Health inspection·December 28, 2023

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few transcribed correctly the nurses would initial every shift that the splint was applied and would document a Y or a N ' indicating yes or no for the presence of redness or edema. LVN stated nurses should follow the physician order and document the application and monitoring of the left hand brace. 2. Review of Resident 1 ' s physician order, dated 11/8/23, indicated RNA services order: Donning and Doffing (practice of putting on and removing) of knee brace on the right starting at 7am to 3pm for 7 times a week. A review of Resident 1 ' s MAR, TAR (treatment administration record), and RNA Treatment records was conducted. There was no evidence of licensed nurses or RNA staff carrying out the physician order and documenting the application of Resident 1 ' s right knee brace. During an interview and concurrent record review with Licensed Vocational Nurse A (LVN A) on 12/19/23 at 12:15 p.m., he stated the physician order for donning and doffing of the right knee brace was transcribed incorrectly. LVN A stated the physician order did not appear in Resident 1 ' s administration record and he confirmed there was no documented evidence that facility staff was applying Resident 1 ' s right knee brace. He further stated if the physician order was transcribed correctly the facility staff would initial the application and removal of the right knee brace. LVN A stated nurses should follow the physician order and document the donning and doffing Resident 1 ' s right knee brace. 3. Review of Resident 1 ' s physician order, dated 10/26/23, indicated RNA services order: Passive range of motion to gentle passive stretching on (B)UE/LE (both upper and lower extremity) for 5 times per week. Focus on stretching the right knee towards extension and left ankle motions. Apply the PRAFO boot (Pressure Relief Ankle Foot Orthosis boot to prevent contractures and pressure ulcers) after stretching. A review of Resident 1 ' s RNA treatment records indicated missing entries for the performance of RNA services as ordered by Resident 1 ' s physician. The RNA treatment record for 11/1/23 through 11/30/23 indicated RNA services were documented as performed only 8 times. The RNA treatment record for 12/1/23 through 12/18/23 indicated RNA services were documented as performed only 3 times. During an interview and concurrent record review with RNA B, on 12/19/23 at 1:50 p.m., he confirmed he was providing RNA services to Resident 1. He reviewed the RNA treatment record for the month of November and December and acknowledged there were blank spaces on the monthly records. He confirmed the physician order was for Resident 1 to receive RNA services 5 times a week. When asked to explain the missing entries he stated the blanks were the days when Resident 1 did not receive RNA services and stated Resident 1 refuses the range of motion exercises frequently. RNA B stated Resident 1 will often scream and yell when RNA B attempts to do range of motion as prescribed, and he will not force Resident 1 to exercise. He further added I can usually only do it once or twice a week. When asked if he documents Resident 1 ' s refusals, RNA B stated he was not aware that he needed to document Resident 1 ' s refusals. During an observation on 12/19/23 at 10:50 a.m., Resident 1 was seated in her wheelchair in the main dining room of the facility. She was not wearing any hand splint on her left hand or a right knee brace. During a concurrent interview with the ADON on 12/19/23 at 10:50 a.m., she confirmed that Resident 1 was not wearing any left hand splint or right knee brace. The ADON stated she was unaware of why Resident 1 was not wearing these devices. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056376 If continuation sheet Page 2 of 3 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 12/28/2023 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)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview and concurrent record review with the ADON, on 12/19/23 at 11:45 a.m., she confirmed Resident 1 had physician orders to wear a left hand splint and a right knee brace. Upon further review of these physician orders, the ADON stated both of these orders were not transcribed correctly, The ADON stated licensed nurses were not initialing the application of the left hand splint or documenting to check for redness and edema, and she confirmed they should be. The ADON further stated the order to apply the right knee brace did not appear on Resident 1 ' s administration record so staff were not documenting the donning and doffing of the right knee brace, and she confirmed they should be. The DON reviewed Resident 1 ' s physician order for RNA services 5 times a week. She reviewed Resident 1 ' s RNA treatment record for November and December and acknowledged there were blank spaces on the record. When asked about the missing entries she stated she was unaware of why the RNA did not document that services were provided 5 times a week as ordered. She confirmed if a resident refuses medications or treatments, the refusal should be documented. Review of the facility policy titled Charting and Documentation, revised July 2017, indicated all services provided to the resident shall be documented in the resident ' s medical record. Documentation of procedures and treatments will include care-specific details, including . e. Whether the resident refused the procedure/treatment . g. The signature and title of the individual documenting. Review of the facility ' s undated Job Description: RNA, indicated Duties and Responsibilities: . Adheres to department procedures regarding documentation of services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056376 If continuation sheet Page 3 of 3