Health inspection·April 4, 2023

F 0552 Ensure that residents are fully informed and understand their health status, care and treatments. 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 inform the residents' responsible party (RP, an individual authorized to act for the resident as an official delegate or agent) of the room changes of the two of four residents investigated, (Residents 1 and 2) when: Residents Affected - Few 1. Resident 1's RP was not informed of the room change when Resident 1 was exposed to Cornavirus disease (COVID-19, an infectious disease caused by a new strain of coronavirus) and 2. Resident 2's RP was not informed of the room change after her isolation (being separated from other residents) due to testing positive for COVID-19. This deficient practice resulted to Resident 1 and 2's RP, to be unaware of the changes and not able to participate in their care and treatment. Findings: 1. During a concurrent observation and interview with Resident 1 on 3/22/23 at 10:45 a.m., Resident 1 appears calm, alert, oriented and responsive to questions. Resident 1 verified that he had a few room changes recently. Review of Resident 1's clinical records indicated, he was admitted to the facility on [DATE] with diagnoses including paranoid schizophrenia (severe mental health condition with symptoms of delusions and hallucinations). Review of Resident 1's progress notes indicated, Resident 1 had room changes on 1/31/23, for altercation with other resident, on 2/14/23, for exposure to positive COVID-19 resident and on 2/23/23, after Resident 1 finished his isolation. Further review of Resident 1's clinical records indicated, there were no RP notifications for the room transfers on 2/14/23 and 2/23/23. During a review and concurrent interview with the infection preventionist (IP) on 3/22/23 at 1:40 p.m., the IP reviewed Resident 1's clinical records and confirmed, there were no documentation indicating the RP was notified for Resident 1's room changes on 2/14/23 and 2/23/23. During a review and concurrent interview with the director of nursing (DON), on 3/22/23 at 3:45 p.m., the DON verified, there were no documentation indicating Resident 1's RP was notified during room changes on 2/14/23 and 2/23/23. The DON further stated, the RP should be notified during a room (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 2 Event ID: 056058 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 056058 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Almaden Health and Rehabilitation Center 2065 Los Gatos-Almaden Road San Jose, CA 95124 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)