Health inspection·June 30, 2023

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to resolve the grievance for one of three residents (1) when Resident 1's complaint about missing her chips, sodas, and baby wipes was not acted on. This failure had the potential to cause frustration for the Resident 1. Findings: Review of Resident 1's admission Record indicated she was admitted to the facility on [DATE]. During an interview with Resident 1 on 6/30/23 at 11:55 a.m., she stated her sodas were missing, and her baby wipes which were stored in the closet were also missing. Resident 1 stated she reported them to the staff. During a concurrent observation, Resident 1's soda pack was placed on the bed next to her bed, and her closet did not have a lock. Review of the facility's grievance binder indicated on 5/2/23 Resident 1 filed a grievance about her missing chips, sodas, and wipes with the recommendations to have Resident 1's items placed in a closet with a lock and Resident 1 had the key. However, the grievance did not indicate that the recommendations were acted on. During an interview with the business office clerk A (BOC A) on 6/30/23 at 2:25 p.m., he stated he worked in the social services office and just transferred to the business office on 6/20/23. The BOC A reviewed Resident 1's 5/2/23 grievance, and confirmed that nothing had been done for Resident 1's complaint on missing items. During an interview with Resident 1 on 6/30/23 at 3:45 p.m., she confirmed that her closet did not have a lock, and she did not have a key. Review of the facility's policy, Grievances/Complaints, Filing, dated 4/2017, indicated The Administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/or representative . 7. The Administrator had delegated the responsibility of grievance and/or complaint investigation to the Grievance Officer who is Social Services and Designee . 12. The resident, or person filing the grievance and/or complaint on behalf of the resident, will be informed (verbally and in writing) of the findings of the investigation and the action that will be taken to correct any identified problems: a. The Administrator, or his or her designee, will make such reports orally within 5 working days of the filing of the grievance or complaint with the facility. b. A (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 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 06/30/2023 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)