the NS stated the nursing staff usually performed BS checks and administered sliding scale insulin around 11 AM, an hour or more before lunch. He stated lunch was normally served from 12 PM to 12:30 PM. A review of Resident 37's medical record indicated a physician's order, dated 1/5/21, for Novolog 100 units/mL, inject as per sliding scale subcutaneously before meals related to diabetes. A review of the facility's current Nursing Drug Handbook indicated, Novolog: Administer immediately (within 5 to 10 minutes) before a meal. On 8/29/22 at 12:16 PM, both Residents 30 and 37 were observed in their respective rooms. No lunch trays were brought to them yet. On 8/29/22 at 12:45 PM, the NS verified no lunch was provided for the two residents yet. During a concurrent interview and record review on 8/29/22 at 3:06 PM, the NS reviewed the Nursing Drug Handbook information for the two insulin types above and acknowledged he gave the insulin too soon. He confirmed lunch was brought out at 12:50 PM today, two hours after he administered the insulin for Residents 30 and 37. During a telephone interview with the facility's consultant pharmacist (CP) on 9/1/22 at 1:25 PM, she stated she would recommend to administer AC (meaning before meals) sliding scale insulin 15 to 20 minutes before a meal or when the resident is about to eat. A review of the facility's P&P titled Medication Administration - General Guidelines, revised 1/2015, indicated, Medications are administered within sixty (60) minutes of scheduled time, except before or after meal orders, which are administered based on mealtimes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056026 If continuation sheet Page 19 of 29 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 056026 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Empress Care Center, LLC 1299 S. Bascom Avenue San Jose, CA 95128 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)

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview, and document review, the facility failed to ensure the planned menu was followed when 11 of 11 residents on mechanical soft diet (texture modified diet that restricts foods that are difficult to chew or swallow) were to be served roast beef. This failure had the potential to result in residents not meeting the nutritional needs thus further compromising the nutritional status of the residents. Findings: Review of the facility titled Cooks Spreadsheet for week 1 Monday lunch (8/29/22) indicated Swedish meatballs for all types of diet. During a concurrent observation and interview with Kitchen Supervisor (KS) on 8/29/22 at 8:30 a.m. in the kitchen, a tray of roast beef was inside the oven. KS confirmed the observation. During a concurrent interview and spreadsheet review with KS on 8/31/22 at 8:31 a.m. in the kitchen, KS stated the roast beef was not on the Monday (8/29/22) menu list. KS verified meatballs are available to be cooked for the day. During an interview with the dietary cook (DC) on 8/29/22 at 8:32 a.m. in the kitchen, the DC stated he cooked the roast beef for residents on mechanical soft diet. DC acknowledged the Swedish meatballs should have been cooked which was written on the menu. During a concurrent interview and review of alternate menu with dietary manager (DM) on 8/29/22 at 10:30 a.m., she stated roast beef was not listed as an alternative. During an interview with registered dietitian (RD) on 9/2/22 at 1:39 p.m., she stated she did not approve a menu change for 8/29/22 and she further stated dietary cooks should follow the daily menu. A review of the facility's policy Menu Planning dated 2020 indicated, All daily menu changes are to be noted on the back of the kitchen spreadsheet. Only the Dietitian, or Food and Nutrition Service Director can make permanent changes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056026 If continuation sheet Page 20 of 29 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 056026 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Empress Care Center, LLC 1299 S. Bascom Avenue San Jose, CA 95128 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)

F 0812 Level of Harm - Minimal harm or potential for actual harm 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 prepared under safe and sanitary conditions when: Residents Affected - Some 1. Frozen meatballs were thawed at room temperature. 2. A sanitizing bucket (contains concentration of chemical sanitizer used for cleaning) was placed too near with clean pots. 3. Sanitizing wipes (pre moistened towelettes that contain disinfecting ingredients) were placed next to potholders and liquid seasonings (vinegar, soy sauce). 4. The oven door was broken. 5. The can opener base was not kept in sanitary condition. 6. There were crumbs seen under the microwave oven. 7. Personal items were seen in the food storage and preparation areas. 8. The log sheet for cleaning the ice scooper was recorded incomplete. These failures had the potential to cause food contamination, spread illness to 45 out of 48 residents. Findings: 1. During a concurrent observation and interview with the kitchen supervisor (KS) on 8/29/22 at 8:28 a.m. in the kitchen, two bags of frozen meatballs on a dry container were being thawed in the sink at room temperature. KS verified the observation and acknowledged thawing should not be at room temperature. During an interview with the dietary manager (DM) and the Registered Dietitian (RD) on 8/29/22 at 10:23 a.m., the DM and the RD confirmed thawing of meats should be under running water. Review of the facility's policy Thawing of Meats dated 2018, indicated, Submerge under running, potable water with a pressure sufficient to flush away loose particles. 2. During a concurrent observation and interview with the KS on 8/29/22 at 8:29 a.m., in the kitchen, a red colored sanitizing bucket was placed too close with clean pots in a cabinet. The KS acknowledged the sanitizing bucket should be in a separate cabinet away from the clean pots used for cooking to prevent contamination. During an interview with the dietary manager (DM) and the Registered Dietitian (RD) on 8/29/22 at 10:22 a.m., the DM and the RD confirmed the sanitizing buckets should be away from clean pots or cooking utensils, equipment to prevent contamination. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056026 If continuation sheet Page 21 of 29 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 056026 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Empress Care Center, LLC 1299 S. Bascom Avenue San Jose, CA 95128 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)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 3. During a concurrent observation and interview with KS on 8/29/22 at 8:30 a.m. in the kitchen, sanitizing wipes was observed to be placed near the potholders, vinegar and soy sauce bottles. KS confirmed the potholders are used to touch hot pots and hot trays containing food. She further stated the sanitizing wipes should be away from the seasoning bottles to prevent contamination. During an interview with the dietary manager (DM) and Registered Dietitian (RD) on 8/29/22 at 10:23 a.m., the DM and RD confirmed the sanitizing wipes should be stored away from cooking utensils and food seasonings to prevent contamination. Review of the facility's policy Food Storage dated 12/14 indicated, Soaps, detergents, cleaning compounds or similar substances will be stored in separate storage areas. 4. During a concurrent observation and interview with KS on 8/29/22 at 8:31 a.m., in the kitchen, the oven door had an oven rack used as a lock to prevent the door from opening. KS opened the oven door and it did not seal upon closure. KS acknowledged the broken oven door can be a safety hazard to the kitchen staff. During an interview with the Maintenance Supervisor (MS) on 9/2/22 at 9:48 a.m., he stated the facility was aware of the broken oven door on 11/16/21, because the maintenance could not fix the broken part. Review of the vendor's order receipt dated 12/14/21 indicated Door hinges are worn, and door assembly is no longer available. Review of the facility's policy titled Safety and Infection Control dated 2018, indicated The kitchen will be equipped with safe equipment, which is to be maintained in good working order. 5. During a concurrent observation and interview with the KS on 8/29/22 at 8:32 a.m. in the kitchen, the surveyor wiped the can opener base with a clean white paper towel and there was a brownish pasty substance. The KS acknowledged the observation and further stated kitchen can opener base should be cleaned after each use to prevent food contamination. During an interview with DM and RD on 8/29/22 at 10:24 a.m., the DM and RD confirmed the can opener should always be cleaned after every use. A review of the facility policy Storage of Food and Supplies dated 2020 indicated, Routine cleaning should be developed and followed. 6. During a concurrent observation and interview with KS on 8/29/22 at 8:33 a.m. in the kitchen, crumbs were seen under the microwave oven. KS verified the observation and stated kitchen surfaces should always be clean. During an interview with the DM and RD on 8/29/22 at 10:25 a.m., the DM and RD confirmed the kitchen surface and equipment should always be clean. A review of the facility policy Storage of Food and Supplies dated 2020 indicated, Routine cleaning should be developed and followed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056026 If continuation sheet Page 22 of 29 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 056026 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Empress Care Center, LLC 1299 S. Bascom Avenue San Jose, CA 95128 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)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 7. During a concurrent observation and interview with KS on 8/29/22 at 8:34 a.m. in the kitchen, a personal binder was placed on top of a bread. KS acknowledged the binder belongs to her and it should not be on top of the bread to avoid squeezing the bread and possible contamination. During a concurrent observation and interview with KS on 8/229/22 at 8:36 a.m. in the kitchen, a bottled drink was seen by the food mixer. KS asked dietary cook (DC) and DC acknowledged that the bottled drink was his bottle and stated personal items should not be in the kitchen. During an interview with DM and RD on 8/29/22 at 10:26 a.m., both confirmed personal belongings should be away from food and kitchen equipment to prevent cross contamination. According to the 2017 Food Code 6-404.11, Because employees could introduce pathogens to food by hand to mouth to food contact personal belongings carry contaminants, areas designated to accommodate employees' personal needs must be carefully located. 8. During a concurrent observation and interview with DM on 8/29/22 at 12:45 p.m. the log sheet for cleaning the ice scooper had no month and were missing initials on the days of 20, 21, 27 and 28. DM acknowledged the log in sheet should be filled out with the right month, staff initials on the date to assure the ice scooper is safe to use. DM stated she is not sure if kitchen or maintenance should be responsible in cleaning the ice scooper. During an interview with MS on 8/30/22 at 8:26 a.m., he stated maintenance department is responsible with maintaining ice machine but not the ice scooper. MS stated facility does not have policy for ice scooper maintenance. During an interview with Infection Preventionist (IP) on 9/2/22 at 11:21 a.m., IP stated kitchen should be responsible in cleaning ice scoopers and maintenance is responsible for ice machine's function and cleanliness. According to the 2017 Food Code 2-103.11, Person in charge ensure clean equipment, utensils and linens FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056026 If continuation sheet Page 23 of 29 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 056026 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Empress Care Center, LLC 1299 S. Bascom Avenue San Jose, CA 95128 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)

F 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to store and ensure food were under sanitary conditions for one of three residents (Resident 6) when the resident's food brought from outside was not properly stored, labeled, and dated. This failure had the potential for food borne illness and food contamination. Residents Affected - Few Findings: During an concurrent observation and interview on 8/29/22, at 9:22 a.m., in Resident 6's room, an unlabeled and undated bottle of Nutella was found at his bedside. Resident 6 stated, it was brought outside by my son. During a follow up observation on 8/30/22, at 8:30 a.m., in Resident 6's room, a bottled of unlabeled and undated peanut butter was found at his bedside. During an interview on 9/01/22, at 10: 56 a.m., certified nursing assistant E (CNA E)confirmed the peanut butter was unlabeled and undated at bedside. CNA E stated, CNA should check the food at bedside and informed the nurse. During an interview with Dietary Manager (DM), on 9/1/22 at 10:51 a.m., she stated that every resident is allowed to bring food from outside. Facility staff should date and store food properly. During an interview with Registered Dietician (RD) ,on 9/1/22 at 1:54 p.m., she stated all staff should follow the facility's policy of labeling and dating food brought from outside. During an interview with the Director of Nursing (DON), on 9/1/22 at 1:45 p.m., he stated, Food on bedside should be labeled and dated. Review of the facility's policy, Bringing in food for a resident, dated 2018, indicated, food and beverages should be labeled and dated to monitor for food safety, need to be marked with resident's name. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056026 If continuation sheet Page 24 of 29 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 056026 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Empress Care Center, LLC 1299 S. Bascom Avenue San Jose, CA 95128 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)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. During a medication pass observation on 8/29/22 at 9:05 a.m., the NS was observed preparing 3 medications for Resident 40. He placed each medication in a small medication cup and put them on a medication tray along with 3 other cups containing water. At the resident's bedside, he placed the medication tray on the resident's overbed table; and started administering the medications via the resident's gastrostomy tube (G-tube, a tube inserted through the abdomen that delivers nutrition and medications directly to the stomach), which required dilution, mixing, and flushing of the tube with water. Residents Affected - Some On 8/29/22 at 9:25 a.m., after finishing the medication administration for Resident 40, the NS brought the medication tray back to the medication cart, and started preparing medications for Resident 43 without wiping down the tray first. He prepared two medications for Resident 43, put them on the same medication tray, and brought to Resident 43's bedside. During an interview on 8/29/22 at 9:57 a.m., the NS confirmed he did not wipe down the medication tray between the medication administration for the two residents, and stated he should have wiped it with the disinfectant wipe after use for each resident. Based on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when: 1. Resident 4's and Resident 43's oxygen tubing were not changed every week; 2. Certified Nursing Assistant I (CNA I) did not wash or sanitize her hands before feeding Resident 13; 3. Licensed Vocational Nurse D (LVN D) did not wash her hands and change the gloves before cleansing Resident 42's pressure ulcers; 4. CNA L did not perform hand hygiene between residents; 5. The nurse supervisor (NS) did not wipe the medication tray with the disinfectant wipe after use for each resident. These failures could result in the spread of infection and cross-contamination in the facility. Findings: 1.a. Review of Resident 4's admission Record indicated she was admitted to the facility on [DATE] with diagnoses including asthma (a chronic disease in which the airways in the lungs become narrowed and swollen, making it difficult to breathe) and dependence on supplemental oxygen. Review of Resident 4's physician order, dated 3/4/22, indicated she had an order for oxygen at 2 liter (L, a metric unit of volume) per minute at bedtime for short of breath, wheezing, and chest pain. During an observation and interview with the nursing supervisor (NS) on 8/29/22 at 10:19 a.m., Resident 4's oxygen tubing was dated 5/3/22. The NS stated Resident 4's oxygen tubing should be changed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056026 If continuation sheet Page 25 of 29 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 056026 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Empress Care Center, LLC 1299 S. Bascom Avenue San Jose, CA 95128 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)

F 0880 every week. Level of Harm - Minimal harm or potential for actual harm 1.b. Review of Resident 43's admission Record indicated she was admitted to the facility on [DATE] with diagnoses including pneumonia (an infection that inflames the lungs' air sacs) and dependence on supplemental oxygen. Residents Affected - Some Review of Resident 43's physician order, dated 8/3/22, indicated she had an order for oxygen at 2 L per minute every shift. During an observation and interview with the NS on 8/29/22 at 10:16 a.m., Resident 43's oxygen tubing was dated 8/21/22. The NS stated Resident 43's oxygen tubing should be changed every week. During an interview with the infection preventionist (IP) on 9/2/22 at 3:05 p.m., she stated the resident' oxygen tubing should be changed every week. Review of the facility's policy, Oxygen Therapy, dated 3/2005, indicated 9. Oxygen tubing is to be replaced every week . 2. Review of Resident 13's admission Record indicated she was admitted to the facility on [DATE] with dysphasia (difficulty swallowing). During an observation on 8/29/22 at 1:07 p.m., certified nursing assistance I (CNA I) carried a chair from a dining room to Resident 13's room, sat down on the chair, and assisted Resident 13's meal without washing or sanitizing her hands. During a concurrent interview, CNA I stated she should wash or sanitize her hands before assisting Resident 13's meal. During an interview with the infection preventionist (IP) on 9/2/22 at 3:09 p.m., she stated CNA I should wash or sanitize her hands after touching the chair and before the resident's feeding. 3. Review of Resident 42's admission Record indicated she was admitted to the facility on [DATE] with diagnoses including pressure ulcer (damage to an area of the skin caused by constant pressure on the area for a long time) of sacral region, pressure ulcer of left heel, and pressure ulcer of right heel. During an observation on 8/31/22 at 10:15 a.m., licensed vocational nurse D (LVN D) provided treatment to Resident 42's coccyx pressure. LVN D held Resident 42's underpad with her gloved hands to turn Resident 42 to the other side, then started cleansing Resident 42's coccyx wound without cleansing her hands and changing the gloves. LVN D also provided treatment to Resident 42's pressure ulcers on the heels. LVN D removed the boot on Resident 42's left foot with her gloved hands, held Resident 42's left leg up, removed the old dressing on Resident 42's left heel, then started cleansing Resident 42's left heel wound without cleansing her hands and changing the gloves. During an interview with LVN D on 8/31/22 at 11:35 a.m., LVN D confirmed she held Resident 42's underpad with her gloved hands to turn Resident 42 to the other side then started cleansing Resident 42's coccyx wound without cleansing her hands and changing the gloves; and she removed the boot on Resident 42's left foot with her gloved hands, held Resident 42's left leg up, removed the old dressing on Resident 42's left heel, then started cleansing Resident 42's left heel wound without cleansing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056026 If continuation sheet Page 26 of 29 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 056026 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Empress Care Center, LLC 1299 S. Bascom Avenue San Jose, CA 95128 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)

F 0880 Level of Harm - Minimal harm or potential for actual harm her hands and changing the gloves. LVN D stated she should cleansing her hands and changing the gloves before cleansing Resident 42's wounds. 4. During a dining observation on 8/29/22 at 12:21 p.m., certified nursing assistant L (CNA L) was putting bibs for the three residents setting in the dining room and did not perform hand hygiene between residents. Residents Affected - Some During an interview on 8/29/22 at 12:22 p.m., with CNA K, she acknowledged the above observation and stated she should have performed hand hygiene between residents . Review of the facility's policy,Handwashing/Hand Hygiene, dated 6/2012, indicated if hands are not visibly soiled use an alcohol-based hand rub containing 60-95% ethanol or isopropanol for all the following situations including before direct contact with residents, before performing any non-surgical invasive procedures, after handling used dressings, contaminated equipment, and after contact with inanimate objects. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056026 If continuation sheet Page 27 of 29 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 056026 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Empress Care Center, LLC 1299 S. Bascom Avenue San Jose, CA 95128 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)

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide a safe and functional environment for one of 12 sampled residents (Resident 21) when Resident 21's bathroom sink was clogged and the toilet bowl had a leak with water spilled on the floor. The facility must provide a safe, functional, sanitary, and comfortable environment for residents and staff. Findings: During an initial tour of the facility on 8/29/2022 at 8:46 a.m., Resident 21's toilet bowl was leaking with water spilled on the floor and a wet white bath towel was observed underneath. During a concurrent observation and interview with Resident 21 on 8/29/2022 at 8:48 a.m., she stated the toilet bowl had a water leak with water spilled on the floor since she had been admitted on [DATE]. Resident 21 stated the facility staff was aware of leaking toilet bowl and that was why a white bath towel was put underneath to absorb water. During an interview, on 8/30/2022 at 11:50 a.m., with the licensed vocational nurse D (LVN D), she stated maintenance was aware of the toilet bowl leak and clogged sink in Resident 21's bathroom. During a concurrent observation and interview with Resident 21 on 8/30/2022 at 8:45 a.m., Resident 21 showed her bathroom sink was clogged. She stated the maintenance staff was aware of it. During a concurrent observation and interview on 8/30/2022 at 8:50 a.m., with housekeeping and laundry supervisor (HLS), he confirmed Resident 21's toilet bowl was leaking and the bathroom sink was clogged. During a concurrent interview and record review on 8/30/2022 at 8:58 a.m., the HLS stated he was unaware of Resident 21's leaking toilet and clogged sink. HLS stated if anything needed repairs, it should be written in the Communication Binder or Maintenance Worksheet Log Binder at the nurse's station. HLS reviewed the Maintenance Worksheet Log Binder and stated it did not indicate there was a problem in resident 21's bathroom. HLS further stated maintenance should have done preventive maintenance by checking each resident's room weekly and checking the Maintenance Worksheet log Binder daily. During an interview on 8/30/2022 at 12:00 p.m., Maintenance Supervisor (MS) stated he was not aware of the leaky toilet and clogged sink in Resident 21's bathroom. MS stated he could repair the leaky toilet and clogged sink if someone had told him. He further stated he used to have weekly preventive maintenance check lists in every resident room, but it had been stopped for a year. Review of Resident 21's Minimum Data Set (MDS, an assessment tool), dated 8/17/2022, indicated her cognition was intact. Review of the facility's policy titled Maintenance Service, dated July 2012, indicated maintenance service shall be provided to all areas of the building, ground, and equipment. The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. Functions of maintenance personnel include providing routinely scheduled maintenance service to all areas. The Maintenance Director is responsible for developing and maintaining a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056026 If continuation sheet Page 28 of 29 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 056026 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Empress Care Center, LLC 1299 S. Bascom Avenue San Jose, CA 95128 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)

F 0921 Level of Harm - Minimal harm or potential for actual harm schedule of maintenance service to assure that the buildings, grounds, and equipment are maintained in a safe and operable manner and responsible for maintaining the following records/reports such as work order requests; Maintenance schedules and etc. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056026 If continuation sheet Page 29 of 29