Inspection visit

Health inspectionMay 13, 2022

Q: What happened during the May 13, 2022 survey of A GRACE SUB ACUTE & SKILLED CARE?

This was a inspection survey of A GRACE SUB ACUTE & SKILLED CARE on May 13, 2022. The surveyor cited 15 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Q: Were any deficiencies cited at A GRACE SUB ACUTE & SKILLED CARE on May 13, 2022?

Yes, 15 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Ensure that residents are fully informed and understand their health status, care and treatments."

Q: What type of survey was this?

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

A GRACE SUB ACUTE & SKILLED CARECMS #05637615 citations on this visit

15 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 15 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0552 Ensure that residents are fully informed and understand their health status, care and treatments. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to obtain an informed consent (process in which a health care provider educates a patient about the risks, benefits, and alternatives of a given procedure or intervention in order to obtain agreement or permission for care, treatment, or services) for an increased dose of an antipsychotic medication (a type of psychotropic medication to manage psychosis including delusions, hallucinations, paranoia, or disordered thought) for one of 23 sampled residents (Resident 48). Residents Affected - Few This failure had the potential to compromise the right of the residents or responsible parties (RPs, persons designated to make decisions of behalf of the residents) to be fully informed regarding care and treatment to make health care decisions. Findings: A review of Resident 48's clinical record indicated she had been receiving Seroquel (an antipsychotic medication) 50 milligrams (mg, unit of measurement) twice daily for bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs) M/B (manifested by) angry outburst, hitting, kicking, biting staff causing impairment in functional capacity, starting on 3/21/22. On 4/19/22, there was a physician's order to add 50 mg dose at bedtime. The total dose was 50 mg three times daily as of 4/19/22. A review of Resident 48's medical record indicated it had the informed consent, dated 3/20/22, for Seroquel 50 mg twice daily. There was none for the additional 50 mg dose added on 4/19/22. During a phone interview on 5/12/22, at 10:00 AM, with Resident 48's RP, she stated she was not familiar with the resident's medications, such as what the medications were and what they were for. She also stated she had not been contacted by a physician regarding the resident's care since the resident was admitted to the facility. During a phone interview on 5/12/22, at 11:00 a.m., with the medical director (MD), he stated the charge nurses give the informed consent form to residents or RPs, and he signs it. He also stated usually he had a hard time getting hold of the RPs. During a concurrent interview and record review on 05/12/22, at 11:13 a.m., with director of Nursing (DON) and licensed vocational nurse (LVN L), they confirmed there was no informed consent document in Resident 48's medical record for Seroquel that was ordered on 4/19/22. They confirmed there should be a documented informed consent for newly prescribed or increased antipsychotic medications. They further explained the prescriber was responsible for obtaining the informed consent from the resident or RP, and the nursing staff's responsibility was to verify with resident or RP if the (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 28 Event ID: 056376 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 056376 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE A Grace Sub Acute & Skilled Care 1250 S. Winchester Boulevard San Jose, CA 95128 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0552 prescriber obtained the informed consent. Level of Harm - Minimal harm or potential for actual harm A review of the facility's policy and procedures titled Psychotropic Medication Use (Antipsychotics), revised December 2016, indicated, Whenever an order is obtained for psychotropic medications, the Licensed Nurse shall verify with the Attending Physician that informed consent has been obtained. The Licensed Nurse documents this verification on the Resident's Consent for Use of Psychotropic Medications form. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056376 If continuation sheet Page 2 of 28 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 056376 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE A Grace Sub Acute & Skilled Care 1250 S. Winchester Boulevard San Jose, CA 95128 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 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 address resident's needs for one of three sampled residents (Resident 74) when Resident 74 was not able to reach for her call light. Residents Affected - Few This failure had the potential for residents' needs not being met. Findings: During a concurrent observation and interview on 5/9/22, at 8:42 a.m., with licensed vocational nurse A (LVN A) in Resident 74's room, Resident 74 was hitting the right siderail of her bed with her right hand. LVN A took the call light hanging on top of a gastric tube feeding machine (a device used for direct feeding to the stomach) situated on the left side of Resident 74. LVN A stated that the call light must be within reach of Resident 74. During an interview on 5/12/22, at 10:27 a.m., with certified nursing assistant H (CNA H), she stated that Resident 74 uses her right hand to use the call light. During an interview on 5/12/22, at 10:32 a.m., with registered nurse C (RN C), she stated that Resident 74 uses the call light for help. During an interview on 5/12/22, at 1:32 p.m., with the director of nursing, she stated that call lights must be within reach of residents. During a review of Resident 74's clinical record dated 9/1/21, the admission diagnosis indicated Resident 74 had hemiplegia (paralysis of one side of the body), hypertension (condition in which the force of the blood is too high), dysphagia (difficulty swallowing foods). Her Minimum Data Set (MDS, an assessment tool), BIMS (Brief Interview for Mental Status) dated 10/25/2021, indicated a score of 13 (no cognitive impairment). During a review of the facility's policy and procedure titled 'Call Lights' dated 12/08, indicated The call light will be put within reach of the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056376 If continuation sheet Page 3 of 28 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 056376 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE A Grace Sub Acute & Skilled Care 1250 S. Winchester Boulevard San Jose, CA 95128 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to protect a residents' personal health information for one of three computer monitors. This failure had the potential for the public to see or access resident's personal medical and demographic information. Residents Affected - Few Findings: During an observation of nursing staff administering medications to residents on 5/11/2022, at 10:35 a.m., one laptop was open with residents' personal health information on laptop screen unattended. During an interview on 5/11/2022, at 10:45 a.m., with registered nurse B (RN B), she stated that she got busy and forgot to log out before going into a resident room. During an interview on 5/13/22 at 10:05 a.m., with the director of nursing, she stated that after giving medications, the nurse must close the laptop screen. No personal health information should be left unattended. A review of the facility's policy titled, Protected Health Information (PHI), Management and Protection, dated April 2014, indicated that It is the responsibility of all personnel who have access to resident and facility information to ensure that such information is managed and protected to prevent unauthorized release or disclosure during administering medications,Concern regarding resident health records in plain sight. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056376 If continuation sheet Page 4 of 28 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 056376 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE A Grace Sub Acute & Skilled Care 1250 S. Winchester Boulevard San Jose, CA 95128 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm During an observation on 5/9/22 at 12:44 p.m., CNAs were seen passing out the lunchtime meal trays to the residents. There were two food carts parked in the hallway of station three and station four which contained the lunch trays of the residents. Two LNs were seen in the hallways of station three and four, standing by their medication carts, and were not participating in the passing of the lunch trays to the residents. Residents Affected - Some During an interview with licensed vocational nurse D (LVN D) on 5/9/22 at 12:44 p.m., he was asked if he checked the contents of the meal trays before the CNAs distributed lunch to the residents on station three and station four. LVN D stated No I did not, I do it if I have time. During an interview with the director of nursing (DON) on 05/12/22 at 8:50 a.m., she stated Our process is to have the licensed nurses check the meal trays and make sure the food matches the diet tray card before the CNAs start passing the trays. During an observation and concurrent interview with licensed vocational nurse E (LVN E) on 05/12/22 at 12:17 p.m., lunch trays were being passed to the residents. LVN E was reading the diet cards while inspecting the contents of the meal tray for each resident prior to giving it to the CNAs to deliver to the residents. LVN E stated she compares the type of diet listed on the diet slip with the actual food on the tray. LVN E stated licensed nurses do this at every meal and for every resident tray. Review of the facility policy Tray Identification, revised April 2007, indicated nursing staff shall check each food tray for the correct diet before serving the residents. Based on observation, interview, and record review, the facility failed to provide care and services in accordance with professional standards or practice when: 1. Licensed nurses (LN) did not check food trays for the correct diets before serving the residents in two of 4 stations (Station AA and Station BB); 2. Two of seven sampled residents' (Resident 64 and 84) medications were not clarified with the physician. Resident 64's vitamin D (to prevent osteoporosis or treat vitamin D insufficiency) order did not have a strength since 12/23/21. Resident 84's as-needed lorazepam (medication to treat anxiety disorder) order did not have a dosing frequency since 3/5/22. These failures had the potential to compromise the residents' health and well-being, and not meeting the residents' therapeutic needs or excessive use of medications for the residents Findings: 1. During an observation in the hallway of station BB on 5/12/22 at 7:41 a.m., two LNs were passing medications in the hallways of stations AA and BB. Certified nursing assistants (CNA) were passing trays in station BB. The LNs were not observed checking the food tray before the CNAs distributed the trays to the residents. 2a. During a medication administration observation on 5/10/22, at 08:47 a.m., LVN J administered 1 tablet of vitamin D 1,000 International Units (IU, unit of potency for vitamins) via Resident 64's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056376 If continuation sheet Page 5 of 28 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 056376 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE A Grace Sub Acute & Skilled Care 1250 S. Winchester Boulevard San Jose, CA 95128 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 gastrostomy tube (G-tube, a tube inserted through the belly that brings nutrition directly to the stomach). Level of Harm - Minimal harm or potential for actual harm During medications reconciliation, Resident 64's vitamin D order was: Residents Affected - Some Vitamin D tablet (cholecalciferol) give 1 tablet via G-tube two times a day for supplement. Start date 12/23/21. The order did not include a strength. During a concurrent interview and record review on 5/10/22, at 11:05 a.m., with DON, she verified there was no strength for vitamin D order. She stated the nursing staff should have clarified with the physician. During another interview with the DON on 5/12/22 at 9:31 a.m., she stated the physician wanted to get the lab work for the vitamin D first before ordering the correct dose for the resident. A review of the medication administration record (MAR) indicated the nursing staff had been administering the vitamin D, without the ordered strength, since the ordered date. A review of Lexi-comp, a nationally recognized drug information resource, indicated vitamin D comes in different dosage forms, such as: 1,000 International Units (IU, unit of potency for vitamins), 5,000IU, 25,000 IU, and 50,000 IU. 2b. A review of Resident 84's physician orders, dated 3/5/22, indicated: lorazepam 0.5 milligram (mg) give 1 tablet by mouth as needed for anxiety or S.O.B (shortness of breath) for 90 Days M/B (manifested by) verbalization of anxiousness. The order did not include a dosing frequency, such as how often it should be given. During a concurrent interview and record review on 05/12/22, at 11:13 a.m. with DON and LVN L, they verified there was no dosing frequency for as needed lorazepam order, and they stated all medications should have a dosing frequency. A review of the Medication Administration Records (MARs) indicated nursing staff administered 10 doses in March 2022, 14 doses in April 2022, and 2 doses in May 2022. A review of the facility's policy and procedures titled Medication and Treatment Order, revised July 2016, indicated, .Orders for medications must include: a. Name and strength of the drug; b. Number of doses, start and stop date, and/or specific duration of therapy (if applicable); c. Dosage and frequency of administration; . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056376 If continuation sheet Page 6 of 28 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 056376 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE A Grace Sub Acute & Skilled Care 1250 S. Winchester Boulevard San Jose, CA 95128 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Based on observation, interview, and record review, the facility failed to provide services to prevent contracture (condition leading to deformity) for two of nine sampled residents (Resident 77 and Resident 28) when: 1. Resident 77's lower extremities (legs and feet) did not have heel protectors (device to prevent deformity) applied on bilateral feet. 2. Resident 28 did not have a splint (device used to protect deformity) applied on his left arm as ordered. These failures had the potential to cause or worsen bone deformities. Findings: 1. During an observation on 5/9/22 at 8:58 a.m., in Resident 77's room, Resident 77's lower extremities did not have heel protectors. During a concurrent observation and interview on 5/9/22 at 3:40 p.m., with licensed vocational nurse A (LVN A) in Resident 77's room. Resident 77's soft heel protectors were inside the cabinet. LVN A stated she would check on the order for soft heel protector application. During a concurrent interview and record review on 5/10/22 at 10:23 a.m. with LVN A, LVN A stated that physician order, dated,11/15/2021, indicated Wear bilateral heel protectors for positioning/contracture management daily. During a review of Resident 77's admission diagnosis dated 10/11/2016, it indicated that she had joint contracture, and muscle weakness. During a review of the facility's policy titled, Mobility and Range dated 2017, indicated that Residents with limited range of motion (ability of a body part to move) will receive treatment and services to prevent a further decrease in range of motion. 2. During an observation on 5/9/22 at 11:18 a.m. in Resident 28's room, the arm splint was inside Resident 28's cabinet. During a follow-up observation and interview on 5/10/22 at 9:10 a.m., with registered nurse B (RN B) and certified nursing assistant M (CNA M) in Resident 28's room, Resident 28 had no splint applied on the left arm. The splint was found inside Resident 28's cabinet. RN B stated the splint should be applied to prevent contracture. During a record review on 5/10/22 at 9:30 a.m. with RN B, Resident 28's physician order dated 5/26/2021, indicated Patient may wear left hand splint daily for positioning and contracture prevention. Resident 28's admission diagnosis indicated that he had hemiplegia (paralysis of one side of the body), cerebral infarction (disrupted blood flow to the brain) During an interview on 5/12/22 at 9:42 a.m. with the director of nursing, she stated that all (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056376 If continuation sheet Page 7 of 28 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 056376 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE A Grace Sub Acute & Skilled Care 1250 S. Winchester Boulevard San Jose, CA 95128 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 Level of Harm - Minimal harm or potential for actual harm orders regarding use of heel protectors/splints should be followed by nurses and therapists to prevent damage to the affected body parts. During a review of facility's policy titled, Splinting (undated), the policy indicated Splinting is used to protect joints at position of rest that contribute to contracture and/or deformity. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056376 If continuation sheet Page 8 of 28 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 056376 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE A Grace Sub Acute & Skilled Care 1250 S. Winchester Boulevard San Jose, CA 95128 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to provide timely assessment and intervention for pain for one of two sampled residents (Resident 68). This failure had the potential for increased pain and discomfort for Resident 68. Residents Affected - Few Findings: During an observation on 5/9/22, at 10:20 a.m., in Resident 68's room, she was rubbing the left side of her face and grimacing. During an interview on 5/10/22, at 9:48 a.m., with certified nursing assistant F (CNA F), she informed the nurse of Resident 68's pain on the left side of her face about two weeks ago. During a review of Resident 68's clinical record dated 3/22/22, Resident 68 was admitted for cerebral vascular accident (disrupted blood flow to the brain), and trigeminal neuralgia (chronic pain condition affecting the trigeminal nerve, this nerve carries sensation from the face to the brain). During an observation on 5/11/22, at 9:52 a.m., in Resident 68's room, registered nurse B (RN B) assessed the resident for pain. During a follow-up interview on 5/11/22 at 9:58 a.m. with RN B, she stated that Resident 68 had pain on the entire left side of head, face, and neck. Resident 68 was still complaining of pain. During an interview on 5/11/22, 1:26 p.m., with the nursing supervisor G (NS G) she stated that she was only made aware of the resident's pain on 5/10/22. NS G further stated that resident's pain should be reported immediately to the nurse and notify the physician accordingly. During an interview on 5/13/22 at 10:05 a.m., with the director of nursing, she stated that the nurse was responsible for assessing residents' pain and intervention. They should check for improvement. If no improvement, the nurse should contact the physician as soon as possible. Review of the facility's policy titled, Pain Assessment and Management, dated March 2020, the purpose of this procedure is to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056376 If continuation sheet Page 9 of 28 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 056376 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE A Grace Sub Acute & Skilled Care 1250 S. Winchester Boulevard San Jose, CA 95128 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 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** Based on observation, interview, and record review, the facility failed to ensure residents receiving dialysis (removal of waste and excess fluid from the body) treatment received care consistent with professional standards for one of one resident (Resident 23) when Resident 23's dialysis site dressing was not removed as ordered. This deficient practice had the potential for the resident to be inadequately assessed and be at risk for complications. Residents Affected - Few Findings: Review of Resident 23's clinical record indicated he was admitted to the facility on [DATE] with diagnoses including end stage renal disease (kidneys no longer functioning in permanent basis) and thrombosis (blood clot) due to vascular prosthetic devices, implants and grafts, subsequent encounter. Review of Resident 23's physician order dated 1/8/21 indicated Resident 23's dialysis days were Tuesdays and Thursdays from 6:15 a.m. to 9:15 a.m. Review of Resident 23's physician order dated 5/8/22 indicated remove dialysis dressing to left arm AV shunt (a connection of artery and vein) (at least 4 hours post dialysis). During an observation on 5/11/22 at 9:53 a.m., with the treatment nurse (TN), Resident 23's arm had a white cover (dressing). Resident 23 confirmed his left arm was his dialysis site. Review of Resident 23's hemodialysis report sheet dated 5/10/22 indicated Resident 23 went to dialysis. During an interview with licensed vocational nurse d (LVN D) on 5/11/22 at 10:24 a.m., LVN D confirmed Resident 23 goes to dialysis on Tuesdays and Thursdays. During an interview with LVN D on 5/11/22 at 10:31 a.m., he confirmed Resident 23's dressing was not removed. During an interview with the director of nursing (DON) on 5/11/22 at 4:25 p.m., the DON reviewed Resident 23's physician order and stated the nurses should follow the physician's order. Review of the facility's undated policy, Dialysis Care indicated . Dressing will be changed in accordance with Attending Physician's order. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056376 If continuation sheet Page 10 of 28 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 056376 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE A Grace Sub Acute & Skilled Care 1250 S. Winchester Boulevard San Jose, CA 95128 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on interview and record review, the facility failed to ensure controlled medications (those with high potential for abuse and addiction) were fully accounted when: Residents Affected - Some 1. Random controlled medication use audit for three of four sampled residents' (Residents 23, 48, and 71) as-needed controlled medications 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. 2. Three of five controlled drug sign-in/sign out sheets (a sheet used to reconcile inventory of controlled medications in the medication cart by the incoming and outgoing nurse during a shift change) were missing signatures. These failures had the potential for misuse or diversion of controlled medications and inaccurate accountability of controlled medications. Findings: 1. The controlled medication Count Sheets for four random residents receiving as-needed controlled medications were requested for review during the survey. a. Resident 23 had a physician's order for Percocet tablet 5-325mg (oxycodone-acetaminophen, a controlled medication for pain) give 1 tablet by mouth every 6 hours as needed for severe pain, start date 8/4/21. During a concurrent interview and record review on 05/10/22, at 03:32 p.m., with licensed vocational nurse (LVN) L, a review of Resident 23's Count Sheet for Percocet and 4/2022 and 5/2022 MARs reflected the nursing staff removed 1 tablet on 4/2/22 at 10:30 a.m., on 5/5/22 at 10 a.m., and on 5/6/22 at 10 AM from the medication cart and documented on the Count Sheet without documenting in the respective administration on the MAR. LVN L verified this finding, and stated any medication given needed to be documented on MAR as well. She confirmed three Percocet tablets were unaccounted for. b. Resident 48 had a physician's order for alprazolam tablet 1mg give 1 tablet via G-tube (a tube inserted through the belly that brings nutrition directly to the stomach) every 12 hours as-needed for anxiety for 90 days m/b (manifested by) pulling out tubing and rolling herself out of bed that poses a danger to herself, start date 4/2/22. During a concurrent interview and record review on 05/10/22, at 03:32 p.m., with LVN L, a review of Resident 48's Count Sheet for alprazolam and 4/2022 MAR reflected the nursing staff removed 1 tablet on 4/21/22 at 10 a.m. from the medication cart and documented on the Count Sheet without documenting the administration on the MAR. LVN L verified this finding and confirmed one alprazolam tablet was unaccounted for. c. Resident 71 had a physician's order for tramadol tablet 50mg give 1 tablet by mouth every 6 hours as needed for mild to moderate pain, start date 2/15/22. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056376 If continuation sheet Page 11 of 28 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 056376 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE A Grace Sub Acute & Skilled Care 1250 S. Winchester Boulevard San Jose, CA 95128 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a concurrent interview and record review on 05/10/22, at 03:32 p.m., with LVN L, a review of Resident 71's Count Sheet for Tramadol and 3/2022 and 4/2022 MAR reflected the nursing staff removed following from the medication cart without documenting in the respective administration on the MAR: 1 tablet on 3/17/22 at 2:30 p.m., 3/26/22 at 2 p.m., 3/28/22 at 2 p.m., 3/31/22 at 2 p.m., 4/2/22 at 2 p.m., 4/5/22 at 2 p.m., 4/6/22 at 2:30 (did not indicate in a.m. or p.m.), 4/8/22 at 2 p.m., 4/11/22 at 11:45 a.m., 4/13/22 at 2 p.m., 4/14/22 at 2 p.m., 4/21/22 at 2:30 p.m., 4/22/22 at 2 p.m., and 4/24/22 at 2 p.m LVN L verified the findings, and stated any medication given needed to be documented on MAR. She confirmed 14 Tramadol tablets were unaccounted for. A review of facility's policy and procedures, titled Administering Medications, revised April 2019, indicated, The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next dose. A review of facility's policy and procedure, titled Documentation of Medication Administration, revised April 2007, indicated, 1. A nurse .shall document all medication administered to each resident on the resident's medication administration record (MAR). 2. Administration of medication must be documented immediately after .it is given. 2. Five controlled drug sign-in/sign out sheets from random medication carts were reviewed during the survey. a. On 5/9/22 at 2:15 p.m., a review of the May 2022 controlled drug sign-in/sign-out sheets for Sub-Acute Unit Medication Carts #1 and #2 was conducted with LVN J. The review identified 14 missing signatures: on 5/1/22 AM (morning) and NOC (midnight) shifts, and from 5/2/22-5/6/22 a.m. shift between nursing shift changes for Medication Cart #1. It also identified 18 missing signatures: on 5/1/22 AM and NOC shifts, from 5/2/22-5/4/22 AM shift, 5/5/22 AM and PM shift, and 5/7/22-5/8/22 AM shift between nursing shift changes for Medication Cart #2. LVN J acknowledged the sheets were incomplete. b. A review of the May 2022 controlled drug sign-in/sign-out sheet for Skilled Nursing Facility Unit Medication Cart #2 on 5/9/22, at 3:37 p.m., with LVN D, identified 8 missing signatures: on 5/5/22 AM shift, and 5/6/22 AM, PM, and NOC shift between nursing shift changes. LVN D verified the sign-in/sign-out sheet was incomplete. A review of facility's policy and procedure titled Controlled Substances, revised April 2019, indicated, At the end of each shift: controlled medications are counted at the end of each shift. The nursing coming on duty and the nurse going off duty determine the count together. A review of the controlled drug sign-in/sign-out sheet reminder, dated May 2022, indicated, 2. Both incoming and outgoing must check narcotics at the end of each shift. 3. If the count is incorrect, the medication nurse must remain on duty until the count is correct. 4. Your signature is your verification that the count is correct. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056376 If continuation sheet Page 12 of 28 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 056376 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE A Grace Sub Acute & Skilled Care 1250 S. Winchester Boulevard San Jose, CA 95128 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - 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 observation, interview and record review, the consultant pharmacist (CP) failed to identify and report the irregular medication orders for two of seven sampled residents (Residents 64 and 84) in the monthly Medication Regimen Review (MRR). This failure resulted in medications not given in accordance with accepted standards of practice and had the potential for not meeting the residents' therapeutic needs or excessive use of medications for the residents. Findings: 1. During a medication administration observation on 5/10/22, at 08:47 a.m., licensed vocational nurse (LVN) J administered 1 tablet of vitamin D 1,000 International Units (IU, unit of potency for vitamins) via Resident 64's gastrostomy tube (G-tube, a tube inserted through the belly that brings nutrition directly to the stomach). During medications reconciliation, Resident 64's vitamin D order was: vitamin D tablet (cholecalciferol) give 1 tablet via G-tube two times a day for supplement. Start date 12/23/21. The order did not include a strength. During a concurrent interview and record review on 5/10/22, at 11:05 a.m., with director of nursing (DON), verified there was no strength for Vitamin D order, she stated the nursing staff should have clarified with the physician. A review of Lexi-comp, a nationally recognized drug information resource, it indicated vitamin D comes in different dosage forms, such as: 1,000 IU, 5,000 IU, 25,000 IU and 50,000 IU. A review of the MRR binder (consisted of the CP's recommendations) indicated no recommendations in January, February, March, and April 2022 for Resident 64's medications. 2. A review of Resident 84's physician orders, dated 3/5/22, indicated: lorazepam 0.5 mg give 1 tablet by mouth as needed for Anxiety or S.O.B (shortness of breath) for 90 Days M/B (manifested by) verbalization of anxiousness. The order did not include a dosing frequency, such as how often it should be given. During a concurrent interview and record review on 05/12/22, at 11:13 a.m. with DON and licensed vocational nurse (LVN) L, they verified there was no dosing frequency for as needed Lorazepam order, and they stated all medications should have dosing frequency. A review of the Medication Administration Records (MARs) indicated nursing staff administered 10 doses in March 2022, 14 doses in April 2022, and 2 doses in May 2022. A review of MRR binder indicated no CP's recommendations related to the lack of dosing frequency for Resident 84's lorazepam in March and April 2022. During a phone interview on 05/12/22, at 01:53 p.m. with the CP, she verified above two medication irregularities. She stated she did not see any recommendations from her regarding the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056376 If continuation sheet Page 13 of 28 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 056376 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE A Grace Sub Acute & Skilled Care 1250 S. Winchester Boulevard San Jose, CA 95128 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 irregularities, and she should have identified the issues and notified the facility. Level of Harm - Minimal harm or potential for actual harm A review of the facility's policy and procedures titled Medication Regimen Review and Reporting, dated 9/18, indicated, The consultant pharmacist reviews the medication regimen and medical chart of each resident at least monthly to appropriately monitor the medication regimen and ensure that the medications each resident receives are clinically indicated. Identification of irregularities .The findings are communicated to the director of nursing or designee and medical director. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056376 If continuation sheet Page 14 of 28 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 056376 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE A Grace Sub Acute & Skilled Care 1250 S. Winchester Boulevard San Jose, CA 95128 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident 13's clinical record indicated he was admitted to the facility on [DATE] with diagnoses including major depressive disorder (persistent feeling of sadness and loss of interest), bipolar disorder (mental illness which a person can experience mood swings [period of overly happy or periods of feeling sad]). During multiple observations on 5/9/22 at 9:47 a.m., 9:50 a.m., 10:12 a.m., 12:03 p.m., 2:02 p.m., Resident 13 was screaming. During an interview with certified nursing assistant K (CNA K) on 5/9/22 at 11:25 a.m., CNA K stated Resident 13 does scream even at night. Review of Resident 13's physician's order dated 2/23/22 indicated Quetiapine Fumarate (seroquel) 50 milligrams (mg, unit of measurement) give 1.5 tablet twice a day for bipolar disorder manifested by angry outburst. During a concurrent interview and record review with nursing supervisor G (NS G) on 5/13/22 at 1:16 p.m., NS G reviewed Resident 13's physician order and stated the behavior should be clarified. During an interview with the DON on 5/13/22 at 2:33 p.m., the DON reviewed Resident 13's clinical record and stated the behavior should be specific to Resident 13. Review of the facility's policy Psychotropic Medication Use (Antipsychotics) dated 12/2016 indicated, Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective. Based on observation, interview and record review, the facility failed to ensure two of 23 sampled residents (Residents 48 and 13) were free from unnecessary psychotropic medications (drugs that affects brain activities associated with mental processes and behaviors) when: 1. The facility increased Resident 48's Seroquel (an antipsychotic medication) for bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs) without adequate indication and documentation, and did not monitor the resident's lipid panel (a test that measures the amount of certain fat molecules called lipids in the blood) annually while the resident was on two antipsychotic medications. 2. For Resident 13, there was no specific behavior for the use of Seroquel. These failures had the potential for increased risks associated with psychotropic medication use that include but are not limited to sedation, anxiety, agitation, and memory loss. Findings: 1a. A review of Resident 48's clinical record indicated she was admitted to the facility with generalized anxiety disorder (severe, ongoing anxiety that interferes with daily activities), schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), and bipolar (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056376 If continuation sheet Page 15 of 28 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 056376 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE A Grace Sub Acute & Skilled Care 1250 S. Winchester Boulevard San Jose, CA 95128 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 disorder. Level of Harm - Minimal harm or potential for actual harm A review of Resident 48's physician's orders reflected she was currently receiving two antipsychotic medications: Residents Affected - Few 1. Seroquel 50 milligrams (mg, unit of measurement) give 1 tablet via G-tube at bedtime for Bipolar Disorder M/B (manifested by) angry outburst hitting, kicking, biting staff causing impairment in functional capacity, dated 4/19/22. 2. Olanzapine tablet 10 mg give 1 tablet via G-tube one time a day for schizophrenia M/B hallucination AEB (as evidenced by) talking to herself, dated 3/24/22. A review of Resident 48's medical record indicated the resident was admitted to the facility in August 2020 with Seroquel 25 mg twice daily for bipolar disorder. It was increased to Seroquel 50 mg twice daily starting on 3/21/22 (this dose was discontinued on 5/2/22). On 4/19/22, there was a physician's order to add 50 mg dose at bedtime. The total dose was 50 mg three times daily as of 4/19/22. There was no documented indication or rationale, such as an increase in behaviors/symptoms, in the medical record supporting the reason why the dose was increased. During a phone interview on 5/12/22, at 11:01 a.m., with the medical director (MD), he stated he did not recall regarding the indication of added Seroquel because he was in the middle of patient care, and he needed to talk to the team. He also stated resident has schizophrenia, and she did not respond to the medications well. During a concurrent interview and record review on 5/12/22, 11:18 a.m., with the director of nursing (DON) and LVN L, they confirmed there was no indication documented for increased Seroquel dose at bedtime from a physician on 4/19/22; also, there was no informed consent (process in which a health care provider educates a patient about the risks, benefits, and alternatives of a given procedure or intervention in order to obtain agreement or permission for care, treatment, or services) for its use. They stated there should be a documented rationale or indication for any increased psychotropic medication, and an informed consent. 1b. A review of Resident 48's medical record indicated she had been receiving both Seroquel and olanzepine, in various doses, since admission in August 2020. A review of Lexi-comp, a nationally recognized drug information resource, it indicated antipsychotic medications have the ability to cause metabolic changes including increase in blood sugar and lipids (such as cholesterol and triglycerides). Lexi-comp indicated to monitor lipid panel 12 weeks after initiation and dose change, then annually for Seroquel and olanzapine use. There was no documented evidence in Resident 48's medical record the facility monitored for lipid panel since the resident's admission. A review of the Medication Regimen Review (MMR) binder (consisted of the Consultant Pharmacist (CP)'s recommendations) indicated the CP recommended to get order from the physician for hemoglobin A1C (a blood test that measures your average blood sugar levels over the past 3 months) and lipid panel on 5/3/22. During a concurrent interview and record review with nursing supervisor (NS) N, on 5/11/22 at 4:30 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056376 If continuation sheet Page 16 of 28 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 056376 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE A Grace Sub Acute & Skilled Care 1250 S. Winchester Boulevard San Jose, CA 95128 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 PM, she confirmed there was no lipid panel monitoring in the resident's medical record. Level of Harm - Minimal harm or potential for actual harm On 5/12/22, a review of Resident 48's nursing progress notes, dated 5/11/22, by NS N indicated, pharmacy MMR dated 4/1/22-4/30/22 with pharmacy recommendation to get order from physician A1C and Lipid panel lab work. Lab A1C was done but not Lipid panel for the use of Seroquel on 5/4/22. Facility contacted lab on 5/11/22, and lab stated they called facility to notify them that the blood collected was not enough for lipid panel but no documentation regarding who they talked to. Facility informed the medical director (MD) to explain above, and MD ordered to do stat lipid panel on 5/11/22. Residents Affected - Few During an interview with LVN L on 5/12/22, at 2:55 p.m., she stated she looked through the medical record and could not find any lipid panel monitoring for Resident 48. She acknowledged the monitoring for lipids was required for residents receiving antipsychotic medications. A review of the facility's policy and procedures (P&P) titled Medication Monitoring Medication Management, dated 1/22, indicated, Antipsychotic medications: indication for use must be thoroughly documented in the medical record . Diagnoses alone do not necessarily warrant the use of an antipsychotic medication. The P&P indicated the following for monitoring: Potential adverse consequences: the facility assures that residents are being adequately monitored for adverse consequences such as: .Metabolic: increase in total cholesterol and triglycerides, unstable or poorly controlled blood sugar, weight gain . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056376 If continuation sheet Page 17 of 28 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 056376 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE A Grace Sub Acute & Skilled Care 1250 S. Winchester Boulevard San Jose, CA 95128 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility had a medication error rate of 15.63% when five medication errors occurred out of 32 opportunities during medication administration for four of five sampled residents (Residents 42, 53, 64, and 72). Residents Affected - Some The deficient practice resulted in medications not given in accordance with the prescriber's orders and/or manufacturer's specifications, which may result in residents not receiving the full therapeutic effect of the medications and possible side effects for residents. Findings: 1. During a medication pass observation on 5/9/22, at 09:01 a.m., with licensed vocational nurse D(LVN D), he administered six medications to Resident 53, including a tablet of aspirin enteric coated (a pain reliever with a coating that creates a delayed release of the medication also prevents stroke) 81 milligrams (mg). A review of Resident 53's clinical record indicated a physician's order, dated 12/29/21, for aspirin low strength tablet chewable 81 mg give 1 tablet by mouth one time a day for stroke prevention. During a concurrent interview and record review on 5/9/22, at 1:46 p.m., with LVN D, he verified the order indicated aspirin chewable tablet, but he administered the enteric coated tablet. He stated he needed to call the physician to change the order to enteric coated because the resident was having stomach problems. During another interview with LVN D on 5/9/22 at 3:37 p.m., LVN D stated the physician wanted to keep the aspirin order as chewable 81 mg tablet. 2. During a medication pass observation on 5/9/22 at 9:17 a.m., with LVN A, she administered 6 medications to Resident 72, including an Artificial Tears eyedrop (used to lubricate dry eyes and help maintain moisture on the outer surface of the eyes). At the bedside, LVN A instilled 1 drop in each of the resident's eyes. A review of Resident 72's clinical record indicated a physician's order, dated 9/13/21, for Artificial Tears Solution 1.4% (polyvinyl alcohol) instill 1 drop in left eye three times a day for dry eyes. During a concurrent interview and record review on 5/9/22, at 02:07 PM, with LVN A, she verified the physician's order indicated Artificial Tears 1 drop only for left eye. 3. During a medication pass observation on 5/9/22, at 10:18 a.m., with LVN O, he prepared and administered seven medications to Resident 42, including 2 tablets of Senna-Plus (a combination of sennosides [laxative] and docusate [a stool softener] to treat constipation) 8.6-50 mg, and 1 tablet of docusate 100 mg. A review of Resident 42's clinical record indicated physician's orders: a. Senna tablet 8.6mg (sennosides) give 2 tablets by mouth two times a day for bowel regularity (2 tabs = 17.2mg), hold for loose stools. Dated 9/22/21. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056376 If continuation sheet Page 18 of 28 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 056376 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE A Grace Sub Acute & Skilled Care 1250 S. Winchester Boulevard San Jose, CA 95128 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some b. Docusate sodium tablet 100 mg give 1 tablet by mouth two times a day for bowel management (hold for loose stool). Dated 9/22/21. During a concurrent interview and record review on 5/9/22, at 01:51 p.m., with LVN O, he showed the bottle of medication he used which was Senna-Plus, then verified the physician's order indicated to give Senna, not Senna-Plus. 4. During a medication pass observation on 5/10/22, at 08:47 a.m., with LVN J, she administered nine medications to Resident 64, including: a. A tablet of multivitamin with mineral (a dietary supplement contains a combination of vitamins and minerals). b. About two thirds of a capful of polyethylene glycol 3350 powder (Brand name Miralax, a laxative to treat constipation) mixed with about 6 ounces (oz) of water. During a concurrent interview and record review on 5/10/22 at 9:21 a.m., with LVN J, she stated the Miralax order was for 17 grams. She confirmed she did not measure the Miralax powder to the rim of the cap, but only about two-thirds full. A review of the manufacturer's directions on the polyethylene glycol 3350 powder bottle with LVN J at this time indicated the bottle cap is a measuring cup designed to contain 17 grams of powder when filled to the top rim. It indicated, Fill to the top of the bottle cap which will provide the correct dose (17g). A review of Resident 64's clinical record indicated physician's orders: Multivitamin tablet (multiple vitamin), give 1 tablet via G-tube (a tube inserted through the belly that brings nutrition directly to the stomach) one time a day for supplement. Dated 11/10/21. Polyethylene glycol 3350 powder, give 17 grams (g) via G-tube one time a day for bowel regularity (give with 4-8 oz fluid of water or juice), hold for loose stools. Dated 1/23/20. During a concurrent interview and record review on 5/10/22, at 10:18 a.m., with LVN J, she showed the bottle of multivitamin with mineral with orange label she used. LVN J verified the physician's order indicated multivitamin only, not multivitamin with minerals. A review of the facility's policy and procedure title Administering Medication, revised April 2019, indicated, Medications are administered in accordance with prescriber orders and The individual administering the medications checks .to verify . the right medication, right dosage . before giving the medication. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056376 If continuation sheet Page 19 of 28 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 056376 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE A Grace Sub Acute & Skilled Care 1250 S. Winchester Boulevard San Jose, CA 95128 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. 7. During multiple observations on 5/9/22 at 9:45 a.m., 9:50 a.m., 9:55 a.m., there were three bags of diabeticource ac (a tube feeding formula) on top of a medication/treatment cart unattended in the hallway. Residents were wheeling themselves in the hallway. During an interview with LVN D on 5/9/22 at 9:55 a.m., LVN D confirmed the above observation and stated the diabetisource ac should be inside the medication cart. During an interview with the DON on 5/10/22 at 4:57 p.m., the DON stated the three bags of diabetisource ac should be inside the medication cart or in the medication room. The DON further added the diabetisource ac were stored in the medication room. Review of the facility's policy, Storage of Medications, dated 11/2020, indicated The facility stores all drugs and biologicals in a safe, secure, and orderly manner. Based on observation, interview, and record review, the facility failed to ensure proper medication storage and labeling of medications when: 1. Temperature monitoring was not consistently documented twice daily on the temperature log sheet, in May 2022, for one of two medication refrigerators; 2. Two insulin (medication to treat high blood sugar) pens had the pharmacy label on the caps instead of the body of the pens; 3. One opened tuberculin purified protein derivative (PPD, a solution used for tuberculin skin test) multi dose vial, one insulin pen, and an opened insulin vial were without the open date or discard date, to make sure they were not used beyond the discard date; 4. Two residents' expired medications were not removed from stock; 5. One unopened insulin vial was not labeled after removing from the refrigerator; 6. One pharmacy dispensed levetiracetam (medication to treat seizures) bottle was without an expiration date on the pharmacy label; 7. Three diabetisource ac (a tube feeding formula) was unattended on top of a cart in the hallway. The deficient practices had a potential for residents to receive medications with reduced potency from expired medications, and/or medication errors due to medications not being labeled. Findings: 1. During a visit to the facility's medication room for skilled nursing unit (Stations 2, 3, and 4) on 5/9/22, at 10:52 a.m. with licensed vocational nurse D (LVN D), the medication refrigerator was observed to contain numerous refrigerated medications including insulin pens, insulin vials, and two flu vaccine syringes. A review of the (REF #1) temperature log for May 2022 indicated it was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056376 If continuation sheet Page 20 of 28 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 056376 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE A Grace Sub Acute & Skilled Care 1250 S. Winchester Boulevard San Jose, CA 95128 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few missing temperatures and signatures on 5/7/22 and 5/8/22 PM (night) shift, and 5/8/22 and 5/9/22 AM (morning) shift. LVN D stated the nursing staff was to monitor and document the temperature monitoring twice daily. He verified the missing temperature monitoring and signatures. A review of the May 2022 temperature log indicated, Refrigerator Temperature to be monitored and documented on DAY SHIFT AND NOC [nocturnal, meaning night) SHIFT. 2. On 5/9/22 at 10:52 a.m., the inspection of REF #1 with LVN D identified two insulin pens which had the pharmacy labels on the caps instead of on the body of the pens. During a telephone interview with the consultant pharmacist (CP) on 5/12/22 at 10:23 a.m., she stated that it was advisable to put the pharmacy label on the body of the pen, not on the cap, to prevent mix-up errors. A review of the 2017 Institute for Safe Medication Practices' (ISMP, a nonprofit patient safety organization with recognized national expertise in medication error prevention) Guidelines for Optimizing Safe Subcutaneous Insulin Use in Adults, it indicated, A patient-specific label is affixed on the body of the insulin pen (not on the removable cap), without obscuring important information on manufacturer labeling or the dose counter/dose window to prevent mix-up errors such as when the caps of two different pens were inadvertently switched. 3. During a visit to the facility's medication room for the subacute unit on 5/9/22, at 11:20 a.m. with the nursing supervisor G (NS G) and director of nursing (DON), one opened PPD multi dose vial was found in the medication refrigerator without an open date. They verified it should have the date of when it was opened. A review of Lexi-comp, a nationally recognized drug information resource, indicated store at 2° Celsius (C) to 8°C (36° Fahrenheit (F) to 46°F); opened vials should be discarded after 30 days. During an inspection of Station 4 Medication Cart #2 on 5/9/22, at 3:37 p.m., with LVN D, Resident 23's Lantus (long last insulin) pen was found in the medication cart without an open date, and Resident 62's opened Lantus multi-dose vial without an open date. LVN D verified these findings. A review of Lexi-comp indicated prefilled pens: once in use, store prefilled pens at room temperature <30°C (<86°F) and use within 28 days. Vials: once punctured (in use), store vials refrigerated or at room temperature <30°C (<86°F) and use within 28 days. 4. During an inspection of Station 4 Medication Cart #2 on 5/9/22, at 3:37 p.m., with LVN D, Resident 23's insulin aspart (a short-acting insulin) multi-dose vial was found in the medication cart with an open date of 4/10/22; the pharmacy label on the insulin indicated to discard 28 days after opening, which indicated the insulin was expired on 5/8/22. LVN D verified this finding. During an inspection of the subacute unit Medication Cart #4 on 5/10/22, at 10:21 a.m., with LVN A, Resident 28's latanoprost eyedrop (to treat glaucoma) was found in the medication cart with an open date of 3/27/22. The pharmacy label on the eyedrop indicated to discard 42 days after opening, which indicated the eyedrop was expired on 5/7/22. LVN A verified this finding. 5. During an inspection of the subacute unit Medication Cart #4 on 5/10/22 at 10:21 a.m., with LVN (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056376 If continuation sheet Page 21 of 28 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 056376 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE A Grace Sub Acute & Skilled Care 1250 S. Winchester Boulevard San Jose, CA 95128 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A, one unopened vial of insulin admelog (short-acting insulin) was identified in the medication cart that was left at room temperature and without the date removed from the refrigerator. The pharmacy label indicated to refrigerate until opened then store at room temperature. LVN A verified this finding. A review of Lexi-comp indicated unopened vials, cartridges, and prefilled pens may be stored under refrigeration between 2°C and 8°C (36°F to 46°F) until the expiration date or at room temperature <30°C (<86°F) for 28 days. 6. During an inspection of the subacute unit Medication Cart #4 on 5/10/22 at 10:21 a.m., with LVN A, one pharmacy-dispensed levetiracetam (medication to treat seizures) bottle was identified in medication cart without an expiration date on the pharmacy label. LVN A verified it did not contain an expiration date. During an interview on 5/10/22, at 11:05 a.m., with DON, she stated each medication product must have an expiration date so the nursing staff would know if the medication was still good to give to the residents. A review of the facility's Policy and Procedures (P&P), titled Administering Medications, revised April 2019, indicated, 12.when opening a multi-dose container, the date opened is reordered on the container. A review of the facility's P&P, titled Storage of medications, revised November 2020, indicated, 4. Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals are to be disposed by the licensed nurse in the pharmaceutical waste . 7. Medications requiring refrigeration are stored in a refrigerator located in the drug room at the nurses' station or other secured location . A review of facility's P&P, titled Labeling of Medication Containers, revised April 2019, indicated, 3. Labels for individual resident medications include all necessary information, such as: .h. the expiration date when applicable . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056376 If continuation sheet Page 22 of 28 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 056376 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE A Grace Sub Acute & Skilled Care 1250 S. Winchester Boulevard San Jose, CA 95128 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0790 Provide routine and 24-hour emergency dental care for each resident. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to assist and provide emergency dental care for one of two sampled residents (Resident 68). This failure had the potential for Resident 68 to suffer pain. Residents Affected - Few Findings: During an observation on 5/09/22, at 10:20 a.m., in Resident 68's room, she was observed rubbing her left side of her face and grimacing. During an interview on 5/10/22, at 9:48 a.m., with certified nursing assistant F (CNA F), CNA F stated that she told the nurse and social services assistant (SSA) of Resident 68's dental pain two weeks ago. During a review of Resident 68's clinical record dated 3/22/22, Resident 68 was admitted for cerebral vascular accident (disrupted blood flow to the brain), and trigeminal neuralgia (chronic pain condition affecting the trigeminal nerve, this nerve carries sensation from the face to the brain). During a concurrent observation and interview on 5/11/22, at 9:52 a.m., with registered nurse B (RN B), in Resident 68's room, she assessed the resident for dental pain using a flashlight. She observed the inside of the resident's mouth and there was no signs of redness, tenderness or swelling. Resident 68 still complained of left lower jaw pain. During an interview on 5/11/22, at 1:26 p.m., with nursing supervisor G (NS G), NS G stated that she was only made aware of the resident's dental pain on 5/10/22. NS G stated that the nurse should follow-up with SSA as soon as possible. During an interview on 5/13/22 at 10:05 a.m. with the director of nursing (DON), she stated that the nurse was responsible for assessing residents' need for a dental referral and communicating that to the SSA as soon as possible. During a review of the facility's policy titled, Dental Services, dated December 2016, the policy indicated Routine and emergency dental services to meet the resident's oral health services in accordance with the resident's assessment and plan of care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056376 If continuation sheet Page 23 of 28 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 056376 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE A Grace Sub Acute & Skilled Care 1250 S. Winchester Boulevard San Jose, CA 95128 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and document review, the facility failed to follow proper sanitation and food handling practices when: Residents Affected - Some 1. There were uncovered food items in the facility's kitchen freezer; 2. There was one unlabeled and undated pitcher of pink liquid in the reach-in refrigerator; and 3. Food service equipment was stored wet. These failures had the potential to cause food contamination and food-borne illness to 47 of 47 residents who received their food from the kitchen. Findings: 1. During the initial kitchen tour on 5/9/22 at 9:10 a.m., with the registered dietician (RD) inside the walk-in-freezer, a large bin containing a plastic bag of dinner rolls was observed. The bag of dinner rolls was open and exposed to the air. Another bin containing a plastic bag of corn dogs was observed to be open and exposed to the air. A third bin containing a plastic bag of bacon was observed to be open and exposed to the air. During a concurrent interview with the RD, he confirmed the plastic bags containing the dinner rolls, corn dogs, and bacon were open and exposed to the air in the freezer. The RD stated the bags should be closed. Review of facility's policy Procedure for Freezer Storage, dated 2018, indicate to store frozen foods in an airtight moisture-resistant wrapper such as a plastic bag or freezer paper to prevent freezer burn. Review of the U.S. Food & Drug Administration 2017 Food Code indicated food shall be protected from cross-contamination by storing the food in packages, covered containers, or wrappings. 2. During the initial kitchen tour on 5/9/22 at 9:10 a.m., with the registered dietician (RD), there was one unlabeled and undated pitcher of pink liquid in the reach-in refrigerator. The RD stated, That is diet juice, it should be labeled and dated. I will discard it now. 3. During the initial kitchen tour on 5/9/22 at 9:10 a.m., with the registered dietician (RD), two blender containers were observed on a wire rack. The two blender containers were stored right side up with their lids on top of each container. One container had visible water pooling inside at the base of the container and the second container had visible water drops inside the container. During a concurrent interview with the RD, he confirmed the blender containers were wet. The RD stated the blender containers should not be stored wet and should be air-dried. Review of facility's policy Electrical Food Machines, dated 2018, indicated to wash after each use, and wash in the dishwasher and allow to air dry. According to the 2017 Food and Drug Administration (FDA) Food Code, Section 4-901.11 Equipment and Utensils, Air-Drying Required, After cleaning and sanitizing, equipment and utensils: shall be air-dried . According to the FDA Food Code 2017 Annex 4-901.11 items must be allowed to drain and to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056376 If continuation sheet Page 24 of 28 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 056376 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE A Grace Sub Acute & Skilled Care 1250 S. Winchester Boulevard San Jose, CA 95128 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 air-dry before being stacked or stored. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056376 If continuation sheet Page 25 of 28 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 056376 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE A Grace Sub Acute & Skilled Care 1250 S. Winchester Boulevard San Jose, CA 95128 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when: Residents Affected - Some 1. Licensed vocational nurse D (LVN D) did not perform hand hygiene in between tasks; 2. Face shield unattended on top of a cart parked in the hallway; 3. Certified nursing assistant K (CNA K) did not tie her isolation gown before entering an isolation room; 4. The restorative nursing assistant (RNA) did not follow the sequence in donning personal protective equipment (PPE). 5. Resident 25 did not have a daily Covid-19 screening monitoring; 6. LVN A did not perform hand hygiene in between changing gloves; 7. Irrigation syringe was hanging on the gastric tube (GT) machine. These failures could result in the spread of infection and cross-contamination that could affect the 87 residents who reside in the facility. Findings: 1. During an observation on 5/9/22 at 9:56 a.m., LVN D went to attend Resident 35, touched the resident's arm, left the room and went to his medication cart and touched computer mouse without doing hand hygiene in between. During an interview with LVN D on 5/9/22 at 9:57 a.m., LVN D confirmed the above observation. During an interview with the director of staff development/infection preventionist (DSD/IP) on 5/13/22 at 1:51 p.m., the DSD/IP stated staff should perform hand hygiene in between tasks. Review of the facility's policy, Handwashing/Hand Hygiene dated 08/2019 indicated, perform hand hygiene before and after direct contact with residents. 2. During an observation on 5/9/22 at 10:01 a.m., there was a face shield on top of the maintenance cart parked in the hallway and unattended. During a concurrent observation and interview with the minimum data set coordinator (MDSC) on 5/9/22 at 10:06 a.m., the MDSC confirmed the above observation and stated the face shield should be properly stored. During a concurrent observation and interview with the DSD/IP on 5/9/22 at 10: 11 a.m., the DSD/IP confirmed the above observation and stated the face shield should be stored properly. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056376 If continuation sheet Page 26 of 28 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 056376 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE A Grace Sub Acute & Skilled Care 1250 S. Winchester Boulevard San Jose, CA 95128 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 5/9/22 at 10:25 a.m., the administrator (ADM) stated the facility was converting three stations into yellow zone (term use to indicate isolation units). 3. During a dining observation on 5/9/22 at 12:24 p.m., CNA K wore an isolation gown and did not fasten the waist tie before entering an isolation room. CNA K entered the isolation room with an untied isolation gown and distributed the meal trays. The waist tie of the gown was touching the floor. During an interview with CNA K on 5/9/22 at 12:28 p.m., she confirmed the above observation. During an interview with the DSD/IP on 5/13/22 at 1:51 p.m., the DSD/IP acknowledged the staff should tie the isolation gown when entering an isolation room. Review of the Centers for Disease Control and Prevention (CDC) website ppe-sequence.pdf (cdc.gov), indicated when donning a gown, fasten in back of neck and waist. 4. During an observation 5/12/22 at 8:05 a.m., the RNA put on gloves, donned an isolation gown, proceeded to an isolation room, and sat down and talked to a resident in the room. During an interview with the RNA on 5/12/22 at 8:10 a.m., the RNA explained the sequence of donning (putting on) a PPE by donning the gloves followed by the gown. At 9:07 a.m., the RNA stated the sequence was to don the gown first followed by the gloves. During an interview with the DSD/IP on 5/13/22 at 1:51 p.m., the DSD/IP stated staff should don the gown first, perform hand hygiene and don the gloves. Review of the CDC's website, ppe-sequence.pdf (cdc.gov) indicated to don the gown first. 5. Review of Resident 25's clinical record indicated he was admitted to the facility on [DATE] with diagnoses including acute respiratory hypoxia (a condition when the lungs were not properly working and blood oxygen levels are low). Review of Resident 25's physician order did not indicate an order for daily screening for Covid-19 (a highly contagious respiratory disease) symptoms. During a concurrent interview and record review with the DSD/IP on 5/13/22 at 11:27 a.m., the DSD/IP reviewed Resident 25's medication administration record (MAR) and acknowledged there was no Covid 19 symptom monitoring. According to the CDC's website, Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes | CDC, updated February 2, 2022 indicated, evaluate residents at least daily for fever and symptoms consisted with Covid-19. 6. During a medication pass observation on 05/09/22, at 09:28 a.m., with LVN A, after entering Resident 72's room, she applied gloves, then pulled the privacy curtain with gloved hands. She stopped the resident's ongoing tube feeding (a therapy where a feeding tube supplies nutrients to people who cannot get enough nutrition through eating) by pressing the pump. Resident 72's ventilator (supplies oxygen to assist with breathing to increase the flow of oxygen to the lungs) started beeping. LVN A performed suction through the resident's tracheostomy (an opening surgically created through the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056376 If continuation sheet Page 27 of 28 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 056376 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE A Grace Sub Acute & Skilled Care 1250 S. Winchester Boulevard San Jose, CA 95128 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm neck into the windpipe to allow direct access to the breathing tube) and mouth. She then removed the old gloves, put on new ones without sanitizing her hands, and proceeded to do the medication administration. During an interview on 5/09/22, at 09:38 a.m., with LVN A, she stated she should have done hand hygiene by sanitizing her hands before putting on new gloves. Residents Affected - Some During an interview on 5/12/22, at 01:23 p.m., with IP/DSD, she stated nurses must do hand hygiene after taking off gloves and before putting on new gloves such as washing hands with soap and water or using hand sanitizer. A review of the facility's policy and procedure titled Handwashing/Hand Hygiene, revised August 2019, indicated, Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: .J. after contact with blood or bodily fluids; k. after handling used dressings, contaminated equipment, etc.; l. after contact with objects (e.g., medical equipment) in the immediate vicinity of the resident; m. after removing gloves . 7. During a concurrent observation and interview on 5/12/22 at 8:40 a.m., with Registered Nurse C (RN C) in Resident 64's room, an irrigation syringe (tube for sucking in and injecting fluid), used for foley catheter (a rubber tube inserted into the bladder to drain urine), was hanging on the gastric tube (GT) machine (device used to give direct feeding to a stomach). It was attached to an intravenous pole (medical device used to hold bags of fluids or feeding machine). RN C stated that the irrigation syringe should not be on the GT machine for possible cross-contamination. During a concurrent observation and interview on 5/12/22 at 8:47 a.m., with the director of nursing (DON), in Resident 64's room, DON validated that foley syringes must be away from the GT machine to prevent infection. During an interview on 5/12/22 at 9:27 a.m., with DSD/IP, she stated that foley syringes should be placed away from GT machines to prevent infection. During a review of the facility's policy and procedure (P&P) titled, Catheter Irrigation, dated October 2010, the P&P number 20 indicated, Label and store irrigation syringe below an Intravenous pole. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056376 If continuation sheet Page 28 of 28

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Citations

15 citations recorded^*CMS

What do CMS severity letters mean?

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

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

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

0552GeneralS&S Dpotential for harm
F552 - Planning and Implementing Care
Ensure that residents are fully informed and understand their health status, care and treatments.
0558GeneralS&S Dpotential for harm
F558 - The right to reside and receive services in the facility with reasonable
Reasonably accommodate the needs and preferences of each resident.
0583GeneralS&S Dpotential for harm
F583 - Privacy and Confidentiality
Keep residents' personal and medical records private and confidential.
0658GeneralS&S Epotential for harm
F658 - Comprehensive Care Plans
Ensure services provided by the nursing facility meet professional standards of quality.
0688GeneralS&S Dpotential for harm
F688 - Mobility
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
0697GeneralS&S Dpotential for harm
F697 - Pain Management
Provide safe, appropriate pain management for a resident who requires such services.
0698GeneralS&S Dpotential for harm
F698 - Dialysis
Provide safe, appropriate dialysis care/services for a resident who requires such services.
0755GeneralS&S Epotential for harm
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
0756GeneralS&S Dpotential for harm
F756 - Drug Regimen Review
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
0758GeneralS&S Dpotential for harm
F758 - Medication Errors
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
0759GeneralS&S Epotential for harm
F759 - Medication Errors
Ensure medication error rates are not 5 percent or greater.
0761GeneralS&S Dpotential for harm
F761 - Labeling of Drugs and Biologicals
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
0790GeneralS&S Dpotential for harm
F790 - Dental services
Provide routine and 24-hour emergency dental care for each resident.
0812GeneralS&S Epotential for harm
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
0880GeneralS&S Epotential for harm
F880 - Infection Control
Provide and implement an infection prevention and control program.

FAQ · About this visit

Common questions about this visit

What happened during the May 13, 2022 survey of A GRACE SUB ACUTE & SKILLED CARE?

This was a inspection survey of A GRACE SUB ACUTE & SKILLED CARE on May 13, 2022. The surveyor cited 15 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at A GRACE SUB ACUTE & SKILLED CARE on May 13, 2022?

Yes, 15 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Ensure that residents are fully informed and understand their health status, care and treatments."

What type of survey was this?

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

SourceView on CMS Care Compare

Next steps

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

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

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

Health inspection·May 13, 2022