Health inspection·January 28, 2025

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to ensure resident's care needs were accommodated for one of six sampled residents (Resident 37) when Resident 37's call light /button (a button device used to request assistance) was not within reach to use. Residents Affected - Few This failure had the potential to affect the resident's ability to request for prompt assistance and help. Findings: Review of Resident 37's Face Sheet (a document that contains a summary of a patient's personal and demographic information) indicated, Resident 37 was admitted to the facility with diagnoses including Parkinsonism (a disease that include symptoms of slowness of movements, muscle rigidity, involuntary tremors/shaking and impaired balance and posture), vascular dementia (decline in mental capacity affecting daily function), and rhabdomyolysis (a breakdown of muscle tissue). Review of Resident 37's Admission's Minimum Data Set (MDS, assessment tool) assessment, dated 12/5/2024, indicated Resident 37's brief interview for mental status (BIMS, cognition level) score was 9 (moderate cognitive impairment). During a review of Resident 37's Care Plan dated 08/08/2023, updated on 01/19/2025, indicated The resident is at risk for falls related to history of falls and balance problem, and with intervention reflected, Keep environment free of hazards, clutter free, call light within reach. During an observation and interview on 1/21/25 at 11:22 a.m., in the room of Resident 37. Resident 37 was awake and sitting in his wheelchair next to his bed. Resident 37 was observed repeatedly verbalizing, I can't find my call light. Can somebody help me find my call light? During an observation and concurrent interview on 1/21/25 at 11:30 a.m. with Certified Nursing Assistant (CNA) B, CNA B was observed searching the bed of Resident 37 and the surrounding area, then was observed removing Resident 37's call light from the surface of the bed of Resident 37' s roommate and attaching the call light onto Resident 37' s bed. CNA B stated, The call light should not be over there. It should be on Resident 37's bed. During an interview on 1/27/25 at 3:30 p.m. with the Director of Nursing (DON) the DON stated, Resident's call lights should be within their reach not on floors or on another resident's bed. A review of the facility's policy and procedure titled, Call Lights-Answering Of dated 3/21/2024, indicated, .7. When leaving the room, ensure that the call light is placed within the resident ' s reach. Maintain Resident ' s Safety. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056058 If continuation sheet Page 2 of 12 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 01/28/2025 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 0584 Level of Harm - Minimal harm or potential for actual harm Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observation, interview, and record reviews, the facility failed to maintain a safe and functional environment when: Residents Affected - Some 1. The toilet in Resident 9's room was clogged; 2. Resident 9's bathroom call light was broken; and, 3. The facility's three of four shower rooms had multiple broken tiles. These failures compromised residents' safety, well-being, and access to a properly maintained living environment. Findings: 1. During an observation and concurrent interview on 1/21/25, at 2:50 p.m., in Resident 9's room, a sign near the toilet indicated it was out of order. Resident 9 stated that the toilet had been clogged for weeks and that he had reported it to the staff. The Director of Nursing (DON), who was nearby immediately reported the issue to the Maintenance Director (MD) F. 2. During an observation and concurrent interview on 1/24/25, at 3:00 p.m., the bathroom call light in Resident 9's room was observed to be broken. Licensed Vocational Nurse (LVN) N confirmed that the call light was not working and reported it to the maintenance staff. During an interview on 1/28/25, at 9:50 a.m., the MD F stated he conducted daily rounds, but his rounds had not identified any broken call lights. The MD F state he did not document his daily maintenance checks. Review of facility's policy, titled, Call Lights-Answering Of dated 3/21/24, indicated, .Preventive Maintenance program is in place for monitoring of the call light system . 3. During an observation on 1/22/25, at 12:27 p.m., multiple broken tiles were observed in three of four shower rooms the facility. During a concurrent observation and interview on 1/28/25, at 10:02 a.m., the MD F confirmed awareness of the above issue and stated he planned to replace the tiles. The MD F also stated he was currently fixing Resident 9's toilet. Review of an undated facility's policy, titled, Physical Plant Interior Maintenance, indicated, .Interior maintenance of the physical plant is an essential function of the preventive maintenance program to assure employee and resident safety .Check all areas of ceramic/vinyl flooring for repairs and cleanliness. Repair/report all damaged areas . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056058 If continuation sheet Page 3 of 12 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 01/28/2025 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 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to maintain and meet current standards of nursing practice when, the medication was not administered according to the physician's order for one of 10 residents (Resident 65). This failure could potentially result in complications of the residents' medical conditions. Residents Affected - Few Findings: During medication administration observation on 1/22/25 at 10:12 a.m., Licensed Vocational Nurse (LVN) A prepared seven medications for Resident 65. The medications included one tablet of aspirin (blood thinner that lowers risk of blood clots) 81 mg (mg, unit of measure), one tablet of docusate sodium (stool softener) 100 mg, one tablet of clopidogrel (an antiplatelet blood-thinning medication) 75 mg, one tablet of loratadine (medication that relieves upper respiratory allergies) 10 mg, 1 tablet of losartan (medication used to lower blood pressure) 75 mg, one tablet of Tradjenta (medication used to control blood sugar levels in the blood) 5 mg and metformin (medication used to control blood sugar levels) 1000 mg. During an observation of medication administration on 1/22/25, at 10:12 a.m., LVN A administered seven medications to Resident 65. Resident 65 swallowed one to two of the tablets at a time with sips of water provided by LVN A. Review of Resident 65's Physician Order Report dated 1/3/2025 indicated to administer metformin tablet 1000 mg; 1 tab; Special Instructions: For diabetes, administer with meals twice a day; 8:00 a.m, 6:00 p.m. A review of Resident 65's medication administration record (MAR) showed LVN A documented for the 8:00 a.m. metformin 1000 mg administration on: 1/22/25 given late at 10:12 a.m. During an interview and record review for Resident 65 on 1/28/25 at 9:05 a.m. with LVN A, LVN A stated metformin should be given with meals or at least thirty minutes after eating food. LVN A also stated Resident 65 was served breakfast between 7:00 a.m. to 7:30 a.m. on the morning of 1/22/25 and verified there were no snacks offered to Resident 65 before administering the metformin. During an interview on 1/28/25 at 9:15 a.m. with the Director of Nurses (DON), the DON stated it is her expectation that all nurses give medications according to physician orders and facility policy. Review of the facility's policy titled, Oral Medication Administration undated, indicated, .9. Administer medications with food according to the Physician's Order or manufacturer's specification. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056058 If continuation sheet Page 4 of 12 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 01/28/2025 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide proper oxygen (a colorless, odorless gas) care and treatment services for four of 18 sampled residents (Residents 168, 60, 268, and 29) when: Residents Affected - Some 1. Resident 168 had an oxygen concentrator (a portable device that provides oxygen) at the bedside, but there was no oxygen signage posted on the door. 2. Resident 60 had an oxygen concentrator at the bedside, but there was no oxygen signage posted on the door. 3. Resident 268 had an oxygen concentrator at bedside, but the nasal cannula had no label, and no oxygen signage posted on the door. 4. Resident 29 had an oxygen concentrator at the bedside, but there was no oxygen signage posted on the door. This deficient practice had the potential to for accidents and hazards that could pose harm to residents in the facility. Findings: 1. During an observation on 1/21/25, at 10:20 a.m., Resident 168 was lying in bed, asleep, with a nasal cannula (NC, device placed in the nostril used to deliver oxygen) delivering oxygen attached from a running oxygen concentrator. There was no oxygen signage posted on Resident 168's door. 2. During an observation on 1/22/25, at 10:40 a.m., Resident 60 was lying in bed, with a NC delivering oxygen attached from a running oxygen concentrator. There was no oxygen signage on Resident 60's door. During a concurrent interview, Licensed Vocational Nurse (LVN) N stated that an Oxygen in Use sign should be posted on the doors of Resident 168 and 60. 3. During an observation on 1/21/25 at 1:58 p.m., Resident 268 was lying in bed asleep, with a nasal cannula delivering oxygen attached from a running oxygen concentrator. The nasal cannula had no label. There was no oxygen signage posted on Resident 268's door. During an interview on 1/21/25 at 2:07 p.m., with LVN M, she confirmed the above observation and stated the nasal cannula should be labeled with date and time, and there should be a signage posted at the door. During an interview on 1/27/25 at 11:12 a.m., with the DON, the DON stated there should be labeling on the oxygen tubing and signage by the door for residents receiving oxygen. 4. Review of Resident 29's medical record indicated Resident 29 was admitted on [DATE] with diagnoses including anemia (low number of red blood cells), spondylosis (wear and tear of the bones of the spine[backbone]), atrial fibrillation (an irregular heart rhythm which can lead to blood clots and stroke), and peripheral vascular disease (a blood vessel disorder that affects blood circulation). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056058 If continuation sheet Page 5 of 12 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 01/28/2025 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of Resident 29's Physician Order Report dated 11/21/24 indicated an order for oxygen support via nasal cannula (a device used to deliver supplemental oxygen or airflow) at 2 liters as needed. During an observation on 1/21/25 at 10:11a.m., Resident 29 was in her room sitting up in bed receiving oxygen via nasal cannula. There was no No Smoking sign posted at the entrance of or anywhere inside Resident 29's room. During an observation and interview on 1/27/25 at 11:18 a.m. with the Director of Nursing (DON) outside of Resident 29's room the DON verified no oxygen signage posting outside the room or anywhere inside the room of Resident 29. The DON stated there should be an Oxygen in Use and/or a No Smoking sign posted on the door of every resident receiving oxygen therapy. Review of the facility's policy titled Oxygen Administration, undated indicated, Post an oxygen precaution (No Smoking) sign on the resident's door. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056058 If continuation sheet Page 6 of 12 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 01/28/2025 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 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure safe food storage practices and sanitary conditions in the kitchen when: Residents Affected - Some 1. Kitchen staff did not wear hair restraints while in the kitchen, 2. Five of seven green peppers were wrinkled and soft, one of 3 cucumbers soft, 3. Three opened spice containers and one vanilla extract bottle with expired dates, 4. Three of eight cutting boards had deep cut marks on their surface, and 5. Two of 18 cans of sliced peaches, one of 12 cans of sliced pears, one of 6 cans of fruit cocktail were dented, and one of three cans of nacho cheese sauce with expired date of 12/23/24, in the emergency food supplies. These failures had the potential to cause food contamination and spread food-borne illness to residents who received their food from the kitchen. Findings: 1. During a concurrent observation and interview on 1/21/25 at 11:50 a.m., with the Dietary Manager (DM), the DM was wearing a head covering brown in color and not covering whole hair while in the kitchen going in and out of the walk-in freezer. The DM stated she does not need to cover whole hair because she was not doing meal prep or in the tray line. During an interview on 1/22/25 at 1:41 p.m., with the Infection Preventionist (IP) G, the IP G stated anyone who enter the kitchen, hairnet must be worn under the hat or own covering. During a concurrent observation and interview on 1/27/25 at 7:12 a.m., with the DM, the DM confirmed that one of the cooks (CK E) was not wearing a hairnet under the visor cap. Review of the facility's policy and procedures (P&P) titled Food Handling Practices, undated, indicated Practice good personal hygiene: restrain hair appropriately. Review of the Food and Drug Administration's (FDA) Food Code 2022 Chapter 2-402, indicated food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food, clean equipment, utensils, lines, and unwrapped single service and single-use articles. 2. During a concurrent observation and interview on 1/21/25 at 12:03 p.m., with the DM, the DM confirmed the green peppers and cucumber were wrinkled and soft. The DM stated the produce are still good because it will be cooked and not served raw or added in salads. The DM also stated the wrinkles will go away once it was cooked or placed in water. During a review of the facility's P&P, titled Food Storage Principles, undated, indicated proper (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056058 If continuation sheet Page 7 of 12 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 01/28/2025 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 food storage is essential for preserving food quality. Level of Harm - Minimal harm or potential for actual harm 3. During a concurrent observation and interview with Administrator (ADM) B, on 1/22/25 at 8:47 a.m., ADM B confirmed three spice containers, and one vanilla extract bottle were expired as follows: Residents Affected - Some a. Ground Thyme with best by date 9/1/24. b. Tarragon Leaves with best by date 11/29/24. c. Ground Allspice with best by date 11/18/24. d. Vanilla Extract with best by date 12/25/24. ADM B stated the spices, and vanilla extract should be thrown away when expired or past best by date. During a review of the facility's P&P, titled Food Storage Principles, undated, indicated Discard foods that have exceeded their expiration date. 4. During a concurrent observation and interview with ADM B on 1/22/25 at 8:50 a.m., ADM B confirmed the three cutting boards had deep cut marks on their surfaces. The ADM B stated they should have been thrown away when they got new cutting boards. Review of the The Federal Food and Drug Administration (FDA) Food Code 2022 Chapter 4-501.12, indicated surfaces such as cutting blocks and boards that are subject to scratching and scoring shall be resurfaced if they can no longer be effectively cleaned and sanitized. 5. During a concurrent observation and interview on 1/23/25 at 2:14 p.m., with the DM in the emergency food supply storage room, the DM confirmed the above observation and stated it will not be used and will be thrown out. During a review of the facility's P&P, titled Food Storage Principles, undated, indicated Discard foods that have exceeded their expiration date. Review of the The Federal Food and Drug Administration (FDA) Food Code 2022 Chapter 3-201.11, indicated rusted and pitted or dented cans may also present a serious potential hazard. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056058 If continuation sheet Page 8 of 12 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 01/28/2025 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 2. During an observation 1/22/25 at 9:00 a.m., housekeeper (HK) P was observed carrying a soiled curtain in the hallway without placing it in a plastic bag or a closed bin. HK P then entered the laundry room and stated that the curtain was dirty and should have been placed in a plastic bag before bringing to the laundry room. The curtain had visible yellow stains. Residents Affected - Some During an interview on 1/27/25 at 2:27 p.m., the Infection Preventionist (IP) G stated that facility policy requires staff to transport soiled linens, curtains, and towels in a closed bin or a plastic bag. The IP G further stated that heavily soiled items should be placed in a red hazard bag. Review of an undated facility's policy, titled, Soiled linen Collection & Transfer, indicated, .Laundry chutes may be used for transporting soiled linens . 3. During a concurrent observation and interview on 1/22/25 at 9:10 a.m., a breathing treatment mask was observed on top of Resident 64's bedside drawer, not stored in a plastic bag. The Licensed Vocational Nurse (LVN) N confirmed that the breathing treatment mask should be stored in a plastic bag to prevent contamination/ infection. During an interview on 1/27/25 at 2:40 p.m., IP G stated that breathing treatment masks should be changed every 72 hours, replaced if visibly dirty, and stored in a plastic bag when not in use. Review of an undated facility's policy,titled, Aerosol (Nebulizer) Therapy indicated, .Clean nebulizer once treatment is completed .place in plastic storage bag . Based on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when: 1. One Licensed Vocational Nurse (LVN) A failed to use the proper disinfectant (chemical liquid that destroys bacteria) to disinfect a shared (used for multiple residents) glucometer (blood glucose meter to measure and display the amount of sugar [glucose] in the blood) according to manufacturer's instructions and accepted professional standards for one resident; 2. One housekeeping staff failed to handle and transport dirty laundry properly; and 3. The facility staff failed to ensure proper storage of Resident 64's breathing treatment (nebulizer treatment, which involves inhaling a mist of medication through a device) mask. These failures could result in cross-contamination and the spread of infection throughout the facility. Findings: 1. During a medication pass observation on 1/22/25 at 12:13 p.m., LVN A was observed removing the glucometer (device used to measure level of glucose [sugar]) in the blood) from the drawer of the medication cart and wiped the glucometer with alcohol pads before obtaining the blood sugar reading for Resident 169. When finished LVN A wiped the glucometer with alcohol pads then placed the glucometer back in the drawer of the medication cart. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056058 If continuation sheet Page 9 of 12 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 01/28/2025 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 During an interview on 1/22/25 at 12:18 p.m. with LVN A, LVN A stated, I always use alcohol wipes to clean the glucometer for convenience. LVN A stated an in-service was conducted recently and was instructed to sanitize the glucometer with Clorox (a disinfectant) wipes or Sani-cloths (a germicidal disinfectant). During an interview with the Director of Nursing (DON), the DON stated she conducted an in-service in December of 2024 for all nursing staff members and a review was conducted on 1/21/25. The DON stated she instructed the staff to use the purple top canister of Super Sani cloths and Clorox wipes to clean all equipment used between residents. The DON stated the dwell time for both wipes is three minutes. The DON also stated she never instructed staff to use alcohol pads for cleaning of equipment because, It does not kill the bacteria. A review of the manufacturer's instructions titled, Medline-Evencare G2, Blood Glucose Monitoring System, indicated, .4. To disinfect your meter, clean the meter with one of the validated disinfecting wipes listed below: .Clorox Healthcare Bleach and Disinfectant Wipes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056058 If continuation sheet Page 10 of 12 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 01/28/2025 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to maintain an effective pest control program to keep the facility free of cockroaches and spiders when: Residents Affected - Some 1. Roach and spider carcasses were observed in the kitchen, 2. No monitor log for deep cleaning of resident rooms reported to have sighting of roaches, and 3. Facility did not follow their facility's plan of correction regarding pest control. These failures had the potential to cause health hazards and food borne illness to residents. Findings: 1. During a kitchen tour on 1/22/25 at 8:47 a.m., accompanied by Administrator (ADM) D, three traps with roach carcasses were observed on the side and under the ice machine, dated 11/17. One roach carcass was observed behind the plastic containers on one side of the kitchen wall. During a tour of the dry storage room on 1/22/25 at 9:23 a.m., with ADM D, one trap was observed with six carcasses of spiders, dated 9/17. In a concurrent interview with ADM D, ADM D confirmed the above observations and stated pest control company comes in weekly to place new traps. During an interview on 1/22/25 at 10:45 a.m., with Dietary Aide (DA) I, DA I stated she saw small roaches in the kitchen in August. DA I stated she reported the sighting to the supervisor. During an interview on 1/22/25 at 10:55 a.m., with the Dietary Manager (DM), the DM stated the pest control company instructed them not to remove the traps. The DM stated she will remove the trap with roaches and not remove if not roaches. During an interview on 1/22/25 at 10:48 a.m., with [NAME] (CK) J, she stated she saw alive and dead roaches three weeks ago. During an interview on 1/22/25 at 10:52 a.m., with CK K, the CK K stated she saw two dead roaches one month ago. During an interview on 1/23/25 at 2:41 p.m., with Pest Control Company (PCM), the PCM stated it is the judgement of the pest control staff if they will change or keep or replace the monitors. The PCM also stated if its still good, as in the glue still works, then they will not replace. During a review of the facility's Pest Control/Sightings Log, dated January 2025, indicated presence of roaches in the kitchen. During an interview on 1/23/25 at 1:07 p.m., with the DM, the DM verified the entries in the log. Review of the Food and Drug Administration's (FDA) Food Code 2022 Chapter 6-501.111 indicated The premises shall be maintained free of insects, rodents, and other pests. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056058 If continuation sheet Page 11 of 12 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 01/28/2025 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 0925 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the Food and Drug Administration's (FDA) Food Code 2022 Chapter 6-501.112 indicated Dead or trapped birds, insects, rodents, and other pests shall be removed from control devices and the premises at a frequency that prevents their accumulation, decomposition, or the attraction of pests. 2. During a concurrent observation and interview on 1/21/25 at 1:45 p.m., with Resident 32, in her room, Resident 32 stated she saw a live roach on 1/10/25 and 1/19/25. Resident 32 stated she reported the sightings to the staff. During a record review of the facility's Pest Control/Sightings Log for the month of January 2025, indicated the 1/19/25 report was not documented. During an interview on 1/22/25 at 4:17 p.m., with Maintenance Director (MD) F, MD F stated he did not get any report regarding pests in the resident room. During an interview on 1/28/25 at 10:25 a.m., with ADM C, he stated they don't keep logs or written report for the rooms that were deep cleaned. ADM C stated that deep cleaning was a remedial action for pest control. During an interview on 1/28/25 at 2:19 p.m., with MD F, MD F stated no written logs of deep cleaning done in the resident rooms. During a review of the facility's policy and procedure (P&P), titled Pest Control, undated, indicated Maintain a written report of pest sightings and remedial actions. 3. During an interview on 1/27/25 at 3:38 p.m., with Infection Preventionist (IP) H, IP H stated during pest control deep cleaning, all belongings are taken out of the resident room. The IP H stated for any sightings in resident rooms, patient is moved out of the room and deep cleaning done. IP H stated maintenance will deep clean the room and housekeeping will mop the floor. During an interview on 1/28/25 at 12:19 p.m., with ADM C, ADM C just nodded his head and did not say anything when told that State Surveyors have not seen any rooms being deep cleaned for the past six days. During an interview on 1/28/25 at 10:25 a.m., with ADM C, ADM C stated rooms that were reported to have sightings will be deep cleaned. ADM C stated all belongings, curtain, bed and resident will be moved out of the room to be deep cleaned. During an interview on 1/28/25 at 1:56 p.m., with Housekeeper (HK) L, HK L stated she does not empty the room during deep cleaning. HK L stated she would move stuff around the room. During a review of the Form CMS 2567 Plan of Correction, date survey completed 9/11/24, indicated Any rooms identified for pest will be deep cleaned by housekeeping and maintenance staff immediately. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056058 If continuation sheet Page 12 of 12