Inspection visit

Health inspectionDecember 22, 2023

EMPRESS CARE CENTER, LLCCMS #05602613 citations on this visit

13 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 13 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 7. Review of Resident 18's clinical records indicated, Resident 18 was an [AGE] year-old female, initially admitted to the facility on [DATE], with diagnoses including recurrent (occurring often) enterocolitis (inflammation that occurs throughout the intestines) due to clostridium difficile (a germ that causes diarrhea and inflammation of the colon), hemiplegia (paralysis of one side of the body) and dysphagia (difficulty swallowing). Resident 18 did not have advance directive and her POLST forms' section D, which indicate if an advance directive is available, dated 8/10/22 and 12/9/23, were left blank. During an interview with the social services director (SSD) on 12/21/23 at 2:57 p.m., SSD verified, Resident 18 did not have advance directive. SSD further verified, Resident 18's POLST forms' section D, which indicate if an advance directive is available, dated 8/10/22 and 12/9/23, were left blank and these sections, should have been filled out. During an interview with medical recorder (MR) on 12/20/23 at 11:45 a.m., MR verified that Resident 18 did not have advance directive and Resident 18's POLST forms' section D, advance directive section, dated 8/10/22 and 12/9/23, were left blank. MR further verified that there was no communication note, about why Resident 18 did not have advance directive. During an interview with the director of nursing (DON) on 12/21/23 at 2:56 p.m., DON verified, Resident 18 did not have advance directive and the advance directive sections of Resident 18's POLST forms, dated 8/10/22 and 12/9/23, were left blank and these forms, should have been completed. Based on interview and record review, the facility failed to follow their policy and procedure (P&P) for an advance directive (AD, a written instruction, such as a living will or durable power of attorney [a document that authorizes a person to act on behalf of resident] for healthcare, when the individual is incapacitated) or completion of physician orders for life-sustaining treatment (POLST, a document that specifies the medical treatments, the resident wants to receive during serious illness) form for 11 of 15 sampled residents (Resident 5, 11, 18, 33, 35, 36, 37, 40, 44, 48, and 251). These failures could lead to the delivery of unnecessary or inappropriate medical services against sampled resident's goals and wishes. Findings: 1. Review of Resident 5's face sheet (FC, a document that gives a resident's information at a quick glance) indicated, Resident 5 was admitted to facility on 10/22/2022. Review of Resident 5's clinical record indicated, there was no document for advance directive available. Review of Resident 5's POLST form dated 4/4/2021 indicated, section D for advance directive, all three options were left (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 32 Event ID: 056026 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 12/22/2023 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 0578 blank. Level of Harm - Minimal harm or potential for actual harm During an interview with social service director (SSD) on 12/21/2023 at 9:14 a.m., SSD confirmed, Resident 5 had no document for advance directive. SSD stated, she should have inquired or obtained document for advance directive for Resident 5 upon his admission to facility. SSD also stated, staff should have completed POLST form with advance directive information for Resident 5. Residents Affected - Some During an interview with director of nursing (DON) on 12/21/2023 at 9:35 a.m., DON confirmed, there was no advance directive for Resident 5 and his POLST form's section D for advance directive information was not completed and left blank. DON stated, SSD should have verified and obtained advance directive for Resident 5. DON also stated, nursing staff should have completed section D for advance directive information for Resident 5's POLST form without leaving blanks for all three options. 2. Review of Resident 11's FC indicated, Resident 11 was admitted to the facility on [DATE]. Review of Resident11's clinical record indicated, there was no document for advance directive available. Review of Resident 11's POLST form dated 5/11/2014 indicated, section D for advance directive information, Advance Directive dated 12/7/2013 available and reviewed. During an interview with social service director (SSD) on 12/21/2023 at 9:14 a.m., SSD confirmed there was no document for advance directive for Resident 11. SSD stated, she should have inquired or obtained document for advance directive for Resident 11 upon his admission to facility. SSD also stated staff should have completed advance directive information for Resident 11's POLST form accurately. During an interview with director of nursing (DON) on 12/21/2023 at 9:35 a.m., DON confirmed there was no advance directive for Resident 11 and his POLST form section D for advance directive information, was not completed accurately. DON stated SSD should have verified and obtained advance directive for Resident 11. DON also stated nursing staff should have completed section D for advance directive information for Resident 11's POLST form with accurate information. 3. Review of Resident 36's FC indicated, Resident 36 was admitted to the facility on [DATE]. Review of Resident 36's clinical record indicated, there was no document for advance directive available. During an interview with social service director (SSD) on 12/21/2023 at 9:14 a.m., SSD confirmed, there was no document for advance directive for Resident 36 available. SSD stated she should have inquired or obtained document for advance directive for Resident 36 upon his admission to facility. During an interview with director of nursing (DON) on 12/21/2023 at 9:35 a.m., DON confirmed, there was no advance directive available for Resident 36. DON stated, SSD should have verified and obtained advance directive for Resident 36. 4. Review of Resident 37's FC indicated Resident 37 was admitted to the facility on [DATE]. Review of Resident 37's clinical record indicated, there was no document for advance directive available. Review of Resident 37's POLST form dated 3/14/2022 indicated, section D for advance directive, all three options were left blank. During an interview with social service director (SSD) on 12/21/2023 at 9:14 a.m., SSD confirmed, there was no document for advance directive for Resident 37. SSD stated, she should have inquired or obtained document for advance directive for Resident 37 upon his admission to the facility. SSD also (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056026 If continuation sheet Page 2 of 32 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 12/22/2023 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 0578 stated, staff should have completed POLST form with advance directive information for Resident 37. Level of Harm - Minimal harm or potential for actual harm During an interview with director of nursing (DON) on 12/21/2023 at 9:35 a.m., DON confirmed, there was no advance directive and POLST form section D for advance directive information was not completed, left blank, for Resident 37. DON stated, SSD should have verified and obtained advance directive for Resident 37. DON also stated, nursing staff should have completed POLST form section D, for advance directive information, without leaving all three options blank. Residents Affected - Some 5. Review of Resident 40's FC indicated, Resident 40 was admitted to the facility on [DATE]. Review of Resident 40's clinical record indicated, there was incomplete advance directive document, missing Ombudsman, or notary public signature. Review of Resident 40's POLST form dated 6/28/2022 indicated, section D for advance directive, all three options were left blank. During an interview with social service director (SSD) on 12/21/2023 at 9:14 a.m., SSD confirmed, document for advance directive was incomplete for Resident 40. SSD stated, she should have followed up for completion of document for advance directive for Resident 40. SSD also stated, staff should have completed POLST form for advance directive information for Resident 40. During an interview with director of nursing (DON) on 12/21/2023 at 9:35 a.m., DON confirmed the incomplete advance directive and POLST section D for advance directive information not completed, left blank for Resident 40. DON stated, SSD should have verified completion of advance directive document, for Resident 40. DON also stated, nursing staff should have completed POLST form section D for advance directive information, for Resident 40 without blanks. 6. Review of Resident 48's FC indicated, Resident 48 was admitted to the facility on [DATE]. Review of Resident 48's clinical record indicated, there was no document for advance directive available. Review of Resident 48's POLST form dated 12/4/2023 indicated, section D for advance directive, all three options were left blank. During an interview with social service director (SSD) on 12/21/2023 at 9:14 a.m., SSD confirmed, there was no document for advance directive for Resident 48. SSD stated, she should have inquired or obtained document for advance directive for Resident 48 upon his admission to the facility. SSD also stated, staff should have completed advance directive information for Resident 48's POLST form. During an interview with director of nursing (DON) on 12/21/2023 at 9:35 a.m., DON confirmed, there was no advance directive document and POLST form section D for advance directive information not completed, left blank for Resident 48. DON stated, SSD should have verified and obtained advance directive document for Resident 48. DON also stated nursing staff should have completed section D for advance directive information for Resident 48's POLST form without leaving blanks for all three options. 8. a. Review of Resident 33's clinical record, indicated, there was no documentation of whether or not Resident 33 had an advance directive. Resident 33's POLST form's section D, which was designated to indicate whether the resident had an advance directive, dated 10/18/23, was not completed. b. Review of Resident 35's clinical record, indicated, there was no documentation of whether or not Resident 35 had an advance directive. Resident 35's POLST form's section D, dated 7/27/22, was not completed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056026 If continuation sheet Page 3 of 32 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 12/22/2023 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some c. Review of Resident 44's clinical record, indicated, there was no documentation of whether or not Resident 44 had an advance directive. Resident 44's POLST form's section D, dated 10/13/22, was reviewed and was not completed. d. Review of Resident 251's clinical record, indicated, there was no documentation of whether or not Resident 251 had an advance directive. Resident 251's POLST form's section D, dated 11/30/23, was not completed. During an interview with MR on 12/20/23 at 1:45 p.m., MR verified, Resident's 33, 35, 44, and 251 did not have advance directives on file. During an interview with SSD on 12/21/23 at 9:14 a.m., SSD confirmed, there were no documentations regarding advance directives, for Residents 33, 35, 44, and 251. SSD stated, she verbally offered, about the advance directives upon admission but did not document these in their clinical records. SSD confirmed, the nurses should have completed section D of the residents' POLST forms. During an interview with DON on 12/21/23 at 2:20 p.m., DON confirmed, there were no advance directives for Residents 33, 35, 44, and 251. DON also confirmed, section D of the residents' POLST forms were not completed. Review of facility's P&P titled, Advance Directives, undated, the P&P indicated, Prior to or upon admission of a resident, the Social Service Director or designee will inquire of the resident, and/or his/her family members, about the existence of any written advance directives. Information about whether or not the resident has executed an advance directive shall be displayed in the medical record. Review of facility's P&P titled, Physician Orders for Life Sustaining Treatment (POLST) or Request regarding Resuscitative Measures Form, undated, the P&P indicated, Complete the form based on resident preferences and medical indications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056026 If continuation sheet Page 4 of 32 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 12/22/2023 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities 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 Pre-admission Screening and Resident Review (PASRR, screening for residents with a mental disorder and residents with intellectual disability) screening document was accurately completed for one out of two residents (Resident 36). This failure had the potential for mentally ill Resident 36 not to receive benefit from specialized mental health care and services. Residents Affected - Few Findings: Review of Resident 36's face sheet (a document that gives a resident's information at a quick glance) indicated, Resident 36 was admitted to the facility on [DATE] with diagnoses including Psychosis (a serious mental disorder characterized by a disconnect from reality) and anxiety (a disorder that involves more than temporary worry or fear that can be mild or severe). Review of Resident 36's readmission PASRR level 1 screening for serious mental illness dated 10/14/2022, indicated, he was noted to have no diagnosed mental illness. During a concurrent record review of Resident's 36's PASRR, and interview with business office manager (BOM) on 12/22/2023 at 7:53 a.m., BOM confirmed, she did not capture Resident 36's diagnoses of psychosis and anxiety for serious mental illness screening when she completed PASRR for Resident 36 on 10/14/2022. BOM stated, she should have answered yes, for diagnosed mental disorder. BOM also stated, Resident 36 will have an opportunity for specialized mental health services if she completed Resident 36's PASRR accurately for mental illness screening. During an interview with director of nursing (DON) on 12/22/2023 at 10:25 a.m., DON confirmed, mental illness screening not completed accurately for Resident 36's level 1 PASRR on 10/14/2022. DON stated, staff should have completed Resident 36's PASRR accurately to receive specialized mental health care and services for Resident 36. During review of the facility's policy and procedure (P&P) titled, Pre-admission Screening and Resident Review (PASRR), undated, the P&P indicated, Identify residents with mental illness (MI) and/or intellectual disability (ID). Ensure these residents receive the services they require for their MI or ID in the appropriate setting determined by DHCS (California Department of Health Care Services: which provides Californians with access to affordable, integrated, high-quality health care). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056026 If continuation sheet Page 5 of 32 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 12/22/2023 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 - Few 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** Based on observation, interview and record review, the facility failed to develop and implement comprehensive, person-centered, care plans for four out of fifteen sampled residents, (Residents 3, 18, 30 and 35), when: 1. for Residents 3, 18 and 30, their activity care plans were not comprehensive and person-centered and 2. for Resident 35, no comprehensive and person-centered care plan for his hearing aids. These failures had the potential to result in the residents, not receiving the interventions necessary to maintain their highest level of well-being. Findings: 1. a. Review of Resident 3's clinical records indicated, Resident 3 was a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses including cerebral atherosclerosis (degenerative vessel wall disease that results in narrowing of the blood vessels in the brain), chronic diastolic congestive heart failure (comes on slowly with age and occurs if the left ventricle muscle becomes stiff or thickened, hence the heart is not pumping blood, as well as it should) and cardiomegaly (enlarged heart, usually a sign of heart valve problem or heart disease). During an observation of Resident 3 on 12/18/23 at 1:50 p.m., Resident 3 was laying in her bed, alert, calm and verbally responsive. Resident 3 is currently on isolation (complete separation from other residents) for testing positive for coronavirus disease 2019 (COVID-19, sickness caused by virus called severe acute respiratory syndrome coronavirus 2 or SARS-CoV-2). Review of Resident 3's active physician orders as of 12/20/23 indicated, Resident 3 may participate in activities not in conflict with resident's plan of care, ordered on 8/31/23. Review of Resident 3's care plans indicated, Resident 3 did not have comprehensive, person-centered activity care plan, that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs. During a concurrent record review of Resident 3's care plans and interview with registered nurse B (RN B), on 12/21/23 at 10:35 a.m., RN B verified, Resident 3 did not have comprehensive, person-centered activity care plan, that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs. RN B further verified that Resident 3 should have comprehensive, person-centered activity care plan. During a concurrent record review of Resident 3's care plans and interview with director of nursing (DON), on 12/21/23 at 2:44 p.m., DON verified, Resident 3 did not have comprehensive, person-centered activity care plan. DON further verified, Resident 3 should have comprehensive, person-centered activity care plan. During an interview with activities supervisor (AS), on 12/22/23 at 12:41 p.m., AS verified that Resident 3 did not have comprehensive, person-centered activity care plan. AS then stated, that she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056026 If continuation sheet Page 6 of 32 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 12/22/2023 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 will update the activity care plan of Resident 3 to make it comprehensive and person-centered. Level of Harm - Minimal harm or potential for actual harm b. Review of Resident 18's clinical records indicated, Resident 18 was an [AGE] year-old female, initially admitted to the facility on [DATE] with diagnoses including recurrent (occurring often) enterocolitis (inflammation that occurs throughout the intestines) due to clostridium difficile (a germ that causes diarrhea and inflammation of the colon), hemiplegia (paralysis of one side of the body) and dysphagia (difficulty swallowing). Residents Affected - Few During an observation of Resident 18 on 12/18/23 at 11:15 a.m., Resident 18 was laying in her bed, on oxygen inhalation, appears calm and comfortable but confused and could not respond to questions when asked. Review of Resident 18's active physician orders as of 12/20/23 indicated, Resident 18 may participate in activities not in conflict with resident's plan of care, ordered on 3/17/23. Review of Resident 18's care plans indicated, Resident 18 did not have comprehensive, person-centered activity care plan, that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs. During a concurrent record review of Resident 18's care plans and interview with RN B, on 12/21/23 at 11:11 a.m., RN B verified, Resident 18 did not have comprehensive, person-centered activity care plan, that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs. RN B further verified that Resident 18 should have comprehensive, person-centered activity care plan. During a concurrent record review of Resident 18's care plans and interview with DON, on 12/21/23 at 2:48 p.m., DON verified, Resident 18 did not have comprehensive, person-centered activity care plan. DON further verified that Resident 18 should have comprehensive, person-centered activity care plan. During an interview with AS, on 12/22/23 at 12:41 p.m., AS verified that Resident 18 did not have comprehensive, person-centered activity care plan. AS then stated, that she will update the activity care plan of Resident 18 to make it comprehensive and person-centered. c. Review of Resident 30's clinical records indicated, Resident 30 was an [AGE] year-old female, admitted to the facility on [DATE] with diagnoses including heart failure, dementia (memory loss) with behavioral disturbance like anxiety and agitation and dysphagia (difficulty in swallowing). During an observation of Resident 30 on 12/18/23 at 11:25 a.m., Resident 30 was laying in her bed, appears calm and comfortable but confused and could not respond to questions when asked. Review of Resident 30's active physician orders as of 12/20/23 indicated, Resident 30 may participate in planned activities not in conflict with resident's plan of care, ordered on 11/2/22. Review of Resident 30's care plans indicated, Resident 30 did not have comprehensive, person-centered activity care plan, that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs. During a concurrent record review of Resident 30's care plans and interview with RN B, on 12/21/23 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056026 If continuation sheet Page 7 of 32 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 12/22/2023 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 - Few at 11:04 a.m., RN B verified, Resident 30 did not have comprehensive, person-centered activity care plan, that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs. RN B further verified that Resident 30 should have comprehensive, person-centered activity care plan. During a concurrent record review of Resident 30's care plans and interview with DON, on 12/21/23 at 2:47 p.m., DON verified, Resident 30 did not have comprehensive, person-centered activity care plan. DON further verified that Resident 30 should have comprehensive, person-centered activity care plan. During an interview with AS, on 12/22/23 at 12:41 p.m., AS verified that Resident 30 did not have comprehensive, person-centered activity care plan. AS then stated, that she will update the activity care plan of Resident 30 to make it comprehensive and person-centered. 2. Review of Resident 35's clinical records indicated, he had diagnoses including hemiplegia (severe or complete loss of strength) and hemiparesis (mild loss of strength), type 2 diabetes mellitus (the body doesn't use insulin properly), cerebral infarction (results of disrupted blood flow to the brain) and sensorineural hearing loss (caused by damaged to the inner ear). Review of Resident 35's Minimum Data Set (MDS, an assessment tool), dated 11/1/23, indicated Resident 35 had a brief interview for mental status (BIMS, mandatory tool used to screen and identify the cognitive condition of residents upon admission into a long-term care facility) score of 3 (scores of 0-7 indicated severe mental impairment), meaning the cognition was severely impaired; his ability to hear was minimal difficulty (difficulty in some environments, e.g.,when person speaks softly or setting is noisy ); and no hearing aids during the completion of hearing. The MDS also indicated, his speech was clear and his vision was adequate. During an observation of Resident 35 on 12/18/23 at 8:28 a.m., in Resident 35's room, Resident 35 just stares during conversation. During an interview with Resident 35's Responsible Party on 12/18/23 at 10:41 a.m., she stated, Resident 35's able to talk, but just hard of hearing. He has hearing aid, but she doesn't know if they are using it. Review of Resident 35's clinical records indicated, there was no care plan addressing the use of Resident 35's hearing aids. Review of Resident 35's nursing progress notes dated 2/19/23, indicated, Hearing aid offered 3x. However, resident kept on refusing. He said he will throw it away if this nurse put it on. and nursing progress notes dated 2/20/23 indicated, Resident still refuses to wear his hearing aid. He said he does not need it. During a concurrent interview and record review with RN B on 12/21/13 at 1:27 p.m., RN B stated, there were no care plans developed for Resident 35 regarding his refusal to wear hearing aids and there was no monitoring on the use of his hearing aids. RN B acknowledged, there should have been care plans for the use of his hearing aids, so all staffs will know about it. During an interview with the DON on 1/30/18 at 3:23 p.m., he acknowledged, the facility staff should have developed care plans for non-compliance with wearing hearing aids and effective communication (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056026 If continuation sheet Page 8 of 32 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 12/22/2023 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 for Resident 35 to facilitate understanding, for better nursing care services. Level of Harm - Minimal harm or potential for actual harm Review of the facility's undated policy and procedure titled, Care Plans, Comprehensive Person-Centered, indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The Interdisciplinary Team (IDT, team of professionals that plan, coordinate and deliver the personalized health care of residents), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. The comprehensive, person-centered care plan will include measurable objectives and timeframes, describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056026 If continuation sheet Page 9 of 32 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 12/22/2023 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the residents received the necessary care and services for seven out of nineteen residents investigated, (Residents 18, 30, 41, 23, 35, 39 and 48), when: Residents Affected - Few 1. for Resident 18, the physician was not notified of her weight loss and weight gain of more than 5 pounds (lbs, unit for measuring weight) and there were no alert charting by nurses for 72 hours of her weight loss and weight gain; 2. for Resident 30, there were no alert charting by nurses for 72 hours of her weight loss of more than 5 lbs; 3. for Resident 23, 35 and 39, the nurses used alcohol wipes to wipe the blood after the needle punctures; 4. for Resident 41, the physician orders for blood pressure (BP) medications without holding parameters and 5. for Resident 48, management for his diabetes, not being followed. These failures had the potential to affect the residents' care and could jeopardize their health and well-being. Findings: 1. Review of Resident 18's face sheet (FC, a document that gives a resident's information at a quick glance) indicated, Resident 18 was an [AGE] year-old female, initially admitted to the facility on [DATE] with diagnoses including recurrent (occurring often) enterocolitis (inflammation that occurs throughout the intestines) due to clostridium difficile (a germ that causes diarrhea and inflammation of the colon), hemiplegia (paralysis of one side of the body) and dysphagia (difficulty swallowing). Review of Resident 18's clinical records indicated, Resident 18 had a weight loss of 12.6 lbs, from 8/2/23 to 9/5/23. The weight loss was not communicated to the physician and there were no alert charting by nurses for 72 hours, regarding the weight loss. Resident 18 also had a weight gain of 7.8 lbs, from 9/5/23 to 10/4/23. The physician was not notified of the weight gain and there were no alert charting by nurses for 72 hours also, about the weight gain. During a concurrent review of Resident 18's clinical records and interview with registered nurse B (RN B) on 12/21/23 at 11:21 a.m., RN B verified, Resident 18 had a weight loss of 12.6 lbs, from 8/2/23 to 9/5/23. The weight loss was not communicated to the physician and there were no alert charting by nurses for 72 hours, regarding the weight loss. RN B also verified, Resident 18 had a weight gain of 7.8 lbs, from 9/5/23 to 10/4/23. The physician was also not notified of the weight gain and there were no alert charting by nurses for 72 hours also, about the weight gain as well. RN B then stated, that for change of condition, like Resident 18's weight loss of 12.6 lbs and weight gain of 7.8 lbs, the physician should be notified and there should be alert charting by nurses for 72 hours, regarding the weight loss and weight gain of more than 5 lbs. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056026 If continuation sheet Page 10 of 32 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 12/22/2023 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a concurrent review of Resident 18's clinical records and interview with the director of nursing (DON) on 12/21/23 at 2:53 p.m., DON verified that the physician was not notified of Resident 18's weight loss and weight gain of more than 5 lbs and there were no alert charting by nurses for 72 hours of the weight loss and weight gain of more than 5 lbs. DON further verified that for change of condition, like Resident 18's weight loss of 12.6 lbs and weight gain of 7.8 lbs, the physician should be notified and alert charting by nurses for 72 hours, should have been done. 2. Review of Resident 30's face sheet indicated, Resident 30 was an [AGE] year-old female, admitted to the facility on [DATE] with diagnoses including heart failure, dementia (memory loss) with behavioral disturbance like anxiety and agitation and dysphagia (difficulty in swallowing). Review of Resident 30's clinical records indicated, Resident 30 had a weight loss of 9.4 lbs, from 8/2/23 to 9/5/23. There were no alert charting by nurses for 72 hours, regarding the weight loss. During a concurrent review of Resident 30's clinical records and interview with registered nurse B (RN B) on 12/21/23 at 10:35 a.m., RN B verified, Resident 30 had a weight loss of 9.4 lbs, from 8/2/23 to 9/5/23. There were no alert charting by nurses for 72 hours, regarding the weight loss. RN B further verified, that for change of condition, like Resident 30's weight loss of 9.4 lbs, there should be alert charting by nurses for 72 hours. During a concurrent review of Resident 30's clinical records and interview with the DON on 12/21/23 at 2:52 p.m., DON verified that there were no alert charting by nurses for 72 hours of the 9.4 lbs weight loss of Resident 30. DON further verified that for change of condition, like Resident 30's weight loss of 9.4 lbs, alert charting by nurses for 72 hours, should have been done. Review of the facility's undated policy and procedure titled, Change of Condition, indicated, It is the policy of this facility that all changes in the resident condition will be communicated to the physician. Any sudden or serious change in a resident's condition manifested by a marked change in physical or mental behavior will be communicated to the physician . The licensed nurse in charge will notify the physician. All symptoms and unusual signs will be communicated to the physician promptly . The nurse in charge is responsible for notification of physician prior to end of assigned shift when a significant change in resident's condition is noted . The licensed nurse responsible for the resident will continue assessment and documentation every shift for seventy-two (72) hours or until condition has been stable. 3. A review of Resident 23 clinical record indicated that Resident 23 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus(DM, high blood sugar) without complications. During a fingerstick glucose (blood sugar) check observation on 12/19/23 at 11:55 a.m., Registered Nurse (RN) B was observed using an alcohol wipe to wipe the blood on Resident 23's finger after the needle punch. A review of Resident 35 clinical record indicated that Resident 35 was admitted to the facility on [DATE] with diagnoses including type 2 DM with other specified complications. During a fingerstick glucose check observation on 12/19/23 at 12:08 p.m., Registered Nurse (RN) B was observed using an alcohol wipe to wipe the blood on Resident 35's finger after the needle (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056026 If continuation sheet Page 11 of 32 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 12/22/2023 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 puncture. Level of Harm - Minimal harm or potential for actual harm During an interview with RN B on 12/19/23 at 12:10 p.m., RN B stated that he should not have used the alcohol wipe to wipe the blood for Residents 23 and 35, which might have caused irritation and discomfort. He further stated that he should use dry gauze or cotton balls to wipe the blood after needle puncture. Residents Affected - Few A review of Resident 39 clinical record indicated that Resident 39 was admitted to the facility on [DATE] with diagnoses including type 2 DM with unspecified complications. During a fingerstick glucose check observation on 12/19/23 at 12:21 p.m., Registered Nurse (RN) C was observed using an alcohol wipe to wipe the blood on Resident 39's finger after the needle puncture. During an interview with RN C on 12/19/23 at 12:30 p.m., RN C stated that She should not have used the alcohol wipe to wipe the blood to avoid pain and discomfort. During an interview with the Director of Nursing (DON) on 12/22/23 at 01:57 p.m., the DON stated that the nurse should have used cotton balls to wipe the blood after the needle puncture for testing accuracy and comfort. During a review of the facility's undated policy and procedure, titled, Obtaining a Fingerstick Glucose level, the P&P indicated, Discard the first drop of blood if alcohol is used to clean the fingertips because alcohol may alter the results . wipe the fingertip with a cotton ball to seal the puncture site . 4. A review of Resident 41 clinical record indicated that Resident 41 was admitted to the facility on [DATE] with diagnoses including essential hypertension (High blood pressure that doesn't have a known cause is called essential or primary hypertension). A review of Resident 41's clinical record indicated the following physician orders for blood pressure (BP) medications without holding parameters: Amlodipine Besylate oral tablet 10mg, give one tablet by mouth on time a day related to essential hypertension, dated 7/12/23. Losartan potassium oral tablet 25mg, give one tablet orally once daily related to essential hypertension, date 7/12/23. Metoprolol Tartrate oral tablet 25mg, give one tablet orally once daily related to essential hypertension, date 7/12/23. During a concurrent interview and record review with Registered Nurse (RN) B on 12/21/23 at 10:11 a.m., RN B confirmed that the above three physician orders for Resident 41 needed to be completed with parameters to hold if systolic BP was less than 100 and the heart rate was less than 60 for Metoprolol. He further stated that BP medications should have parameters to prevent low blood pressure and low heart rate. During a review of the facility's undated policy and procedure, titled Physician Orders and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056026 If continuation sheet Page 12 of 32 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 12/22/2023 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Telephone Orders, the P&P indicated, All orders must be specific and complete with all necessary detail to carry out the prescribed order without any questions. Review of resident 48's face sheet ((FS: a document that gives a resident's information at a quick glance) indicated Resident 48 admitted to facility on 12/4/2023 with diagnoses including type 2 diabetes ( a chronic condition that affects the way the body either does not produce enough insulin [a hormone regulates the amount of glucose in the body], or it resists insulin), malignant neoplasm of urethra (a type of cancer that starts in the urethra [tube that carries urine out of the body]), and hypertension (a condition in which the force of the blood against the artery walls is too high). Review of Resident 48's physician orders dated 12/5/2023 indicated, Insulin NPH (an intermediate-acting insulin given to control blood sugar levels for residents with diagnosis of diabetes) Subcutaneous (injection given just under the skin) Suspension (liquid medication) 100Unit/ML (Unit/ML: concentration of a unit of fluid volume equal to one-thousandth of a liter) Inject 5 units subcutaneously two times a day related to Type 2 Diabetes. Review of Resident 48's diet order dated 12/4/2023 indicated, Regular diet Puree texture, Thin liquids consistency. Review of Resident 48's clinical record indicated there was no evidence of monitoring for fasting blood sugar (FBS: levels are measured several hours after eating, gives a more accurate view of resident's glucose levels) testing or lab work orders for diabetes management. Review of facility's registered dietitian (RD) recommendations dated 12/7/2023 indicated there were evidence of RD recommendations for Resident 48 for his diabetes management. During an interview with registered nurse B (RN B) on 12/19/2023 at 3:00 p.m., RN B confirmed Resident 48 receiving NPH insulin two times a day, and there were no FBS monitoring or lab work orders for Resident 48's diabetes management. RN B also acknowledged Resident 48's diet as regular diet. RN B stated Resident 48 should have received diabetic diet (a meal plan for when, what, and how much to eat to get the nutrition resident needs while keeping his/her blood sugar levels within target range) instead of regular diet, monitored his FBS and requested physician for lab orders for Resident 48's diabetes management. During an interview with RD on 12/19/2023 at 3:30 p.m., RD acknowledged she did not recommend diet change or blood glucose monitoring for Resident 48. RD stated she should have recommended to change his diet to diabetic diet and blood glucose lab work orders for his diabetes management for Resident 48. During an interview with director of nursing (DON) on 12/21/2023 at 9:45 a.m., DON stated Resident 48 should have received diabetic diet, monitored FBS and lab work for his diabetes management as indicated in facility's policy. Review of facility's policy and procedure (P&P) titled, Diabetes-Clinical Management, undated, the P&P indicated, For residents who have or are suspected (but not yet confirmed) to have diabetes, the physician may order pertinent testing: for example, a fasting or random blood glucose test. In addition to physical assessment, pertinent lab tests might include renal function (kidney function tests to measure how well kidneys are working), lipid (cholesterol) levels , and urinalysis (a test of urine) (especially, looking for glycosuria [excess sugar in urine] and proteinuria [excess protein in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056026 If continuation sheet Page 13 of 32 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 12/22/2023 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 urine]). Diet and lifestyle modifications, where feasible and accepted by the resident. 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 14 of 32 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 12/22/2023 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. Based on observation, interview and record review the facility failed to ensure to follow their policy and procedure (P&P) for bed side rails (adjustable metal or rigid plastic bars that attach to the bed) for six of six sampled residents (Resident 5, 11, 36, 37, 40, and 48). This failure had the potential to place sampled residents at risk for accidents, entrapment, and unsafe environment. Findings: 1. Review of Resident 5's face sheet (FS: a document that gives a resident's information at a quick glance) indicated Resident 5 was admitted to facility on 10/22/2022. Review of Resident 5's physician orders indicated there was no physician order to use side rails for Resident 5's bed. Review of Resident 5's clinical record indicated there were no documentations for physical restraint assessment and informed consent for use of side rails for his bed. Review of Resident 5's care plans indicated there was no care plan for use of bed side rails. During an observation on 12/19/2023 at 12:15 p.m., noted left side bed rail up while Resident 5 was in bed. During an interview with certified nursing assistant G (CNA G )12/19/2023 at 12:20 p.m., CNA G confirmed Resident 5's left side bed rail was up. CNA G stated Resident 5 uses side rail to change his position while in bed. During an interview with facility's medical recorder (MR) on 12/21/2023 at 2:45 p.m., MR confirmed there were no documents for assessment, informed consent, care plan and physician order for use of side rails for Resident 5. During a concurrent observation of bed rail for Resident 5 and interview with director of nursing (DON) on 12/22/2023 at 10:45 a.m., DON confirmed left side bed side rail in use for Resident 5. DON also acknowledged there was no documented evidence of assessment, informed consent, physician order, and care plan for use of side rail for Resident 5. DON stated staff should have completed physical restraint assessment, care plan, obtained order from physician and informed consent for use of side rail for his bed. 2. Review of Resident 11's FS indicated Resident 11 was readmitted to facility on 8/11/2020. Review of Resident 11's physician order dated 3/5/2021 indicated, may have bilateral ½ side rails for bed mobility/positioning. Review of Resident 11's clinical record indicated there was no evidence of documentation for informed consent for use of side rails for his bed. During an observation on 12/18/2023 at 7:55 a.m., observed Resident 11 bed's bilateral 1/2 side rails were up while Resident 11 was in bed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056026 If continuation sheet Page 15 of 32 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 12/22/2023 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview with MR on 12/21/2023 at 2:45 p.m., MR confirmed there was no documentation for informed consent for use of side rails for Resident 11. During a concurrent observation of bed rail for Resident 11 and interview with director of nursing (DON) on 12/22/2023 at 10:45 a.m., DON confirmed right and left side bed side rail in use for Resident 11. DON also acknowledged there was no informed consent for use of side rail for Resident 11. DON stated staff should have obtained informed consent for use of side rail for his bed before started using side rails for Resident 11. 3. Review of Resident 36's FS indicated, Resident 36 was admitted to facility on 9/2/2021. Review of Resident 36's physician orders dated 11/1/2021 indicated, R side padded half side rails up while resident in bed for possible seizure (a sudden, uncontrolled burst of electrical activity I the brain can cause uncontrollable movements) activity. Review of Resident 36's clinical record indicated there was no evidence of documentation for informed consent for use of side rails for his bed. During an observation on 12/18/2023 at 8:35 a.m., noted both ½ side rails were up while resident 36 was in bed. Further observation indicated, right side rail was not padded, and Resident 36 got out of the bed by himself while holding both SR. During an interview with MR on 12/21/2023 at 2:45 p.m., MR confirmed there was no documentation for informed consent for use of side rails for Resident 36. During a concurrent observation of bed rails for Resident 36 and interview with director of nursing (DON) on 12/22/2023 at 10:45 a.m., DON confirmed both bed side rails were in use for Resident 36. DON also acknowledged there was no informed consent for use of side rail and not followed physician order for his bed rails. DON stated staff should have obtained informed consent for use of side rail for his bed before started using side rails and followed physician order for side rails for Resident 36. 4. Review of Resident 37's FS indicated, Resident 37 was admitted to facility on 3/14/2022. Review of Resident 37's physician orders dated 8/8/2022 indicated, May have bilateral ½ side rails for bed mobility/positioning. Review of Resident 37's clinical record indicated there was no evidence of documentation for informed consent for side rails use for Resident 37. During an observation on 12/18/2023 at 8:30 a.m., noted both side rails were up while resident was in bed. During an interview with MR on 12/21/2023 at 2:45 p.m., MR confirmed there was no documentation for informed consent for use of side rails for Resident 37. During a concurrent observation of bed rails for Resident 37 and interview with director of nursing (DON) on 12/22/2023 at 10:45 a.m., DON confirmed both side rails were in use for Resident 37's bed. DON also acknowledged there was no informed consent for use of side rails. DON stated staff should (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056026 If continuation sheet Page 16 of 32 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 12/22/2023 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some have obtained informed consent for use of side rail for his bed before started using side rails for Resident 37. 5. Review of Resident 40's FS indicated, Resident 40 was admitted to facility on 6/28/2022. Review of Resident 40's physician orders dated 6/29/2022 indicated, May have bilateral ½ side rails for bed mobility/positioning. Review of Resident 40's clinical record indicated there was no evidence of documentation for informed consent for side rails use for Resident 40. During a concurrent observation and interview with Resident 40 on 12/18/2023 at 7:50 a.m., noted both side rails were up while resident was in bed. Further observation noted Resident 40 used both side rails to change his position slightly by himself. Resident 40 stated he can use both side rails to change his position in bed by himself at times. During an interview with MR on 12/21/2023 at 2:45 p.m., MR confirmed there was no documentation for informed consent for use of side rails for Resident 40. During a concurrent observation of bed rails for Resident 40 and interview with director of nursing (DON) on 12/22/2023 at 10:45 a.m., DON confirmed both side rails were in use for Resident 40's bed. DON also acknowledged there was no informed consent for use of side rails. DON stated staff should have obtained informed consent for use of side rail for his bed before started using side rails for Resident 40. 6. Review of Resident 48's FS indicated Resident 48 was admitted to facility on 12/4/2023. Review of Resident 48's physician orders dated 12/4/2023 indicated, Both ½ side rails up when in bed for turning & repositioning as enabler. Review of Resident 48's clinical record indicated there was no documentation for physical restraint assessment for use of side rails for his bed. Review of Resident 48's care plans indicated there was no care plan for use of both side rails. During a concurrent observation and interview with Resident 48 on 12/18/2023 at 8:20 a.m., observed both side rails were up when Resident 48 was in bed. Resident 48 stated he can use both side rails to get out of bed by himself. During an interview with facility's MR on 12/21/2023 at 2:45 p.m., MR confirmed there were no documents for assessment, and care plan for use of bed side rails for Resident 48. During a concurrent observation of bed rail for Resident 48 and interview with director of nursing (DON) on 12/22/2023 at 10:45 a.m., DON confirmed both side rails were in use for Resident 48's bed. DON also acknowledged there was no document for assessment, and care plan for use of side rails for Resident 48. DON stated staff should have completed physical restraint assessment, and care plan for use of side rails for his bed. During review of facility's P&P titled, Usage of bedside rails, undated, the P&P indicated, The facility assesses every resident admitted in the facility within seven days upon admission, quarterly, annually and as often as needed. Safety and protection: In this case, it is noted that after the assessment of the resident by the licensed nurse and the IDT (an interdisciplinary team brings together (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056026 If continuation sheet Page 17 of 32 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 12/22/2023 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 0700 Level of Harm - Minimal harm or potential for actual harm knowledge from different health care disciplines to help residents receive the care they need) and with MD (Medical Doctor) order and due to resident medical problems, it necessitates to have both side rails up while in bed. For any purpose of bedside rails usage, it is a must to have consent of the resident/resident's representative (an agent to make healthcare decisions on resident's behalf) or both and MD order. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056026 If continuation sheet Page 18 of 32 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 12/22/2023 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 interviews and record review, the facility failed to ensure a physician's order for a PRN (as needed) psychotropic medication (medication capable of affecting the mind, emotions, and behavior) was limited to 14 days of use, for one of 15 sampled residents (Resident 101). This failure had the potential to lead to the administration of unnecessary medication to the resident. Findings: A review of Resident 101's clinical record indicated she was admitted to the facility on [DATE] with diagnoses including anxiety disorder (intense, excessive, and persistent worry and fear about everyday situations) and major depressive disorder. Further review of Resident 101's clinical record indicated a physician's order, dated 12/18/23, for Lorazepam 0.5 milligram (mg., a unit of measure) every 8 hours as needed (PRN) without a stop date. During a concurrent interview and record review with Registered Nurse (RN) B on 12/21/23 at 3:54 p.m., RN B reviewed the physician's order and stated there should be a 14-day limit to PRN psychotropic medication orders. During an interview with the Director of Nursing (DON) on 12/22/23 at 1:57 p.m., the DON stated, there should be a 14-day limit for psychotropic medication to prevent administering unnecessary medication to the resident. A review of the facility's undated policy, Psychotropic Medication Use, indicated .Residents will not receive PRN dose of psychotropic medications unless that medication is necessary to treat a specific condition that is documented in the clinical record; PRN orders for antipsychotic medications will not be renewed beyond 14 days .the duration of the PRN order will be indicated in the order . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056026 If continuation sheet Page 19 of 32 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 12/22/2023 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 7.41 % when two medication errors occurred out of 27 opportunities during the medication administration for two residents (Residents 45 and 24). The failure resulted in medications not being given according to the manufacturer's specifications and physician's order and had the potential to affect residents' health and well-being in the facility. Residents Affected - Few Findings: 1. During a medication pass observation on 12/20/23 at 8:05 a.m., the Licensed Vocational Nurse E (LVN E) was observed administering the chewable aspirin 81 mg (mg, a unit of measure) to Resident 45. A review of Resident 45's physician's order, dated 11/01/2023, indicated administering enteric coated Aspirin low dose delayed releases oral tablet 81mg by mouth once a day related to cerebral infraction. During an interview with LVN E on 12/20/23 at 2:20 p.m., LVN E confirmed that she administered chewable Aspirin 81 mg to resident 45 instead of enteric-coated. She further stated that she should have followed the physician's order to administer the enteric-coated aspirin. During a phone interview with the facility consultant pharmacist (CP) on 12/22/23 at 11:56 a.m., The CP stated the chewable aspirin was absorbed in the stomach. In contrast, enteric-coated aspirin was absorbed in the small intestine. Those two formulations of aspirin are different and not interchangeable. 2. During a medication pass observation on 12/20/23 at 4:20 p.m., the licensed vocational nurse F (LVN F) was observed administering lubricant eye drops to Resident 24 using Resident 43's eye drops. During an interview with LVN F on 12/20/23 at 4:25 p.m., LVN F acknowledged that she should not have administered the eye drops to Resident 24 using Resident 43's eye drops. She should administer the right medication to the right resident. During an interview with the Director of Nursing (DON) on 12/22/23 at 1:57 p.m., The DON stated that the nurse should administer the right medication to the right resident, not use other resident's medication. A review of the facility's undated policy and procedures (P&P) titled POLICY AND PROCEDURE IN MEDICATION ADMINISTRATION, indicated, Drugs must be administered in accordance with the written orders of the attending physician (5 rights) .medications ordered for one resident must not be administered to another resident . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056026 If continuation sheet Page 20 of 32 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 12/22/2023 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review, the facility failed to appropriately label the lubricant eye drops bottle for 2 out of 15 sampled residents (Residents 24 and 43). This deficient practice resulted in the nurse administering the wrong eye drops and had the potential to affect residents' health and well-being in the facility. Findings: During a medication pass observation on 12/20/23 at 4:20 p.m., Licensed Vocational Nurse F (LVN F) administered lubricant eye drops to Resident 24 using a bottle, not labelled with resident identification information. During an inspection of Medication Cart 1 on 12/20/23 at 04:22 p.m., with LVN F, two opened bottle of lubricant eye drops were inside Medication Cart 1 for Residents 24 and 43 without residents' identification information and open date. During an interview with LVN F on 12/20/23 at 4:25 p.m., LVN F confirmed that the eye drops bottle she used with Resident 24 was Resident 43's eye drops bottle. LVN F acknowledged that she should have labeled each bottle with resident identification information to prevent administering the wrong medication. During a phone interview with the facility consultant pharmacist (CP) on 12/22/23 at 11:56 a.m., the CP stated, each resident should have their own individual eye drops bottle, with resident identification information and open date. During a review of the facility's undated policy and procedure, titled labeling and storing medications, the P&P indicated, the label of each resident's individual prescription medication container will clearly indicate: the resident's full name .liquid medication -vials, injectables, irrigation, solutions, Ophthalmic/Otic must be dated and initialed by the licensed nurse who first opened the container . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056026 If continuation sheet Page 21 of 32 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 12/22/2023 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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Based on observation, interview and record review, the facility failed to accommodate food preferences for two out of six sample residents (Residents 35 and 40). This failure had the potential for decreased meal intake, negative effect on health and well-being for sample residents. Findings: Review of Resident 40's lunch tray card dated 12/18/2023 indicated, Dislikes: Tomato Products, Spinach. Review of facility's lunch menu dated 12/18/2023 indicated, Fish with Tarragon, Cajun Country Rice, Creamed Spinach, Sweet Corn Salad, Fruit Bavarian Cream. During lunch observation on 12/18/2023 at 12:54 p.m., noted Resident 40's lunch meal tray was served with creamed spinach, and carrots along with other food items from lunch menu. During an interview with certified nursing assistant A (CNA A) on 12/18/2023 at 12:57 p.m., CNA A confirmed Resident 40's lunch tray card dated 12/18/2023 indicated, Resident 40 does not like spinach and tomato products. CNA A also confirmed Resident 40 was served creamed spinach, and carrots during lunch on 12/18/2023. CNA A stated dietary staff should not have served spinach for Resident 40. During a concurrent review of Resident 40's lunch tray card for resident's food dislikes for spinach, Resident 40's lunch meal tray picture, facility's lunch menu on 12/18/2023 and interview with dietary manager (DM) on 12/19/2023 at 3:20 p.m., DM confirmed, Resident 40 had been served creamed spinach and carrots during lunch on 12/18/2023. DM stated dietary staff should not have served creamed spinach and carrots and should have provided substitute for creamed spinach and carrots for Resident 40. Review of facility's policy and procedure (P&P) titled, Resident Food Preferences, undated, the P&P indicated, The food service department will offer a limit number of food substitutes for individuals who do not want to eat the primary meal. 2.Review of Resident 35's clinical record indicated he had diagnoses of hemiplegia (severe or complete loss of strength) and hemiparesis (mild loss of strength), type 2 diabetes mellitus (the body doesn't use insulin properly) and cerebral infarction (results of disrupted blood flow to the brain). During review of facility's lunch menu dated 12/18/23 indicated, Fish with Tarragon, Cajun Country Rice, Creamed Spinach, Sweet Corn Salad, Fruit Bavarian Cream. Review of Resident 35's lunch meal ticket dated 12/18/23, indicated Resident 35's dislike was tomato products, spinach, potatoes. During a concurrent dining observation and interview on 12/18/23 at 1: 03 p.m., with Resident 35's room it was observed CNA D feeding Resident 35 had spinach on his food tray. CNA D confirmed Resident 35's lunch meal ticket dated 12/18/23 indicated, Resident 35's dislike was spinach. CNA D also confirmed Resident 35 was served with spinach during lunch on 12/18/23. CNA D stated, that why I did not serve to him the spinach. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056026 If continuation sheet Page 22 of 32 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 12/22/2023 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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete During a concurrent interview and review of Resident 35's lunch meal ticket for resident's food dislikes for spinach, Resident 35's lunch meal ticket picture, with DS on 12/19/23 at 3:24 p.m.,DS confirmed Resident 35's been served with spinach during lunch on 12/18/23. DS stated dietary staff did not follow the dislikes of the Resident and served with spinach. Review of facility's policy and procedure (P&P) titled, Resident Food Preferences, undated, the P&P indicated, The food service department will offer a limit number of food substitutes for individuals who do not want to eat the primary meal. Event ID: Facility ID: 056026 If continuation sheet Page 23 of 32 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 12/22/2023 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 record review the facility failed to ensure safe and sanitary food service operations were carried out according to standards of practice when: Residents Affected - Few 1. dented can was found in the dry storage area, 2. the two-compartment sink did not have air gaps (an unobstructed vertical space between the water outlet and the flood level of a fixture) and 3. the Maintenance Supervisor (MS) did not follow safe sanitary practice in the kitchen. These failures had the potential to cause food contamination and spread food-borne illness to the forty-three residents who received their food from the kitchen. Findings: 1. During an initial kitchen observation on 12/18/23 at 8:57 a.m., with the Dietary Supervisor (DS), there was one large dented can in the dry storage area. The DS took away the dented can and placed it under the designated area. During an interview with DS on 12/19/23 at 3:30 p.m., DS confirmed the above observations and stated, the dented can should have been placed in the designated area. She stated, We put a sign already for dented cans area. During a review of the facility's policy and procedure (P&P) titled, Food Storage, undated, the P&P indicated, All newly delivered food items are placed in their respective designated area. At which time, items are inspected for damage. Damaged packaging to be assesses and removed if identified. Review of the United States Food and Drug Administration's 2022 Food Code indicated, pitted or dented cans may present a serious potential hazard. 2. During a concurrent observation and interview on 12/19/23 at 3:00 p.m., in the kitchen with the DS, the two 2 compartment sink was without an air gap. The DS stated, she was not sure about the air gap, the Maintenance Supervisor (MS) was responsible for the air gap. During a concurrent observation and interview with MS on 12/19/23 at 3:07 p.m., MS stated, the 2-compartment sink don't need air gap since it's not used, just for water. MS further stated, its only used during manual washing. During an interview on 12/20/23 at 9:34 a.m. with MS, he confirmed, the 2-compartment sink had no air gap. The facility will fix it and air gap will be installed. During a review of the facility's P &P titled, Accident Prevention - Safety Precautions dated 12/14 revised, the P&P indicated, Backflow Prevention /Air Gaps . An air gap is the most reliable backflow prevention device. It is the physical separation of the potable and non -potable water supply system by an air space. All steam tables, ice machines, and bins, food preparation sinks, display cases . and other equipment that discharge liquid waste or condensate shall be drained through an air gap (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056026 If continuation sheet Page 24 of 32 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 12/22/2023 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 into an open floor sink. Level of Harm - Minimal harm or potential for actual harm During a review of the Food and Drug Administration (FDA) Food Code 2022, section 5-202.13, titled, Backflow Prevention, Air Gap, it indicated, An air gap between the water supply inlet and the flood level rim of the plumbing fixture, equipment, or nonfood equipment shall be at least twice the diameter of the water supply inlet and may not be less than 25 mm (1 inch). Residents Affected - Few 3. During a kitchen observation with MS on 12/19/23 at 3:07 p.m., MS opens the door, entered the kitchen and came inside. Noted MS was wearing gloves but did not wash his hands, before explaining the concerns about air gap. MS then touched the clean empty tray racks for cups that was blocking the dishwashing machine, while he was showing the dishwasher sink air gap. During an interview with MS on 12/20/23 at 9:34 a.m., MS confirmed, he was wearing gloves from outside and did not follow the sanitary practice in the kitchen. MS stated, he should sanitize and need to wash his hands inside the kitchen sink because he's going inside the kitchen. During an interview with IP on 12/21/23 at 4:11 p.m., IP stated, standard precaution must be observed, such as in any procedure of wearing gloves and hand hygiene after care must be observed. The staffs should wash their hands, every time they change task. During an interview with DS on 12/20/23 at 12:11 p.m., DS stated, staff should remove dirty gloves and should wash hands when changing gloves and when entering the kitchen. During a review of the facility's P &P titled, Preventing Foodborne Illness- Employee Hygiene and Sanitary Practices undated, the P&P indicated, Food and nutrition services employees follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056026 If continuation sheet Page 25 of 32 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 12/22/2023 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** Based on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when: Residents Affected - Some 1. For Residents 23 and 35, the nurse did not perform hand hygiene between glove changes, 2. For Resident 45, the nurse did not perform hand hygiene after medication administration, 3. Staff's face mask below nose 4. Staff did not perform hand hygiene 5. Nursing staff did not use required PPE 6. Urine drain bag on floor for Resident 5 These failures could result in the spread of infection and cross-contamination that could affect the 49 residents residing in the facility. Findings: 1. During a medication pass observation on 12/19/23 at 11:55 a.m., Registered Nurse B (RN B) did not perform hand hygiene between glove changes after insulin injection to Resident 23. During a medication pass observation on 12/19/23 at 12:08 p.m., RN B did not perform hand hygiene between glove changes after insulin injection to Resident 35. During an interview with RN B on 12/19/23 at 12:10 p.m., RN B stated that he should have sanitized his hands between glove changes to prevent infections. 2. During a medication pass observation on 12/20/23 at 8:50 a.m., Licensed Vocational Nurse E (LVN E) was observed, not performing hand hygiene after administering medications to Resident 45, then exiting Resident 45's room, and putting on a new pair of gloves to clean the medication tray. During an interview with LVN E on 12/19/23 at 9:00 a.m., LVN E stated that she should have sanitized her hands after administering medications and before wearing a new pair of gloves. During an interview with the Director of Nursing on 12/22/23 at 1:57 p.m., the DON stated that staff should have sanitized their hands between glove changes and after contact with items in the resident rooms to prevent infections. During a review of the facility's undated policy and procedure (P&P), titled, Standard Precautions, the P&P indicated, hand hygiene is performed with ABHR or soap and water after contact with items in the resident room; and after removing PPE, after removing gloves . 3. During a concurrent observation and interview with facility's social service director (SSD) on 12/18/2023 at 9:34 a.m., noted SSD was in hallway, her surgical face mask below her nose. SSD (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056026 If continuation sheet Page 26 of 32 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 12/22/2023 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 Residents Affected - Some confirmed her surgical mask was not covered her nose. SSD stated surgical face mask should have covered both nose and mouth. 4. During a concurrent observation and interview with house keeping H (HK H) on 12/18/2023 at 9:34 a.m., observed HK H removed both gloves, discarded in garbage bin, taken cell phone from her uniform pocket without performed hand hygiene after removed both gloves. During an interview HK H acknowledged she did not wash her hands after removed gloves or before taken cell phone from pocket. 5. a. During an observation and interview with registered nurse B (RN B) on 12/18/2023 at 10:50 a.m., RN B entered to Covid-19 (contagious infectious disease caused by virus) resident's isolation room [ROOM NUMBER] without face shield. During an interview with RN B on 12/18/2023 at 11:08 a.m., RN B confirmed, he did not wear face shield before he entered to Covid-19 isolation room. RN B stated, he should have placed face shield as a part of personal protective equipment (PPE) for Covid-19 isolation residents' rooms. b. During a concurrent observation and interview with RN C on 12/18/2023 at 10:54 a.m., observed RN C wore N95 (a type of respirator mask filters at least 95% of airborne particles) mask on top of surgical mask. RN C acknowledged she placed N95 mask on top of surgical mask. RN C stated she should have removed surgical mask before she applied N95 mask. c. During an observation on 12/18/2023 at 12:23 p.m., noted certified nursing assistant I (CNA I) placed N 95 mask on top of surgical mask. During an interview with CNA I on 12/18/2023 at 12:36 p.m., CNA I stated, she should not have worn N 95 on top of surgical mask. 6. During an observation on 12/19/2023 at 12:15 p.m., Resident 5's foley catheter (F/C: a semi-flexible plastic tube one end inserted into resident's bladder and other end attached to a drainage bag that collects urine) drainage bag not in privacy bag and on floor while Resident 5 was in bed. During an interview with CNA G on 12/19/2023 at 12:20 p.m., CNA G acknowledged Resident 5's F/C drainage bag was not in privacy bag, and on floor. CNA G stated F/C drainage bag should have been in privacy bag and above the floor for infection control. During an interview with facility's infection preventionist (IP) on 12/21/2023 at 11:34 a.m., IP confirmed facility following Center for Disease Control and Prevention's (CDC: nation's leading science-based data-driven, service organization that protects the public's health) recommendations for required PPE for staff. IP stated SSD's surgical mask should have covered her nose and mouth. IP also stated staff should have placed face shield before entered to Covid-19 isolation room and should not have placed N 95 mask on top of surgical mask. IP further stated staff should have performed hand hygiene between tasks to provide clean and healthy environment for residents and prevent spreading infections. During an interview with RN B on 12/21/2023 at 4:10 p.m., RN B stated F/C drainage bag should not be on the floor for infection control practice. During review of facility's policy and procedure (P&P) titled, Personal Protective Equipment - Gloves, undated, the P&P indicated, Wash your hands after removing gloves. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056026 If continuation sheet Page 27 of 32 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 12/22/2023 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 Residents Affected - Some During review of facility's P&P titled, Personal Protective Equipment- Using Face Masks, undated, the P&P indicated, Place the mask over the nose and mouth. The facility allow and encourage individuals to use a mask or respirator based on personal preference, informed by their perceived level of risk for infection based on their recent activities and their potential for developing severe disease if they are exposed. During review of facility's P&P titled, Catheter Care, Urinary, undated, the P&P indicated, Be sure the catheter tubing and drainage bag are kept off the floor. Review of CDC's recommendations for PPE for transmission-based precautions for healthcare personnel for caring residents with respiratory viral infections, dated 12/2023, indicated, N95 or higher-level respirator, and eye protection for Covid-19. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056026 If continuation sheet Page 28 of 32 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 12/22/2023 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. 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 follow facility's written policy and procedure (P&P) for pneumococcal (PNA- an serious infection of one or both of the lungs caused by bacteria, viruses, fungi, or chemical irritant) vaccine (a preparation that is used to stimulate the body's immune response against diseases) for four out of five sampled residents (Resident 5, 11, 26, and 36). This failure had the potential for acquiring PNA and its associated health complications for sampled residents. Residents Affected - Few Findings: 1.Review of Resident 5's face sheet (FS: a document that gives a resident's information at a quick glance) indicated, [AGE] years old Resident 5 admitted to facility on 10/22/2022. Review of Resident 5's immunization record indicated, Resident 5 received PCV 13 (PNA vaccine and a conjugate [conjugate: a type of subunit vaccine which combines a weak antigen with a strong antigen as a carrier so that the immune system has stronger response to the weak antigen] vaccine used to protect against disease caused by the bacterium streptococcus pneumoniae [BSP: a type of bacteria causes PNA]) vaccine on 8/19/2020. Further review of Resident 5's immunization log indicated, scheduled PNA vaccine timing was not followed after Resident 5 received 1 dose of PCV13 vaccine on 8/19/2020. During an interview with facility's infection preventionist (IP) on 12/21/2023 at 11:12 a.m., IP stated facility following Center for Disease Control and prevention (CDC: Nation's leading science-based data-driven, service organization that protects the public's health) 's guidelines for PNA vaccine for all residents. IP confirmed Resident 5 received PCV 13 on 8/19/2020, and he did not receive PCV 20 (a type of vaccine made with an active immunizing agent used to prevent infection caused by certain types of pneumococcal bacteria) or PPSV 23 (a type of PNA vaccine protects against 23 types of pneumococcal bacteria) vaccine one year after he received PCV 13. IP stated staff should have provided PCV 20 or PPSV 23 one year after PCV 13 vaccine was given for Resident 5 for PNA as recommended by CDC. 2.Review of Resident 11's FS indicated, [AGE] years old Resident 11 readmitted to facility on 8/11/2020. Review of Resident 11's immunization record indicated Resident 11 received PCV 13 vaccine on 11/14/2020. Further review of Resident 11's immunization log indicated, scheduled PNA vaccine timing was not followed after Resident 11 received 1 dose of PCV 13 vaccine on 11/14/2020. During an interview with facility's IP on 12/21/2023 at 11:12 a.m., IP confirmed Resident 11 received PCV 13 on 11/14/2020, and did not receive PCV 20 or PPSV 23 vaccine after he received PCV 13. IP stated Resident 11 should have received PCV 20 or PPSV 23 vaccine one year after PCV 13 vaccine was given as recommended by CDC. 3.Review of Resident 26's FS indicated, [AGE] years old Resident 26 admitted to facility on 9/21/2017. Review of Resident 26's immunization record indicated, Resident 26 did not receive PNA vaccine since her admission. During an interview with facility's IP on 12/21/2023 at 11:12 a.m., IP confirmed Resident 26 did not receive any type of PNA vaccine in the facility. IP stated staff should have offered and administered CDC recommended PNA for Resident 26. 4.Review of Resident 36's FS indicated, [AGE] years old Resident 36 admitted to facility on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056026 If continuation sheet Page 29 of 32 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 12/22/2023 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 0883 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 9/2/2021. Review of Resident 36's immunization record indicated, Resident 36 received PCV 13 on 4/23/2022. Further review of Resident 36's immunization log indicated scheduled PNA vaccine timing was not followed for Resident 36 after he received 1 dose of PCV 13 on 4/23/2023. During an interview with facility's IP on 12/21/2023 at 11:12 a.m., IP confirmed Resident 36 received PCV 13 on 4/23/2022, and did not receive PCV 20 or PPSV 23 vaccine after one year. IP stated Resident 36 should have received PCV 20 or PPSV 23 after 4/2023 as recommended by CDC. Review of facility's P&P titled, Pneumococcal Vaccine, undated, the P&P indicated, Administration of the pneumococcal vaccines are made in accordance with current Center for Disease Control and Prevention (CDC) recommendations at the time of the vaccination. Review of CDC recommendations for Pneumococcal Vaccine Timing for Adults, dated 3/15/2023, indicated, For adults 65 years or older who have not previously received any pneumococcal vaccine, CDC recommend you: Give 1 dose of PCV 15 (type of conjugate PNA vaccine) or PCV20. If PCV 15 is used, this should be followed by a dose of PPSV 23 at least 1 year later. For adults 65 years or older who have only received PCV13, CDC recommends you either: Give 1 dose of PCV20 at least 1 year after PCV 13. Or Give 1 dose of PPSV 23 at least 1 year after PCV 13. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056026 If continuation sheet Page 30 of 32 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 12/22/2023 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 0909 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. Based on observation, and interview, the facility failed to ensure to install and conduct inspections to identify loose fitting bed side rails (SR adjustable metal or rigid plastic bars those attached on both sides of to the bed) for three out of eight sampled residents (Resident 11, 36, and 40)'s beds. These failures had the potential to place sampled residents at risk for accidents and unsafe environment. Findings: 1. Review of Resident 11's face sheet (FS, a document that gives a resident's information at a quick glance) indicated Resident 11 was readmitted to facility on 8/11/2020. Review of Resident 11's physician order dated 3/5/2021 indicated, may have bilateral ½ side rails for bed mobility/positioning. During an observation on 12/18/2023 at 7:55 a.m., observed Resident 11 bed's bilateral 1/2 SR were up while Resident 11 was in bed. Further observation of SR indicated Resident 11's bed right SR was loose fitted and moving side to side loosely. During a concurrent observation and interview for Resident 11's bed SR with facility's maintenance supervisor (MS), and director of nursing (DON) on 12/21/2023 at 2:04 p.m., DS confirmed bed's both SR were loose and moving loosely side to side. DS stated facility beds, and SR were old, need to replace with new beds with secured SR. During a concurrent observation and interview for Resident 11's bed with DON on 12/21/2023 at 2:04 p.m., DON confirmed, both SR of Resident 11's bed were loose and moving loosely. DON stated MS should have checked SR for proper fitting for Resident's safety, and to prevent accidents while Resident 11 was using SR as enabler. 2. Review of Resident 36's FS indicated, Resident 36 was admitted to facility on 9/2/2021. Review of Resident 36's physician orders dated 11/1/2021 indicated, right side padded half side rails up while resident in bed for possible seizure (a sudden, uncontrolled burst of electrical activity I the brain can cause uncontrollable movements) activity. During an observation on 12/18/2023 at 8:35 a.m., noted both ½ SR were up while Resident 36 was in bed. Further observation indicated, right side SR was loosely fitted, moving side to side loosely and was not padded. Noted Resident 36 got out of the bed by himself while holding both SR. During a concurrent observation and interview for Resident 36's bed SR with MS, and DON on 12/21/2023 at 2:04 p.m., DS confirmed bed's right SR was loose and moving loosely side to side. DS stated facility beds, and SR were old, need to replace with new beds with secured SR. During a concurrent observation and interview for Resident 36's bed with DON on 12/21/2023 at 2:04 p.m., DON confirmed Resident 11's bed right SR was loose and moving loosely. DON stated MS should have checked SR for proper fitting for Resident's safety, and to prevent accidents. DON also stated staff should have followed physician's order to pad the Resident 36's bed right SR to prevent injury during seizure activity and should have removed left SR for Resident 36's bed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056026 If continuation sheet Page 31 of 32 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 12/22/2023 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 0909 3. Review of Resident 40's FS indicated, Resident 40 was admitted to facility on 6/28/2022. Level of Harm - Minimal harm or potential for actual harm Review of Resident 40's physician order dated 2/12/2023 indicated, may have bil ½ side rails for bed mobility/positioning. Residents Affected - Few During an observation on 12/18/2023 at 7:50 a.m., observed Resident 40 bed's bilateral 1/2 SR were up while Resident 40 was in bed. Further observation indicated Resident's 40's bed right SR was fitted loose and moving side to side loosely. During observation, noted Resident 40 made slight change in position in bed by holding both ½ SR during this observation. Resident 40 said he can use his bed's SR as needed. During a concurrent observation and interview for Resident 40's bed SR with facility's MS and DON on 12/21/2023 at 2:04 p.m., MS confirmed Resident 40's bed's right SR was loose and moving side to side loosely. DS stated beds, and SR in facility were old, need to replace with new beds with secured SR. During a concurrent observation and interview for Resident 40's bed SR with DON on 12/21/2023 at 2:04 p.m., DON confirmed Resident 40's bed right SR was loose and moving loosely. DON stated MS should have checked SR for proper fitting for Resident 40's safety, and to prevent accidents while Resident 40 was using SR as enabler. During review of facility's policy and procedure (P&P) titled, Usage of bedside rails, undated, the P&P indicated, The facility will insure that appropriate and proper usage of the bedside rails are implemented for resident benefits. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056026 If continuation sheet Page 32 of 32

Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.

Citations

13 citations recorded^*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

0578GeneralS&S Epotential for harm
F578 - The right to request, refuse, and/or discontinue treatment, to participate in or
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
0645GeneralS&S Dpotential for harm
F645 - Preadmission Screening for individuals with a mental disorder and individuals
PASARR screening for Mental disorders or Intellectual Disabilities
0656GeneralS&S Dpotential for harm
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
0684GeneralS&S Dpotential for harm
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
0700GeneralS&S Epotential for harm
F700 - Bed Rails
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
0758GeneralS&S Dpotential for harm
F758 - Medication Errors
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.
0759GeneralS&S Dpotential for harm
F759 - Medication Errors
Ensure medication error rates are not 5 percent or greater.
0761GeneralS&S Dpotential for harm
F761 - Labeling of Drugs and Biologicals
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
0806GeneralS&S Dpotential for harm
F806 - Food and drink
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
0812GeneralS&S Dpotential for harm
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
0880GeneralS&S Epotential for harm
F880 - Infection Control
Provide and implement an infection prevention and control program.
0883GeneralS&S Dpotential for harm
F883 - Influenza and pneumococcal immunizations
Develop and implement policies and procedures for flu and pneumonia vaccinations.
0909GeneralS&S Dpotential for harm
F909 - Conduct Regular inspection of all bed frames, mattresses, and bed
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.

FAQ · About this visit

Common questions about this visit

What happened during the December 22, 2023 survey of EMPRESS CARE CENTER, LLC?

This was a inspection survey of EMPRESS CARE CENTER, LLC on December 22, 2023. The surveyor cited 13 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at EMPRESS CARE CENTER, LLC on December 22, 2023?

Yes, 13 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate ..."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.

Data from CMS Care Compare public records. Dataset last refreshed June 22, 2026. If you believe any information is inaccurate, report it here.

Health inspection·December 22, 2023