Health inspection·April 28, 2023

F 0656 Level of Harm - Minimal harm or potential for actual harm 3. For Resident 56, the facility failed to develop a care plan to address the management of diabetis mellitus (DM, increase blood sugar) foot. These failures had the potential to result in the residents not receiving the care and services necessary to maintain their health, safety and well-being. Residents Affected - Few Findings: 1. A review of Resident 61's clinical record indicated she was admitted on [DATE] with diagnoses including unspecified dementia (impaired ability to remember, think, or make decisions that interfere with doing everyday activities) and dysphagia (difficulty swallowing and taking more time and effort to move food or liquid from your mouth to your stomach). During a concurrent observation and interview with Resident 61 on 4/24/2023 at 1:10 p.m., in Resident 61's room, Resident 61 spoke non-english language all the time, and no communication boards were noted at the bedside. During a concurrent interview and record review with the Licensed Vocational Nurse J (LVN J) on 4/23/2023 at 5:36 p.m., the LVN J verified there was no care plan to address the communication barriers, and she stated the resident should have a care plan for her communication issue. During an interview with the Director of Nursing (DON) on 4/28/2023 at 10:45 a.m., she confirmed that Resident 61 could not speak English and the nurses should have developed a care plan to address the communication barriers. A review of the facility's undated policy and procedure titled Comprehensive Plan of Care indicated, the comprehensive plan of care must address the resident's individual needs, strengths, and preference .reflect interventions to meet both short- and long-term resident goals FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056058 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 056058 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2023 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)

F 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. 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 provide communication services to one of 18 sampled residents (Resident 28) who spoke in their non-English language. This failure had the potential for the resident not to maintain or improve her ability to carry out the activities of daily living (ADL). Residents Affected - Few Findings: Review of Resident 28's clinical records indicated she was admitted on [DATE] and had diagnoses including dementia (a decline in mental capacity affecting daily function), major depressive disorder (a mood disorder that causes a feeling of sadness and loss of interest), and left radius fracture (broken forearm bone). During an observation and interview on 4/24/23 at 8:29 a.m., Resident 28 was trying to communicate with certified nursing assistant E (CNA E) in her non-English language, and CNA E stated she could not understand Resident 28. CNA E further stated she could only communicate with the resident through gestures and assumed the resident's needs. Review of Resident 28's care plan of communication-language barrier dated 12/21/22 indicated to provide a translator via phone service and provide communication cards for basic needs to the resident. During an interview and record review with director of nursing (DON) on 4/27/23 at 9:32 a.m., the DON acknowledged Resident 28 spoke only in her non-english language. The DON stated a communication binder in the language of Resident 28 have been provided and facility staff were using the binder to communicate with the resident during ADL care. The DON further stated the translator via phone service was not available to the facility yet. During an observation and interview with the DON on 4/27/23 at 9:39 a.m. in Resident 28's room, there was no communication binder. The DON stated she could not locate Resident 28's communication binder. The DON acknowledged the communication binder in the language of Resident 28 should have been available during ADL care. During an interview with licensed vocational nurse C (LVN C) on 4/27/23 at 9:42 a.m., she acknowledged Resident 28 spoke non-English language. LVN C stated she was not aware of the communication binder in the language of Resident 28 and did not provide a translator via phone service. During an interview with CNA E on 4/27/23 at 10:02 a.m., she stated the communication binder in the language of Resident 28 was missing for a long time. During an interview and record review with the DON on 4/27/23 at 10:35 a.m., she reviewed Resident 28's care plans and stated Resident 28's communication care plan was a generalized, and a standing care plan. The DON acknowledged the care plan should have been person-centered, and individualized for the resident. Review of the facility's undated policy, Resident Communication, indicated, Purpose: to improve or maintain the resident's self-performance in using newly acquired functional communication skills . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056058 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 056058 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2023 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)

F 0676 Use communication boards and picture books, . Level of Harm - Minimal harm or potential for actual harm Review of the facility's undated policy, Care Plan Essentials, indicated, Purpose: To provide a quick reference guide to particular needs of individual residents, . related to individualized care and treatment of the resident . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056058 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 056058 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2023 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)

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** 3. Review of Resident 23's physician order indicated she had an order for creatinine with estimated glomerular filtration rate (creatinine with eGFR, a test that measures the level of kidney function and determines the stage of kidney disease) on the second Monday of March and September, started on 3/25/19. But creatinine with eGFR test results were not found for 3/2020, 9/2020, and 9/2021. Residents Affected - Some During an interview with the director of nursing (DON) on 4/28/23 at 4:37 p.m., she reviewed Resident 23's clinical record, verified with the laboratory staff, and confirmed the creatinine with eGFR test was not done for Resident 23 in 3/2020, 9/2020, and 9/2021. The DON stated Resident 23's creatinine with eGFR test should have been completed 4. Review of Resident 172's admission Record indicated he was admitted to the facility on [DATE] with diagnoses including sepsis (a serious condition in which the body responds improperly to an infection) and pressure ulcer (damage to an area of the skin caused by constant pressure on the area for a long time). Review of Resident 172's physician order, dated 4/16/23, indicated he had an order to cleanse his sacrum wound with normal saline (NS, a 0.9% sterile solution of salt in water), pat dry, apply Cavilon (used to treat skin irritation) to the periwound skin, apply Eakin ring moldable barrier (helps prevent leaks and skin irritation by forming an absorptive barrier) to the inferior edge, pack the wound with Aquacel Ag (antimicrobial primary dressings), then cover with several 4 by 4 inch gauzes to make sure Aquacel Ag contact with wound bed, then cover with large Mepilex (absorbent foam dressing) every two days and as needed. During a wound treatment observation with the WCN on 4/26/23 at 10:50 a.m., the WCN cleansed Resident 172's sacrum wound with NS, patted dry, applied Cavilon to the periwound skin, applied Eakin ring moldable barrier to the inferior edge, packed the wound with Aquacel Ag, then cover with Mepilex. The WCN did not cover the wound with several 4 by 4 inch gauzes to make sure Aquacel Ag contact with the wound bed. During an interview with the WCN on 4/26/23 at 11:45 a.m., he confirmed that he did not cover the wound with several 4 by 4 inch gauzes to make sure Aquacel Ag contact with the wound bed. The WCN stated he should follow the physician's order. Review of the California Board of Registered Nursing website, California Business and Professions Code, Division 2, Chapter 6, Article 2, Section 2725(b)(2), indicated registered nurses should ensure the safety, protection of residents; administration of medications, and therapeutic agents, necessary to implement a treatment, disease prevention, ordered by and within the scope of the licensure of a physician. 2. During an observation and interview on 4/24/23 at 9:45 a.m., there was one medication in a medication cup on the window frame. Resident 37 stated the night shift nurse gave to her, but she didn't take the medication. Review of Resident 37's physician order dated 2/22/23 indicated: Omeprazole (acid reducer) 20 milligram (mg, a type of unit measurement) 1 capsule oral before breakfast for GI (gastrointestinal) prophylaxis once a day at 6:30 am. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056058 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 056058 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2023 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)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a concurrent observation and interview with registered nurse B (RN B) on 4/24/23 at 9:45 a.m., she confirmed the medication was left unattended and stated the medication should have not be left unattended in the room. RN B stated the nurse should have verified Resident 37 if she took her medication. Review of the facility's undated policy Oral Medication Administration, indicated Purpose was to administer oral medications in an accurate, safe, timely, and sanitary manner. Procedure: 10. Verify that medications are actually taken. Based on observation, interview, and record review, the facility failed to provide care and services in accordance with professional standards of practice for four of 18 sampled residents (Residents 35, 37, 23, and 172) when: 1. For Resident 35, the facility failed to change the wound dressing as ordered and failed to label the wound dressing with the initial, date, and time; 2. For Resident 37, medication was left unattended in the room; 3. Creatinine with estimated glomerular filtration rate (creatinine with eGFR, a test that measures the level of kidney function and determines the stage of kidney disease) test was not done for Resident 23 as ordered; and 4. The wound care nurse (WCN) did not provide treatment to Resident 172's sacrum wound as ordered by the physician. These failures had the potential to negatively affect the health and safety of the residents. Findings: 1. Review of Resident 35's clinical record indicated he was admitted on [DATE] and had the diagnosis of diabetes (a disease that causes high blood sugar), chronic venous insufficiency (improper functioning of the vein valves in the leg, causing swelling and skin changes). Review of Resident 35's physician order, dated 4/23/2023, indicated a left medial heel (LMH) open blister: Cleanse with normal saline, pat dry, and apply Puracol plus collagen (a native collagen wound dressing that promotes natural healing) every other day and cover with Opti foam (Silicone Faced Foam Dressing provides gentle adhesive to create an optimum healing condition) then reassess after 21 days. Left medial shin (LMS) open area: Cleanse with normal saline, pat dry, and apply Puracol plus collagen every other day and cover with Opti foam, then reassess after 21 days. During a concurrent observation and interview with the Licensed Vocational Nurse D (LVN D) in Resident 35's room on 4/28/2023 at 11: 21 a.m., Resident 35's LMS open area was covered with a dressing dated 4/23/2023 by the wound care nurse (WCN). LMH open blister was covered by an Opti foam dressing with brownish drainage, and no initial, date and time was noted on the dressing. LVN D confirmed the above observation and stated the LMS dressing should have been changed on 4/25/23 and 4/27/23 and those two missed treatments could cause infection and delay the wound healing. The nurse should have labeled the LMH dressing with the initial, date, and time. During a phone interview with LVN K on 4/28/2023 at 3:39 p.m., she confirmed that she did not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056058 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 056058 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2023 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)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some change the LMS dressing for Resident 35 on 4/25/2023 and 4/27/2023 and accidentally charted as completed on those two days. During an interview with the WCN on 4/28/2023 at 4:05 p.m., he verified that LVN K did not change the LMS dressing on 4/25 and 4/27 as ordered, and LVN K should have labeled the LMH dressing with the initial, date, and time for next shift nurse to follow up. A review of the facility's undated policy and procedure titled Wound Care and Treatment indicated, .verify that there was a physician's order for this procedure . The policy and procedure also indicated, dress wound .mark tape with initials, time and date then apply to dressing . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056058 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 056058 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2023 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)

F 0687 Provide appropriate foot care. 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 provide necessary podiatry services for one of 18 sampled residents (Resident 56) when his toenails were long enough to curl under. This failure had the potential to affect the resident's foot health and contribute to injury and/or infection. Residents Affected - Few Findings: Review of Resident 56's clinical records indicated he was admitted on [DATE] and had diagnoses including hemiplegia (a symptom that involves the loss of the ability to move on one-side of body) and hemiparesis (one-sided weakness), hypertension (high blood pressure), and type 2 diabetes (high blood sugar). During an observation and interview with Resident 56 on 4/24/23 at 10 a.m., he stated that his toenails were very long, and he needed a podiatry service. Resident 56's great toenail was long and hypertrophied (excessively enlarged), and his 2nd to 5th toenails were discolored and curled under the toes. Resident 56 stated he had not seen a podiatrist since his admission. Review of Resident 56's Minimum Data Set (MDS, an assessment tool) dated 3/28/23 indicated his brief interview for mental status (BIMS, cognition level) score was 12, moderately impaired. Further review of the clinical record indicated Resident 56 had a physician's order, dated 12/30/21, for podiatry services for treatment of hypertrophied toenails and/or other problems as needed. During an observation and interview with registered nurse B on 4/24/23 at 10:10 a.m., she confirmed the observation and stated the podiatrist (foot doctor) need to trim the resident's toenails because he had diabetes. RN B stated nurses report diabetic residents' toenail care needs to the social service worker (SSW). RN B further stated she reported Resident 56's podiatry needs to the SSW long time ago. During an interview with director of nursing (DON) on 4/25/23 at 2:27 p.m., she stated she could not locate any document indicating that podiatry services were provided to Resident 56. The DON acknowledged the facility should have provided podiatry services to the resident. During an interview with the DON on 4/28/23 at 9:23 a.m., she stated the podiatrist visited the facility monthly, and a monthly list was provided by the SSW. The DON stated Resident 56 was not included in the list without reason, and the facility missed him for podiatry services. Review of the facility's undated policy Foot Care, indicated, The nurse must pay special attention to the care of feet for persons with peripheral vascular disease or diabetes. A licensed nurse, therapist, or podiatrist must trim toenails of a diabetic resident. Review of the facility's undated policy Referral to Outside Agencies, indicated, To establish guidelines for making referrals to outside agencies that will meet the psychosocial and/or concrete needs of a resident, . Referral can be made by the social service director, licensed nurse, or a member of the IDT based on a resident's individualized, specific need . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056058 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 056058 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2023 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)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, interview, and record review, the facility failed to ensure residents had an environment free from accident hazards when red sharps (objects with sharp points or edges such as needles or syringes) containers were left open, unattended, and accessible on two out of three medication carts. This failure had the potential to put residents and staff at risk for injuries from needlesticks and sharp objects. Findings: During a concurrent observation and interview on 4/24/23, at 12:33 p.m., at Medication Cart 2, with registered nurse B (RN B), a red sharps container was observed sitting on top of the medication cart. The lid was open and the container was approximately 70-80% full. RN B placed a used insulin syringe and needle into the open container on top of the cart. She stated she agreed that the sharps container can be tampered with by residents who are curious, or those with dementia who might want to put their hands in or dump the contents out. RN B stated the sharps container on the side of the medication cart did not have a lid and that's why she had to use this container on top of the medication cart. During an observation on 4/24/23, at 12:39 p.m., at medication cart 3 in the nursing station, another red sharps container was observed sitting on top of the medication cart, near a laptop, unattended, with the lid open. The container was approximately 30% full. During an interview on 4/24/23, at 12:43 p.m., with licensed vocational nurse C (LVN C), she confirmed the sharps container was opened on top of the cart, unattended, and contained lancets (used to prick the skin) and syringes. She agreed it was hazardous and stated, The sharps container on the side of the medication cart ran out of lids that's why we have to use this one. LVN C removed the sharps container from the top of the medication cart and placed it inside the drawer. During an interview on 4/24/23, at 3:15 p.m., with the LVN D, he stated, We are waiting for the [sharps] containers that fit in the medication cart and we are using those [sharps] containers in the meantime. During an interview on 4/25/23, at 8:58 a.m., with the infection preventionist (IP), regarding sharps containers left open, unattended, on top of medication carts, and accessible to anyone, she agreed that it was dangerous and stated, We ran out of rectangle bins for the carts and those containers are used as substitute. For the ones they are using, they should be locked in the [medication] cart when they leave the cart. It should not be left unattended. During a review of the facility's undated policy and procedure titled, Wastes & Cleaning Practices indicated, Contaminated sharps are discarded immediately .in containers that are closable . Ensure that sharps containers are not opened, emptied, or cleaned manually in or in any other manner which would expose employees to the risk of percutaneous (through the skin) injury [penetration of skin by a contaminated needle or sharp object] . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056058 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 056058 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2023 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)

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Residents Affected - Few Based on observation, interview, and record review, the facility failed to provide dialysis services consistent with professional standards for one of three residents (22) who received hemodialysis (medical procedure to remove fluid and waste products from the blood and to correct electrolyte, i.e. salts and mineral imbalances by using a machine and an artificial kidney) when staff and Resident 22's clinical record indicated the wrong dialysis access site; and Resident 22's dialysis communication records were missing. These failures had the potential for the resident to be inaccurately assessed and be at risk for complications. Findings: Review of Resident 22's admission Record indicated he was admitted to the facility on [DATE] with diagnoses including end stage renal disease and dependence on renal dialysis. During an observation and interview with Resident 22 on 4/26/23 at 1:55 p.m., indicated Resident 22's dialysis access site was on his left upper arm. Resident 22 stated that was the only dialysis site he had, and he did not have any dialysis access site on his chest. However, Resident 22's clinical record indicated his dialysis access site was on his right upper chest. During an interview with certified nursing assistant N (CNA N) on 4/28/23 at 10:50 a.m., he stated Resident 22's dialysis access site was on his right upper chest. During an interview with the director of nursing (DON) on 4/28/23 at 3:35 p.m., she reviewed Resident 22's clinical record and stated Resident 22's dialysis access site was on his right upper chest. During an observation and interview with the DON on 4/28/23 at 3:44 p.m., she observed the dialysis access site on Resident 22 and confirmed Resident 22's dialysis access site was on his left upper arm. The DON stated Resident 22's dialysis access site on his right upper chest was discontinued. When Resident 22 had a new dialysis access site on his left upper arm, the facility should have assessed the site and updated Resident 22's clinical record, but that was not done. Review of Resident 22's dialysis communication records, from 1/2023 to 4/2023, indicated his dialysis communication record was missing for 1/24/23, 1/31/23, 2/9/23, and 2/14/23. During an interview with the DON on 4/28/23 at 3:57 p.m., she review Resident 22's clinical record and confirmed Resident 22's dialysis communication record was missing for 1/24/23, 1/31/23, 2/9/23, and 2/14/23. Review of the facility's undated policy, Hemodialysis, indicated Purpose: To provide residents with safe, accurate, and appropriate care, assessments and interventions to improve resident outcomes. Review of the facility's undated policy, Care of Residents with End-Stage Renal Disease (ESRD), indicated Residents with ESRD will be cared for according to currently recognized standards of care. Procedure: 1. Staff caring for residents with ESRD, including residents receiving dialysis care outside the facility, shall be trained in the care and special needs of these residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056058 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 056058 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2023 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)

F 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to review the risks and benefits of bed rails (adjustable metal or rigid plastic bars that attach to the bed) with the resident or resident representative (RR, a person empowered to make decisions for the resident/person legally responsible and liable for a decision or an action) and obtain the physician's order and informed consent prior to the use of bed rails for one of 18 sampled residents (Resident 7). This failure had the potential to put the resident at risk for entrapment and serious injury due to not being aware of the risks and benefits of bed rails. Findings: Review of Resident 7's clinical records indicated he was admitted on [DATE] and had diagnoses including type 2 diabetes (high blood sugar), seizures (uncontrolled jerking movements of the arms and legs caused by abnormal brain activity), and depressive episodes. During the initial tour of the facility conducted on 4/24/23 at 10:18 a.m., Residents 7 had half bed rails elevated. Review of Resident 7's physician orders indicated there was no order of the use of bed rails. Review of Resident 7's clinical records indicated there was no consent form for bed rails, indicating the risks and benefits of bed rail use were explained to the resident or resident representative. During an interview and record review with licensed vocational nurse F (LVN F) on 4/25/23 at 3:55 p.m., she confirmed there was no physician order and/or consent for a bed rail. During an observation and interview with LVN F on 4/25/23 at 4 p.m., Resident 7 had half bed rails elevated, and LVN F confirmed the observation. LVN F stated the facility should have obtained the physician's order and informed consent prior to the use of bed rails. During an interview with director of nursing (DON) on 4/27/23 at 9:50 a.m., she stated the facility should have obtain the physician's order and informed consent prior to the use of bed rails. Review of the facility's undated policy Side rails, indicated, Requirements are . Complete informed consent, reviewing risks and benefits with responsible party, including risk for entrapment. Obtain MD order, including diagnosis/medical necessity for use of restraint. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056058 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 056058 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2023 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)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview and record review, the facility failed to implement procedures to ensure safe handling of hazardous drugs (medications capable of causing serious effects); and ensure controlled medications (those with high potential for abuse and addiction) were fully accounted when: 1. Hazardous drug handling procedures were not implemented during medication pass observation for Resident 274; 2. Random controlled medication use audit for two of six sampled residents (Residents 12 and 322) did not reconcile. The medications were signed out of the controlled drugs accountability sheet (Count Sheet, an inventory sheet that keeps record of the usage of controlled medications) but not documented on the Medication Administration Records (MAR) to indicate they were given to the residents. These failures had the potential for exposing staff and residents to serious side effects from hazardous drugs including cancer and fertility problems; and misuse or diversion (the illegal distribution or abuse of prescription drugs or their use for purposes not intended by the prescriber) and inaccurate accountability of controlled medications. Findings: 1. During a medication pass observation for Resident 274 on 4/24/23, at 8:42 a.m., registered nurse B (RN B) was observed preparing two capsules of CellCept (mycophenolate, an immunosuppressant medication that lowers the activity of the body's immune system) and 11 other medications with ungloved hands. The red pharmacy auxiliary sticker label (a label added on to a dispensed medication package by a pharmacist that displays additional warnings, information, or instructions) indicated Hazardous Drugs on the CellCept medication package. During an interview on 4/24/23, at 9:14 a.m., with RN B, regarding the hazardous drug auxiliary sticker label for CellCept, she stated, The hazardous drug sticker means I am supposed to wear gloves. On 4/25/23, a review of Resident 274's clinical record indicated a physician's order, dated 4/14/2023, for CellCept (mycophenolate) 250 milligrams (mg, unit of measurement) capsule, give two capsules by mouth twice a day. During an interview on 4/25/23, at 11:13 a.m., with the director of nursing (DON) in the presence of the regional director of clinical operations (RDCO), they stated, the consultant pharmacist (CP) would inform the facility about hazardous drugs on a resident-by-resident basis and would provide an in-service for resident specific hazardous drugs. They confirmed the CP had not provided a hazardous drug list or any in-services on hazardous drug handling procedures. The DON said the red pharmacy auxiliary label Hazardous Drug means nurses should have wear gloves to protect themselves. During a telephone interview on 4/26/23, at 9:47 a.m., with the CP, she stated nurses should have wear gloves while handling hazardous drugs. She said when a resident is on a hazardous drug, she would make the recommendation to wear gloves and the instructions should have been reflected on the MAR. The CP confirmed she did not provide the facility with a list of hazardous drugs and she had not done an in-service on hazard drug handling procedures. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056058 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 056058 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2023 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)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of Lexicomp Online, a nationally recognized drug information resource, indicated for CellCept capsule, Hazardous Drugs Handling Considerations .Use appropriate precautions for . handling . preparation . administration . Follow NIOSH [The National Institute for Occupational Safety and Health, the United States federal agency responsible for conducting research and making recommendations to prevent work-related injury and illness] .recommendations and institution-specific policies/procedures for appropriate containment strategy. A review of the Prescribing Information (PI, detailed description of a drug's uses, dosage range, side effects, drug-drug interactions, and contraindications that is available to clinicians) for CellCept (mycophenolate mofetil capsule), dated August 2022, indicated, Handling and Disposal .[CellCept] has demonstrated teratogenic [ability to disturb the growth and development of an embryo or fetus] effects in humans . Wearing disposable gloves is recommended . Avoid inhalation or direct contact with skin or mucous membranes of the powder contained in CellCept capsules. During a review of the facility's policy and procedures (P&P) titled, Cytotoxic [A substance that kills cells] Agent Guidelines, dated January 2023, the P&P indicated, Cytotoxic medications . should be handled using gloves . Nurses handling and administering cytotoxic medications are to use a non-touch technique, wearing gloves . Careful hand hygiene must be adhered to throughout the process. 2. The controlled medication Count Sheets for six random residents receiving controlled medications were requested for review during the survey. a. Resident 12 had a physician's order for methadone (a controlled medication for pain) tablet 5mg, give one tablet by mouth every 8 hours for pain management, start date 3/17/23. During a concurrent interview and record review on 4/25/23, at 11:19 a.m., with the DON, a review of Resident 12's Count Sheet for methadone and the 4/2023 MAR reflected the nursing staff removed 1 tablet on 4/3/23 at 2 p.m. the medication cart and documented on the Count Sheet while documenting the respective administration as Not administered: Refused on the MAR. The DON validated the discrepancy in documentation between the Count Sheet and the MAR. She said, It should have been wasted on the controlled [substance] record. I don't know the reason it was documented on [Controlled Substance] record as given. b. Resident 322 had a physician's order for hydrocodone-acetaminophen (a controlled medication for pain) tablet 10-325mg, give 1 tablet by mouth every 6 hours as needed for moderate to severe pain, start date 3/23/23. During a concurrent interview and record review on 4/25/23, at 11:35 a.m., the DON, a review of Resident 322's Count Sheet for hydrocodone-acetaminophen and the 4/2023 MAR reflected the nursing staff removed 1 tablet on 4/15/23 at 9 a.m., on 4/20/23 at 1:30 p.m., and on 4/22/23 at 2 p.m. from the medication cart and documented on the Count Sheet without documenting the respective administration on the MAR to show they were administered to the resident. The DON confirmed three hydrocodone-acetaminophen tablets were not accounted for. During a follow-up interview with the DON on 4/25/23, at 1:48 p.m., she stated she could not locate documentation for the missing documentation of controlled medications for Residents 12 and 322. During a review of the facility's P&P titled, Oral Medication Administration (undated), it indicated, Documentation: 1. Electronic Medication Administration Record; 2. On the individual control drug (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056058 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 056058 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2023 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)

F 0755 record, sign out all controlled substances administered; 3. Document in the electronic health records system. 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: 056058 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 056058 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2023 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)

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based on interview, and record review, the facility failed to request a medication regimen review (MRR) following changes in condition (worsening of an existing problem or the emergence of new signs or symptoms, such as falls or seizures) for two out of five sampled residents (Resident 48 and 59); and failed to ensure the consultant pharmacist (CP) identified potential medications contributing to falls and make recommendations to the facility for reduction or discontinuation of one of the medications during the monthly MMRs for Resident 59. This failure had the potential for medications not being optimized for best possible health outcome, and unnecessary or prolonged use of medications which could lead to medication adverse effects (such as falls) for the residents. Findings: 1. A review of Resident 59's clinical record indicated she was admitted to the facility with diagnoses including fracture of right femur (thigh), Alzheimer's disease (memory problem), brief psychotic (condition that affect the mind, where there has been some loss of contact with reality) disorder, unspecified dementia (mental decline) with behavioral disturbance, other reduced mobility, unspecified fall subsequent encounter, and muscle weakness.' A review of Resident 59's clinical record indicated she had been receiving Seroquel (an antipsychotic medication) 25 milligrams (mg, unit of measurement) every 12 hours since 8/2022. In January 2023, it was reduced to 12.5 mg in the morning, and 25 mg in the evening (37.5 mg total) for dementia with behavioral disturbance as m/b aggression i.e. hitting. Resident 59's clinical record showed, on 2/18/23, the physician ordered a new medication, mirtazapine (an anti-depressant, which has sedating effect) 7.5 mg daily at each bedtime. Four days later, on 2/22/23, Resident 59 sustained a fall. A review of the nursing progress notes for fall, written on 2/22/23 at 8:26 p.m., indicated on 2/22/23 Resident 59 went inside of the nurses station, fell on the floor, was unable to stand, complained of left hip pain, 911 was called, and Resident 59 was taken to the hospital. A review of the hospital Discharge Instructions, dated 3/2/23, indicated Resident 59's reason for hospital visit was for a right intertrochanteric [three to four inches from the hip joint] hip fracture. A review of the nursing progress notes, written on 3/2/23, at 3:56 p.m., indicated, [Resident 59] admitted from [hospital] .with acute R [right] intertrochanteric femur fracture . On [February] 23rd r-hip [right hip] nailing [a type of surgery to fix a broken or fractured hip] was done . A review of Resident 59's clinical record indicated she had another fall on 3/14/23. A review of the nursing progress notes for fall, written on 3/14/23 at 6:18 p.m., indicated, Around 4p.m., CNA [certified nursing assistant] called to writers attention that resident is on the floor in a sitting position scooting herself closer to the door. When asked what happened, resident unable to say how she ended on the floor . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056058 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 056058 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2023 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)

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few According to Lexi-comp, a nationally recognized drug information resource, the combined use of Seroquel and Mirtazapine results in a drug-drug interaction (interaction between a drug and another substance that prevents the drug from performing as expected). It indicated, CNS [Central Nervous System] Depressants [medications that slow brain activity, which causes drowsiness and muscle relaxation] may enhance the adverse/toxic effect of other CNS Depressants . Dose reductions of one or both CNS depressant agents may be necessary. Monitor for additive CNS-depressant effects whenever two or more CNS depressants are concomitantly used . Risk Rating C [a moderate risk level]: Monitor therapy. Lexi-comp indicates both Seroquel and mirtazapine could cause drowsiness, sedation, and falls. During an interview with the director of nursing (DON) on 4/27/23, at 10:21 a.m., when asked whether the facility asked the pharmacist to review Resident 59's medication regimen to see if the fall could have been attributed by the medications, the DON said, No, we don't normally do that. I just talk to the doctor whenever the residents had a change of condition. During a telephone interview with the CP on 4/27/23, at 11:12 a.m., she stated whenever a resident had change of condition such as a fall, the facility should request for an MRR from the pharmacy to see if medications could have been the contributory factor. She added, A change of condition MRR should have been requested after [Resident 59] fell. When asked whether she identified in the monthly MRR in February or March regarding the potential for Seroquel and mirtazapine to contribute to her falls and made recommendation for changes, the CP stated, No I didn't. A recommendation should have been made, either decrease or change one of those medications. Mirtazapine and Seroquel are both sedating. I didn't make further recommendations. A review of the CP's monthly MRRs for Resident 59, from 2/2023 to 4/2023, indicated there were no recommendations from the CP for consideration of changes to Seroquel and/or mirtazapine, as they could have contributed to the resident's falls. 2. Review of Resident 48's clinical record indicated she was admitted to the facility with diagnoses including unspecified convulsions (a condition in which muscles contract and relax quickly and cause uncontrolled shaking of the body) and epilepsy (aka seizure, a condition that affects the brain and causes frequent seizures). A review of the clinical record indicated physician's orders, as follows: a. levetiracetam (used for seizures) 100 mg tablet, 1 tablet by mouth every 12 hours, dated 3/5/23; and b. lacosamide (used for seizures) 100 mg tablet, 1 tablet by mouth twice a day, dated 4/7/23. A review of nursing progress notes, dated 4/3/23, at 2:55 p.m., indicated, At 9 a.m., CNA reported to the LN [licensed nurse] that the resident was having jerky movement. LN went immediately to assess the resident. Noted resident was having episode of seizure . seizure episode lasted about 1 [minute] . resident returned back to baseline after 2 [minutes] . During a concurrent interview and record review with the DON, on 4/28/23, at 10:07 a.m., regarding the MRR for when Resident 48 had a seizure, the DON reviewed the clinical record, she stated, The pharmacist comes monthly but for change of conditions we don't communicate with the pharmacist, only the doctor . If the doctor says to contact the pharmacist, then I would call the pharmacist. The DON (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056058 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 056058 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2023 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)

F 0756 confirmed no MRR was completed after Resident 48 had a seizure. Level of Harm - Minimal harm or potential for actual harm During a review of the facility's policy and procedures (P&P) titled, Changes in Resident Condition (undated), the P&P indicated, Procedure . b. a significant change in the resident's physical, mental or psychosocial status; c. a need to alter treatment significantly (i.e., a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment) . Residents Affected - Few During a review of the facility's P&P titled, Medication Regimen Review and Reporting, dated January 2023, the P&P indicated, More frequent medication regimen reviews may be deemed necessary. This may include when the resident experiences an acute change of condition . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056058 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 056058 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2023 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)

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. 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 1 of 18 sampled residents (Resident 33) was free from unnecessary medications when the nursing staff did not monitor for signs and symptoms of adverse effects related to the use of blood thinning medications. Resident 33 was receiving Xarelto (generic name rivaroxaban, an anti-coagulant, or blood thinning medication). This failure had the potential for side effects of this medication (such as bleeding, excessive bruising, etc.) to go undetected or recognized for timely intervention. Residents Affected - Few Findings: On 4/26/23, a review of Resident 33's clinical record indicated he was admitted to the facility on [DATE] with diagnoses including paraplegia (the inability to voluntarily move the lower parts of the body). A review of Resident 33's hospital record's History and Physical (H&P), dated 4/8/22, indicated a medication list which included Xarelto. A review of Resident 33's clinical record indicated a physician's order, dated 11/21/22, for Xarelto (rivaroxaban) tablet 20 mg (milligrams, unit of measure) 1 tablet by mouth once a day for DVT (deep vein thrombosis, a blood clot in a deep vein, usually in the legs). Monitor for s/s (signs and symptoms) of bleeding/bruising. A review of the Prescribing Information (detailed description of a drug's uses, dosage range, side effects, drug-drug interactions, and contraindications that is available to clinicians) for Xarelto, dated February 2023, it indicated it was an anticoagulant that can cause serious and fatal bleeding. A review of Lexicomp online, a nationally recognized drug information resource, indicated the following for Xarelto, Monitor for signs and symptoms of bleeding (bruising or bleeding that is not normal .nosebleeds that won't stop, bowel movements that are red or black like tar, throwing up blood or liquid that looks like coffee grounds). On 4/26/23, a review of Resident 33's clinical record indicated a care plan, dated 11/21/22, it indicated, Monitor for bleeding, ecchymosis [bruise], hematoma [blood pooling outside the blood vessel], hematuria [blood in urine], hematemesis [vomiting blood], and other s/s of bleeding and refer to AP. During a concurrent interview and record review of Resident 33's Medication Administration Record (MAR) with the director of nursing (DON) on 4/26/23, at 1:23 p.m., the DON said, We monitor and document for bleeding. Resident has a catheter, so we look for bleeding in catheter and bruises and bleeding during observation during med [medication] pass . I don't see any documentation in the active orders in the chart. The DON confirmed there was no documentation the nursing staff monitored for s/s of bleeding related to the use of Xarelto. During a review of the facility's policy and procedures (P&P) titled, Anticoagulant Therapy (undated), the P&P indicated, Throughout anticoagulant therapy monitor the resident for signs and symptoms of bleeding . Documentation: 1. Physician Order; 2. Anticoagulant Therapy Flow Sheet; 3. Medication Administration Record; 4. Document in the electronic health records system . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056058 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 056058 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2023 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)

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 failed to ensure the facility medication error rate did not exceed five percent or greater when observation of 34 opportunities during the medication pass resulted in two errors. The calculated medication error rate was 5.88 percent. Residents Affected - Few These failures placed Residents 38 and 274 at risk for not receiving the full therapeutic effects of medications when medications were not given according to the manufacturer's specifications. Findings: 1. During a medication pass observation for Resident 38 on 4/24/23, at 7:54 a.m., registered nurse A (RN A) was observed administering six medications, which included potassium chloride (used to treat low levels of potassium) extended-release tablet, with a cup containing about 6 ounces (or 180 milliliters [ml], unit of measurement) of water. At the bedside, Resident 38 was observed taking all his medications with two sips of water or about half of the water cup. RN A did not insist on the resident taking more water with his medications. During an interview on 4/24/23, at 8:08 a.m., with RN A, she stated Resident 38 consumed approximately 120 ml of water with his medications. A review of Lexicomp online, a nationally recognized drug information resource, indicated the following for potassium chloride tablets: Oral dosage forms should be taken with meals and a full glass of water or other liquid to minimize the risk of GI [gastrointestinal] irritation. On 4/24/23, a review of Resident 38's clinical record indicated a physician's order, dated 4/21/2023, for potassium chloride tablet extended release 20 mEq (milliequivalent, unit of measurement) 1 [tablet] oral once a day. During a follow-up concurrent interview and record review, on 4/24/23, at 3:28 p.m., with RN A, the facility's current Nursing Drug Handbook, dated 2021, was reviewed. It indicated, Potassium Chloride: Oral dosage forms should be taken with meals and a full glass of water . RN A reconfirmed Resident 38 was given approximately 120 ml of water and stated One full glass was 240 ml. That was good to know. 2. During a medication pass observation for Resident 274 on 4/24/23, at 8:42 a.m., registered nurse B (RN B) was observed administering 12 medications, which included ferrous sulfate (iron, used to treat or prevent low blood levels of iron) tablet and calcium (used to treat or prevent low blood levels of calcium) tablet. During a concurrent interview and record review with RN B on 4/24/23, at 3:19 p.m., she reviewed Resident 274's clinical record and stated Resident 274 was given iron and calcium at the same time since 4/14/23. When asked if there were any concerns with iron and calcium administered at the same time, RN B stated, Calcium could inhibit the absorption of iron, should move to a different time. On 4/24/23, a review of Resident 274's clinical record indicated the following physician's orders: - ferrous sulfate tablet 325 milligrams (mg unit of measurement), 1 tablet oral, give between 9:30 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056058 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 056058 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2023 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)

F 0759 to 10 am once a day, dated 4/14/23; Level of Harm - Minimal harm or potential for actual harm - calcium tablet 500 mg, 1 tablet oral twice a day, dated 4/14/23. Residents Affected - Few During a telephone interview on 4/26/23, at 9:47 a.m., with the consultant pharmacist (CP), she stated iron and calcium should have not be given at the same time because calcium could decrease absorption of iron, and I would recommend nurses to separate by two hours. A review of Lexicomp Online, indicated for calcium tablet, Drug interactions . Iron Preparations: [calcium] may decrease the absorption of Iron Preparations . Consider separating doses of oral iron and [calcium] in patients who require chronic use of both agents and monitor for reduced iron efficacy. Risk D [a high risk level]: Consider therapy modification. During a review of the facility's policy and procedures titled, Oral Medication Administration (undated), it indicated, 8. Offer plenty of drinking water .if not contraindicated . Note manufacturer's specifications for administering medications with adequate fluids. For example . potassium supplements. 9. Administer medications . according to the manufacturer's specification. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056058 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 056058 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2023 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)

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 ensure proper medication storage and labeling of medications in two of two medication carts inspected when: 1. Medication Cart 3 contained two (2) expired medications and one (1) test strip (thin plastic strips which measures blood sugar levels) vial opened without an open date label; 2. Medication Cart 1 contained one (1) expired medication and one (1) test strip vial opened without an open date label. The deficient practices had a potential for residents to receive unsafe and ineffective medications (reduced potency) from being used past their discard (expiration) date and not being removed from active stock. Findings: 1. On 4/24/23 at 10:36 a.m., an inspection of Medication Cart 3 with licensed vocational nurse C (LVN C) identified: a. one opened and expired Rocklatan (used to treat glaucoma) eye drop bottle, dated opened on 3/9/23; b. one opened and expired medication inhaler Trelegy Ellipta (medication for lung disease), dated opened on 3/1/23; c. one test strip (material for testing blood sugar) vial was opened but did not have an open date label. A review of the manufacturer's labeling for Rocklatan with LVN C indicated to discard opened bottle after 6 weeks. A review of the labeling from the manufacturer for Trelegy Ellipta with LVN C indicated to discard it 6 weeks after opening the foil tray or when the counter reads 0 (after all blisters have been used), whichever comes first. A review of the labeling from the manufacturer for the test strips with LVN C indicated the test strips should have been used within six months after opened. LVN C confirmed the Rocklatan eye drops expired on 4/20/23 (6 weeks after opening); and the Trelegy Ellipta inhaler expired on 4/12/23. LVN C said it was important not have expired medications in the cart because the medications might not work. Additionally, LVN C verified the opened test strip vial was not labeled with an open date. 2. On 4/24/23 at 11:13 a.m., an inspection of Medication Cart 1 with registered nurse A (RN A) identified one expired Narcan (used to reverse opioid overdose) medication. RN A confirmed the Narcan medication was expired in December 2021 and said it should have been removed from the medication cart. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056058 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 056058 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2023 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)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Additionally, one opened test strip vial did not have an open date label. RN A verified the opened test strip vial was undated and stated she could not tell when the test strips expired. A review of the labeling from the manufacturer for the test strips with RN A indicated they should have been used within six months after opened. During a telephone interview on 4/26/23, at 9:47 a.m., with the consultant pharmacist (CP), she stated nurses should have check medication carts daily and remove expired medications from the carts. She said if a resident received expired medication, We don't know how efficacious it [the medication] would be. During a review of the facility's policy and procedures (P&P) titled, Storage of Medication, dated January 2023, the P&P indicated, Outdated .medications .are immediately removed from stock, disposed of .and reordered from the pharmacy . During a review of the facility's P&P titled, Medications and Medication Labels, dated May 2016, the P&P indicated, Multi-dose vials shall be labeled to assure product integrity, considering the manufacturer's specifications . Nursing staff should document the date opened on multi-dose vials on the attached auxiliary label. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056058 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 056058 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2023 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)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 facility document review, the facility failed to ensure food was stored and distributed and the kitchen floor was maintained in accordance with professional standards for food service safety when: 1. The resident food refrigerator was found out of the safe temperature range; 2. Multiple resident meal trays had crack, rough edges; 3. The floor below the dish machine had two broken tiles; and 4. The ice machines had rough whitish build up on parts. These failures had the potential to cause the growth of microorganisms or attract pests which could cause foodborne illness or cross contaminate food or ice (cross contamination occurs when unclean surfaces or utensils spread germs to food and could potentially cause foodborne illness) for the 68 residents eating at the facility. Findings: 1. During an observation on 4/24/23 at 8:33 a.m., the resident food refrigerator had one bag of shredded cheese inside. The two thermometers inside the refrigerator read 48 F (degrees Fahrenheit - a unit of temperature measurement) and 47 F and the cheese was 46 F. During a concurrent interview at that time, the director of nursing (DON) confirmed the observations and stated the refrigerator should have been 41 F or less and it was not safe to store foods in the refrigerator until the temperature gets down. During an observation and concurrent interview on 4/24/23 at 9:47 a.m., with the dietary services supervisor (DSS), the resident refrigerator was 48 F and there was no food inside and no sign on the outside saying not to use the refrigerator. DSS confirmed the observation. A review of facility document titled Temperature Log (for food) - Once Daily, undated, indicated Normal refrigerator temperature: 35-41 F (Fahrenheit) and Notify maintenance if temperature, ref (refrigerator) in nursing unit, was not within range. 2. During an observation on 4/25/23 at 11:12 a.m., approximately 80 pink resident meal trays were stacked by the trayline (equipment where hot foods for resident meals are served from). Approximately half of the pink meal trays had cracks on their corners, and most had chips and were rough to touch on the corners. Some cracks were large enough that the inside of the tray could be seen and white or black residue was in some cracks. During an interview at that time, the dietary services supervisor (DSS) confirmed the observation and said he is replacing the meal trays bit by bit. He pointed to approximately 20 maroon colored meal trays on the shelf below and stated he bought those to replace some of the cracked trays. During an observation on 4/25/23 at 11:54 a.m., during the lunch meal service in the kitchen, the pink trays from the stack described above were used for the resident lunch service. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056058 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 056058 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2023 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)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of facility document titled, Meal Service, dated 2023, indicated Plates and serving equipment; plates, cups, silverware, special feeding devices, that are chipped or unsightly will be discarded. According to the 2022 Food and Drug Administration (FDA) Food Code, non-food-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris and shall be free of unnecessary ledges, projections, and crevices. Non-food contact surfaces of equipment that are exposed to splash, spillage, or other food soiling or that require frequent cleaning shall be constructed of a corrosion-resistant, nonabsorbent, and smooth material and shall be cleaned at a frequency necessary to preclude accumulation of soil residues. The 2022 FDA Food Code Annex further explains that hard-to-clean areas could allow the growth of foodborne pathogenic microorganisms and the objective of cleaning is to remove soil from nonfood contact surfaces so that pathogenic microorganisms will not be allowed to accumulate. The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. 3. During an observation on 4/24/23 at 8:08 a.m., two floor tiles under the dishmachine were cracked and missing pieces of tile exposing the floor beneath and sharp edges, water pooled in the gaps. During a concurrent interview at that time, the DSS stated he had reported the broken tiles to maintenance department three weeks ago and they plan to replace the tile. During an interview on 4/24/23 at 3:28 p.m., the DSS stated when there are issues in the kitchen they usually put them in the maintenance binder but the broken tiles were not in the binder. The DSS stated he sent an email with a list of maintenance issues in the kitchen to the Administrator (Admin) a couple of weeks ago and he would normally discuss issues like this with the Admin in the morning meeting. Review of facility document titled Dietary Problems, undated, sent as an attachment to an email sent 4/11/23 to Admin, indicated among other issues: Tile needs repair (cracked). During an interview on 4/26/23 at 9:08 a.m., the maintenance supervisor (MS) stated he was not aware of the broken tiles in the kitchen. He said usually the kitchen communicates maintenance issues to him through the maintenance binder, but broken tiles were not in the binder. He further stated sometimes the kitchen tells him issues verbally. During a concurrent observation and interview at that time in the kitchen, the MS confirmed there were two broken tiles under the dishmachine and they needed to be fixed. According to the 2022 FDA Food Code, floors shall be designed, constructed, and installed so they are smooth and easily cleanable. The 2022 FDA Food Code defines smooth as a floor, wall, or ceiling having an even or level surface with no roughness or projections that render it difficult to clean. The Food Code Annex further explains that floors that are of smooth, durable construction and that are nonabsorbent are more easily cleaned. Requirements and restrictions regarding floor coverings are intended to ensure that regular and effective cleaning was possible and that insect and rodent harborage was minimized. 4. During a concurrent observation and interview in the presence of the DSS on 4/24/23 at 9:51 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056058 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 056058 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2023 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)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some a.m., at the ice machine in the kitchen, the MS stated he cleans the ice machine every month and the instructions for cleaning are inside the door of the machine. The MS said he empties the ice bin then cleans with warm water. He said he uses the descaler/cleaner (used to remove lime scale and mineral deposits which are a buildup of a white, chalk-like substance that forms where water collects or where water is dispensed) solution with the warm water, but does not use a sanitizer after cleaning. The MS removed the cover over the ice making part of the machine and inside the cover was a white, rough, crusty build-up that could be scraped off with a fingernail. The DSS confirmed the observation. The DSS stated the ice machine cleaning vendor just cleaned and sanitized the ice machine one to two weeks ago. The vendor cleans the machine every three to six months. The vendor was not able to remove the white build-up on the ice maker cover when they were here. During a concurrent observation and interview in the presence of the DSS on 4/24/23 at 10:07 a.m., at the dispenser ice machine in the nursing unit, the ice dispenser chute had a white, crusty ring around the bottom. The DSS confirmed the observation. The MS stated he cleans this machine with warm water and does not use a descaler/cleaner or sanitizer. He last cleaned it last month and he does not have the manufacturer's instructions for how to clean and sanitize the machine. The MS was not able to open up the machine so the inside could be seen. The DSS stated the ice machine cleaning vendor said this machine looked clean when they were here so they did not clean it and that they can only clean the outside. Review of facility documents Invoices from the ice machine cleaning vendor dated 1/30/23 and 4/20/2023 indicated the vendor cleaned the ice machine in kitchen on these dates, but did not have any information regarding the ice machine at the nursing station. During an interview on 4/24/23 at 1:50 p.m., the DSS stated the maintenance department does not have logs for either ice machine for when ice machine cleaning was done by them. During an interview on 4/26/23 at 9:08 a.m., the MS stated he was not trained at the facility on how to clean the ice machines; he studied air conditioning in school so he already knew how to clean ice machines. Review of facility document titled 'Sanitation and Infection Control Subject: Cleaning Ice Machine', dated 2023, indicated ice machines will be cleaned and sanitized once a month, follow manufacturer recommendations to clean the internal mechanisms of the ice machine, and if another department is responsible for cleaning the ice machine, make sure the process is being followed according to policy for technique and time frame. The individual responsible must be properly trained by the manufacturer with approved competency. Review of facility documents (for the kitchen ice machine) titled 'Air/Water/Remote Condenser Ice Machines Technician's handbook' and 'Cleaning/Sanitizing Procedure' (from inside the door of kitchen ice machine), undated, indicated cleaning/sanitizing procedure removes mineral deposits from areas or surfaces that are in direct contact with water; ice machine cleaner is used to remove lime scale and mineral deposits, and depending upon the amount of mineral build-up, a larger quantity of (cleaner) solution may be required. Review of facility document (for the nursing station ice machine) titled 'Ice and Water Dispensers Operation and Service Manual', dated 2/13, indicated the recommended cleaning procedures that follow should be performed at least as frequently as recommended and more often if environmental conditions dictate - drain line - weekly, drain pan/drip pan weekly, exterior as needed, condenser monthly, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056058 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 056058 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2023 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)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete dispenser and components, ice machine, transport tube, ice storage/bin - semi-annually. The manual further indicated cleaning of the condenser can usually be performed by facility personnel, and cleaning/descaling and sanitizing of the ice machine system should be performed by your facility's trained maintenance staff or a [Brand] authorized service agent. The manual further indicated a 38-step process for cleaning/descaling and sanitizing the machine semi-annually but more often if conditions dictate and indicated to use the manufacturer's ice machine cleaner/descaler and sanitizing products, a process for cleaning/ descaling and sanitizing the ice machine, and a process for cleaning/descaling and sanitizing the dispenser. Event ID: Facility ID: 056058 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 056058 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2023 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)

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 maintain proper infection control practices when: Residents Affected - Some 1. Resident 17's suction tubing and canister were undated; 2. The wound care nurse (WCN) placed Resident 172's urine bag on his bed and let it touching the floor, opened Resident 172's night stand with contaminated gloved hand, and asked certified nursing assistant L (CNA L) to hold the clean dressing on Resident 172's left heel wound with her contaminated gloved hand; 3. Speech therapist (ST) did not practice standard precautions; 4. CNA did not use proper personal protective equipment (PPE) for contact precautions; 5. CNA wore PPE in the hallway and disposed of a unsealed trash bag from the contact isolation room on the storage room floor. 6. Registered Nurse B (RN B) failed to disinfect the rubber stopper of a medication vial before inserting the adaptor (a device) to dilute the medication; and 7. RN B did not properly dispose of personal protective equipment (PPE, gown and gloves) in the dedicated receptacle for one resident (Resident 274) with contact precautions (anyone entering the room is required to wear a gown and gloves). These failures have the potential to result in transmission of infection among residents. Findings: 1. Review of Resident 17's admission Record indicated she was admitted to the facility on [DATE] with pneumonitis (inflammation of the lungs) diagnosis. Review of Resident 17's physician order indicated she had an order for oral suction as needed for excessive secretion, started on 2/25/23. During an observation and interview with registered nurse A (RN A) on 4/24/23 at 9:21 a.m., Resident 17's suction tubing and canister were undated. RN A stated Resident 17's suction tubing and canister should be dated. During an interview with the infection preventionist (IP) on 4/28/23 at 2:05 p.m., she stated the suction tubing and the canister should be dated. Review of the facility's undated policy, Cleaning and Disinfecting Emergency Suction Equipment, indicated Procedure: . 3. Discard suction catheter, disposable canister, and tubing into designated receptacle if the canister is 3/4 full of secretions and no longer than weekly replacements. 2. Review of Resident 172's admission Record indicated he was admitted to the facility on [DATE] with diagnoses including sepsis (a serious condition in which the body responds improperly to an (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056058 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 056058 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2023 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)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some infection) and pressure ulcer (damage to an area of the skin caused by constant pressure on the area for a long time). During a wound treatment observation with the WCN and CNA L on 4/26/23 at 10:50 a.m., the WCN started the pressure ulcer treatment on Resident 172's sacrum (the large, triangle-shaped bone in the lower spine that forms part of the pelvis) and left heel by picked up Resident 172's urine bag which was hung on his bed side and put it on Resident 172's bed. While cleansing Resident 172's wound on his sacrum, the WCN noticed Resident 172 had feces at his anus area. The WCN wiped the feces with gauzes then opened Resident 172's night stand and got the wipe package with his gloved contaminated hand and asked CNA L to cleanse Resident 172's anus area. After cleansing and applying treatment and the clean dressing on Resident 172's left heel, the WCN needed to cut the abdominal pad, so he asked CNA L to hold the clean dressing on Resident 172's left heel with the same gloved hand that she turned Resident 172, held him, wiped his anus area, and put on the diaper for him. After the treatments were done, CNA L picked up the urine bag on Resident 172's bed and handed to the WCN. Instead of hanging the urine bag on the bed side, the WCN let it freely hung down from Resident 172's bed, and the urine bag was touching the floor. During an interview with the WCN on 4/26/23 at 11:45 a.m., he stated the urine bag should not be placed on the resident's bed and should not be touching the floor. The WCN stated he should remove the gloves and cleanse his hands before opening Resident 172's night stand for the wipe package, and CNA L should have remove the gloves and cleanse her hands before holding the clean dressing on Resident 172's left heel wound. During an interview with the infection preventionist (IP) on 4/28/23 at 2:02 p.m., she stated the urine bag should not be placed on the resident's bed and should not be touching the floor. The WCN should have remove the gloves and cleanse his hands before opening Resident 172's night stand, and CNA L should have remove the gloves and cleanse her hands before holding on the clean dressing on Resident 172's left heel wound. Review of the facility's undated policy, Standard Precautions, indicated Procedure: . 4. Gloves: . Remove gloves promptly after use, and wash hands immediately before touching non-contaminated items and environmental surfaces, and before going to another resident. Review of the facility's undated policy, Indwelling Catheter Care, indicated Fundamental Information: Maintenance: . Keep the drainage tube and collection bag lower than bladder at all times . Procedure: . 18. Attach collection bag, below bladder level, to bed frame. 3. During an observation on 4/24/23 at 12:37 p.m., ST G came out of one resident room with a coffee cup. ST G put the cup on top of the meal tray cart and entered another room without hand hygiene. During an interview with ST G on 4/24/23 at 12:38 p.m., ST G confirmed the observation and stated she should have performed hand hygiene after touching the cup. During an interview with infection preventionist (IP) on 4/28/23 at 2:11 p.m., she stated facility staff should perform hand hygiene after contact with any subject. Review of the facility's undated policy Standard Precautions, indicated, All employees are expected to practice standard precautions to reduce both the risk of transmitting infections and the likelihood of exposure to bloodborne pathogens. Wash hands after touching or coming in contact with blood, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056058 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 056058 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2023 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)

F 0880 body fluids, secretions, excretions and contaminated items. Level of Harm - Minimal harm or potential for actual harm 4. During an observation on 4/24/23 at 12:43 p.m., CNA H entered one resident room on contact precaution to distribute a lunch tray without gloves and/or a gown. The signage for contact precaution was placed on the room door, and a personal protective equipment (PPE) cabinet was placed next to the room door. Residents Affected - Some During an interview with licensed vocational nurse I (LVN I) on 4/24/23 at 12:43 p.m., he confirmed the observation. LVN I stated CNA H should have used proper PPE for contact precautions, like gloves and a gown, when entering the room. During an interview with CNA H on 4/24/23 at 12:45 p.m., he confirmed the observation and stated he did not know the room was on contact precaution. CNA H stated he should have used gloves and gown when entering the room. Review of the facility's undated policy Transmission Precautions: Contact, indicated, Wear clean, non-sterile gloves when entering the room. Wear a clean, non-sterile gown upon entering the resident's room. 5. Review of Resident 274's clinical record indicated he was admitted on [DATE] and had the diagnoses, including bacteremia (the presence of bacteria in the bloodstream). A review of Resident 274's physician order, dated 4/17/2023, indicated resident was on contact isolation from 4/17/2023 to 5/3/2023 for MDRO (a multidrug-resistant organism resistant to many antibiotics) enterobacter urinary tract infection. During a concurrent observation and interview with the infection preventionist (IP) on 4/25/2023 at 11: 25 a.m., in the hallway. The Certified Nursing Assistant O (CNA O) was walking in the hallway with full PPE (equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses), including a gown, a head cover, and a pair of gloves and shoe covers. She held a trash bag, opened the storage room with her gloved hand, and threw the trash bag on the floor. The IP stated that CNA O should not wear any PPE in the hallway. She further stated that the shoe covers contaminated the hallway floor, and the glove contaminated the storage doorknob, potentially spreading infection in the facility. During an interview with the CNA O on 4/25/2023 at 11:33 a.m., she stated that she came into Resident 274's contact isolation room to pick up the trash and should have taken off the PPE before leaving the isolation room. She further stated that she might spread germs to the facility. During a concurrent observation and an interview with IP P on 4/25/2023 at 11:43 a.m., in front of the storage room. Observed the trash bag from 274's isolation room was on the floor and open to the air. IP P verified the above observation and stated Resident 274 was on contact isolation for MRSO, and the staff Should seal the trash bag and should not dispose of the trash bag on the floor. During an interview with the Director of Nursing (DON) on 4/28/2023 at 2:06 p.m., the DON stated that the CNA should have sealed the wastes from the contact isolation room in a plastic bag and disposed of it in a trash can with a lid to prevent spreading of infectious and contiguous disease. A review of the facility's undated policy and procedure titled Personal Protective Equipment (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056058 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 056058 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2023 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)

F 0880 Guidelines, indicated, remove PPE after it becomes contaminated, and before leaving the work area. Level of Harm - Minimal harm or potential for actual harm A review of the facility's undated policy and procedure titled Standard Precautions, indicated, remove gloves promptly after use, and wash hands immediately before touching non-contaminated items and environmental surfaces, and before going to another resident Residents Affected - Some A review of the facility's undated policy and procedure titled wastes and cleaning practices, indicated, seal waste materials from regulated waste receptacles in regulated waste collection boxes. 6. During a medication pass observation for Resident 274 on 4/24/23, at 8:53 a.m., registered nurse B (RN B) was observed preparing an intravenous (IV, a way of giving a drug through a needle or tube inserted into a vein) medication, ceftriaxone (an antibiotic used to treat infections). RN B did not wipe the medication vial's rubber stopper after she removed the cap, proceeded to insert the adapter to the medication vial, and connected the saline (diluent) bag to the adapter. During an interview on 04/24/23, at 9:14 a.m., with RN B, she stated the medication vial is clean because it's covered with the cap. She stated, We clean if vial was opened like for insulin [used to treat diabetes], we clean top of vial before drawing insulin, but this one is covered with cap so I believe it's clean .not open to air. That is my understanding and that is the way we are doing it. On 4/24/23, a review of Resident 274's clinical record indicated a physician's order, dated 4/21/2023, for ceftriaxone 2 g (grams, unit of measure) intravenous (directly into a vein) twice a day, dated 4/14/23. During an interview on 4/25/23, at 8:58 a.m., with the infection preventionist (IP), she stated, nurses need to wipe the top of medication vials with alcohol and then they can poke it [with the adapter] even if there is a cap. The Association for Professionals in Infection Control and Epidemiology (APIC) is the leading professional association for infection preventionists. According to the APIC Position Paper On Safe Injection, Infusion, And Medication Vial Practices In Healthcare, dated January 2016, it indicated, Medication Vials . Disinfect the rubber septum on all vials prior to each entry, even after initially removing the cap of a new, unused vial. (https://www.apic.org/Resource_/TinyMceFileManager/Position_Statements/2016APICSIPPositionPaper.pdf) 7. During a medication pass observation for Resident 274 on 4/24/23, at 8:53 a.m., RN B was observed administering an IV medication, ceftriaxone. RN B left Resident 274's room to obtain new tubing (flexible plastic tube connected to the saline bag that delivers the IV medication into the vein), removed her gloves and gown, placed in the trash can next to resident's bedside. On 4/24/23 at 9:08 a.m., during the same medication pass observation, RN B returned to Resident 274's room with new tubing after re-gowned and new gloves. RN B programmed the IV medication pump (medical device that delivers medications into the body in controlled amounts) to deliver the IV medication, removed her gloves and gown, and placed into the trash can next to resident's beside again. During an interview on 4/24/23, at 9:14 a.m., with RN B, she stated, the PPE are supposed to be discarded in the proper receptacle. She continued, I put in the garbage bag, but I'm supposed to put in the covered trash can. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056058 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 056058 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2023 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)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of the signage affixed on Resident 274's room door indicated, CONTACT PRECAUTIONS EVERYONE MUST . Put on gown before room entry. Discard gown before room exit . Use dedicated or disposable equipment. During an interview with the IP on 4/25/23, at 8:58 a.m., she stated, nurses should use the black trashcan inside the room with a lid that was the designated receptacle for PPE, they cannot put [PPE] into the resident's trash can. During a review of the facility's policy and procedures titled Personal Protective Equipment (PPE) Guidelines, dated 2/7/22, it indicated, How to take off (Doff) PPE gear . Remove gown .dispose in trash receptacle. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056058 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 056058 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2023 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)

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 ensure one of six residents (Resident 51) received pneumococcal vaccinations based on the facility's policy. This failure had the potential to expose the resident to pneumococcal infections (caused by common bacteria [streptococcus pneumonia] that can affect different parts of the body). Residents Affected - Few Findings: Review of Resident 51's clinical record indicated he was admitted to the facility on [DATE]. Review of Resident 51's Pneumococcal Vaccination Consent Form dated 6/24/22 indicated, responsible party (RP, person who is accountable in making decision on behalf of the resident) consented for the pneumococcal vaccine to be given. Review of the immunization list provided by the facility, indicated Resident 51 did not have the pneumococcal vaccine. During an interview with infection preventionist (IP) on 4/26/23 at 10:44 a.m., she confirmed the pneumococcal vaccine was not followed up. The IP acknowledged the pneumococcal vaccine should have been given to the resident. Review of the facility's undated policy, Pneumococcal Vaccine indicated, All residents will be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. Pneumococcal vaccines will be administered to residents (unless medically contraindicated, already given, or refused) per our facility's physician-approved pneumococcal vaccination protocol. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056058 If continuation sheet Page 32 of 32