Other·December 5, 2017

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during a recertification survey conducted from 11/13/17 through 11/16/17. The facility was licensed for 99 beds. The census at the time of the survey was 86. The sample size was 18.

F323, 483.25(d)(1)(2)(n)(1)-(3) Free of Accident/Hazards/Supervisions/Devices had a scope and severity of "G". A Class "B" Citation was also issued. Representing the California Department of Public Health: 34383, Health Facilities Evaluator Nurse; 32892, Health Facilities Evaluator Nurse; 36624, Health Facilities Evaluator Nurse; 37959, Health Facilities Evaluator Nurse; and 38243, Health Facilities Evaluator Nurse.

F176 SS=D RESIDENT SELF-ADMINISTER DRUGS IF DEEMED SAFE CFR(s): 483.10(c)(7)

F176 01/03/2018 (c)(7) The right to self-administer medications if the interdisciplinary team, as defined by §483.21(b)(2)(ii), has determined that this practice is clinically appropriate. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure no medication and treatments were left at the bedside for 2 non-sampled residents (Resident LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2R4D11 Facility ID: CA070000009 If continuation sheet 1 of 26 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555483 (X3) DATE SURVEY COMPLETED 11/16/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VISTA MANOR NURSING CENTER 120 Jose Figueres Ave San Jose, CA 95116 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 20 and 21) to self-administer without physician's orders. These failures had the potential for unsafe administration of medications or treatments that could possibly result to adverse effects and reactions. Findings: During the initial tour on 11/13/17 at 8:28 a.m., two tubes labeled "Medline clear and skin protectant" and "Hydrophilic wound dressing" creams were found at the bedside table of Resident 20. In a concurrent interview with registered nurse E (RN E), she confirmed the above observation and stated, she was not sure if those creams could be left at bedside but had to check with the director of nursing (DON). RN E then took the creams out of the room. Resident 20's clinical record indicated, she was admitted to the facility on 11/7/2017, with "Assessment for Self-Administration of Medications" done on 11/7/17 indicating she cannot self-dminister medications. No evidence was found indicating that a care plan, physician's order or IDT review for medication self-administration were done. During an interview with DON on 11/14/17 at 11:35 a.m., she stated no creams used for treatment or for skin protection and prophylaxis are be left at bedside without a doctor's order. In an interview with the assistant director of nursing (ADON) on 11/15/17 at 10:30 a.m., she stated, she talked to Resident 20 and told her that no creams are to be left at bedside and only nurses are allowed to apply creams used for skin protection. During an interview with the treatment nurse FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2R4D11 Facility ID: CA070000009 If continuation sheet 2 of 26 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555483 (X3) DATE SURVEY COMPLETED 11/16/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VISTA MANOR NURSING CENTER 120 Jose Figueres Ave San Jose, CA 95116 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (TN) on 11/16/17 at 2:00 p.m., she stated treatment creams should be kept in the treatment cart and not at the resident's bedside. 2. A review of Resident 21's interdisciplinary team (IDT, a coordinated group of experts from several different fields who work together toward a common goal that requires multiple skills sets or areas of expertise in order to succeed) assessment for self - administration of medications dated 10/29/17 indicated Resident 21 preferred licensed nurses (LN) to administer his medications. During the initial tour, on 11/23/17, at 8 a.m., a plastic bottle of herbal dietary supplement was at the bedside of Resident 21. In another observation and interview, on 11/15/17 at 4:50 a.m., Resident 21's family member (FM) was at the bedside. The FM stated she brought the bottle of Chinese herb, a kind of fruit syrup, for Resident 21's sore throat (condition marked by pain in the throat, caused by inflammation (reddened, swollen, hot) due to a cold or other virus). The FM stated she did not notify the facility staff about the herbal bottle. In a concurrent interview, on 11/15/17, at 5 p.m., the DON stated Resident 21 should have a physician's order for the herbal medication. She also stated Resident 21 should not be allowed to keep the herbal medication at bedside. A review of the facility's 12/2016 revised policy on "Self Administration of Medication" indicated, residents have the right to selfadminister medications if the he nurse will obtain a physician's order for each resident conducting self-administration of medications". It also indicated that to maintain the safety and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2R4D11 Facility ID: CA070000009 If continuation sheet 3 of 26 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555483 (X3) DATE SURVEY COMPLETED 11/16/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VISTA MANOR NURSING CENTER 120 Jose Figueres Ave San Jose, CA 95116 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE accuracy of medication administration, the interdisciplinary team would do an assessment and evaluation process to determine if a resident is capable of self-administration. The staff shall identify and give to the charge nurse (CN) any medications found at the bedside that are not authorized for self-administration.

F221 SS=D RIGHT TO BE FREE FROM PHYSICAL RESTRAINTS CFR(s): 483.10(e)(1), 483.12(a)(2)

F221 01/03/2018 §483.10(e) Respect and Dignity. The resident has a right to be treated with respect and dignity, including: §483.10(e)(1) The right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms, consistent with §483.12(a)(2). 42 CFR §483.12, 483.12(a)(2) The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident’s symptoms. (a) The facility must(1) Ensure that the resident is free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident’s medical symptoms. When the use of restraints is indicated, the facility must use the least restrictive alternative for the least amount of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2R4D11 Facility ID: CA070000009 If continuation sheet 4 of 26 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555483 (X3) DATE SURVEY COMPLETED 11/16/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VISTA MANOR NURSING CENTER 120 Jose Figueres Ave San Jose, CA 95116 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE time and document ongoing re-evaluation of the need for restraints. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure Resident 6 was free from physical restraint when behaviors of getting up or ambulating unassisted was not properly assessed, evaluated or monitored and when restraint was indicated to prevent unassisted transfer. This failure could have contributed to Resident 6's agitation and repeated falls. Findings: A review of Resident 6's clinical record indicated he was admitted on 11/21/16 with diagnoses including dementia (decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities) and altered mental status (AMS, changes in brain function, such as confusion, amnesia (memory loss), loss of alertness, disorientation (not cognizant of self, time, or place), defects in judgment or thought, unusual or strange behavior, poor regulation of emotions, and disruptions in perception) secondary to urinary tract infection (UTI, infection in any part of the urinary system kidneys, ureters, bladder and urethra). A review of the nurses notes on 11/22/16 indicated Resident 6 was verbally responsive with confusion, with episodes of getting up unattended, and was non-compliant to stay in the wheelchair. On 11/23/16, Resident 6 was again verbally responsive with confusion with episodes of repeatedly getting up from wheelchair, had attempted to ambulate, was combative and attempted to hit staff. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2R4D11 Facility ID: CA070000009 If continuation sheet 5 of 26 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555483 (X3) DATE SURVEY COMPLETED 11/16/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VISTA MANOR NURSING CENTER 120 Jose Figueres Ave San Jose, CA 95116 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of the seat belt (a band to tie or buckle around the body (usually at the waist) restraint (a device that retards something's motion) indicated a seatbelt consent from the family member (FM) not the responsible party (RP, person who has a level of control over health care decisions) was obtained on 11/23/16 to prevent unassisted transfer and ambulation. A review of the IDT quarterly physical restraint assessment dated 2/26/17, 5/30/17, and 8/23/17 indicated seatbelt in wheelchair to prevent unassisted transfer and ambulation. A review of the restraint care plan dated 11/24/16 indicated Resident 6 was "at risk for agitation due to use of physical restraint" (seatbelt in wheelchair) and to monitor resident behavior while on restraints. A review of the following physician's orders were indicated for agitation: on 8/25/17, Paxil (an antidepressant drugs, used to treat major depressive disorder (causes severe symptoms that affect feeling, thinking, and handling daily activities, such as sleeping, eating, or working) was started for depression with agitation (state of feeling irritated or restless) manifested by fidgeting, on 8/26/17, Depakene 250 milligram/5 mililiter (mg/ml, unit of measurement) was started for agitation with behavioral disturbance manifested by grabbing staff, and on 8/24/17, Ambien was started every hour of sleep for insomnia. During several observations, on 11/13/17 at 11 a.m., 11:03 a.m., 11:50 a.m., 12:15 p.m., and on 11/14/17 at 10:10 a.m., Resident 6 was observed seated on his wheelchair with a seatbelt on, alarm attached to the wheelchair, propelling himself in the hallway and moving around, at times a family member was around, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2R4D11 Facility ID: CA070000009 If continuation sheet 6 of 26 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555483 (X3) DATE SURVEY COMPLETED 11/16/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VISTA MANOR NURSING CENTER 120 Jose Figueres Ave San Jose, CA 95116 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE at times Resident 6's wheelchair was parked in front of the nurses station, and during lunch time was pushed by staff in the dining/activity room. During an interview, on 11/13/17, at 11 a.m., CNA P stated the resident used seatbelt when up in wheelchair every time. CNA P also stated Resident 6 fought at times. She stated Resident 6 was confused and do not know what to do at times. During an interview, on 11/14/17, at 10:55 a.m., LVN Q stated Resident 6 had a seatbelt restraint for unassisted transfer, unassisted ambulation and unassisted standing. LVN Q also stated Resident 6 used a seatbelt restraint daily because of behavior. During an interview and record review, on 11/15/17, at 8 a.m., the DON reviewed Resident 6's clinical record and stated behavior episodes for unassisted transfer or ambulation was not assessed, monitored or evaluated. The DON also reviewed Resident 6's hourly monitoring for 14 days. She stated staff entries were incomplete for 7/19/17 and 7/20/17. She added there was no IDT assessment or evaluation for the hourly monitoring whether it was effective or not for Resident 6's safety. The DON also reviewed Resident 6's IDT quarterly notes dated 2/26/17, 5/30/17, and 8/23/17 and stated after the seven fall incidents from 2/2/17 to 7/26/17, the IDT had agreed the seatbelt restraint daily was part of the fall prevention care plan. She stated a seatbelt restraint was applied daily to Resident 6 to prevent from unassisted transfer and ambulation. The DON also stated she could not find any rehabilitation evaluation after each fall incident. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2R4D11 Facility ID: CA070000009 If continuation sheet 7 of 26 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555483 (X3) DATE SURVEY COMPLETED 11/16/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VISTA MANOR NURSING CENTER 120 Jose Figueres Ave San Jose, CA 95116 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During an interview, on 11/15/17, at 4:40 p.m. the rehab director (RD) stated there was no specific rehab evaluation done before the physical restraint was applied. A review of the facility's 06/2016 revised procedure "Physical Restraint" indicated practices that inappropriately utilize equipment to prevent resident mobility are considered restraints and are not permitted.

F281 SS=E SERVICES PROVIDED MEET PROFESSIONAL STANDARDS CFR(s): 483.21(b)(3)(i)

F281 01/03/2018 (b)(3) Comprehensive Care Plans The services provided or arranged by the facility, as outlined by the comprehensive care plan, must(i) Meet professional standards of quality. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to assure services provided to the residents met professional standards of quality when licensed nurses did not assess accurately the orthostatic blood pressure(blood pressure obtained while the patient is in the lying as well as in the standing positions) when the Fall Risk Evaluation for fifteen of (15) sampled Residents (1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, and 15) were done. Facility failed to follow physician orders for three out of 15 sampled residents (2, 10, and 11). These failures had the potential of putting all residents at risk for falls, accidents, and health complications. Findings: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2R4D11 Facility ID: CA070000009 If continuation sheet 8 of 26 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555483 (X3) DATE SURVEY COMPLETED 11/16/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VISTA MANOR NURSING CENTER 120 Jose Figueres Ave San Jose, CA 95116 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 1. Review of facility's "Fall risk evaluation" form indicated to evaluate resident status in the eight clinical condition parameters listed (A H), item F "Systolic Blood Pressure" indicated to check for noted drop in systolic (the top number, indicating the amount of pressure in the arteries during contraction of the heart muscle) blood pressure between lying and standing: 0 - no noted drop, 2 - drop less than 20 millimeters mercury (mm Hg), 4 - drop more than 20 mm Hg. During an interview with registered nurse C (RN C), on 11/15/17 at 8:50 a.m., she stated she did admission assessments for residents, she stated she assessed baseline vital signs/blood pressures but could not provide any documentation of blood pressures taken while residents are in lying, sitting or standing positions to satisfy the requirement of section F in the fall risk evaluation. Review of facility policy on Falls Management with effective date September 2015 revised 10/14/17 indicated each resident must be assessed on admission using the fall risk assessment form, quarterly, and any change in condition noted for potential risk for falls in order to take preventive approach. Review of facility policy on blood pressure (BP) measuring revised September 2010, indicated orthostatic (postural) hypotension is defined as a 20 mm/Hg (or greater) decline in systolic blood pressure or a 10 mm/Hg (or greater) decline in diastolic blood pressure upon standing; to measure orthostatic blood pressure, repeat steps eight (8) through fourteen (14) immediately after helping the resident to a standing position, note changes in both the systolic and diastolic measurements compared to the reading taken while the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2R4D11 Facility ID: CA070000009 If continuation sheet 9 of 26 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555483 (X3) DATE SURVEY COMPLETED 11/16/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VISTA MANOR NURSING CENTER 120 Jose Figueres Ave San Jose, CA 95116 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE resident was in seated position; the following information should be recorded in the resident's medical record: date and time blood pressure was measured, name and title of individual(s) who measured the blood pressure, and the blood pressure reading. 2. Resident 10's Fall Risk Evaluations, item F done on 10/6/16, 11/2/16, 2/1/17, 5/21/17, 7/31/17, and 10/29/17, were scored zero (0- no drop in the systolic blood pressure) while the fall risk evaluation done on 11/13/17 scored two (2 - there was a drop in the systolic blood pressure of less than 20 mmHg between lying and standing). Resident 11's Fall Risk Evaluation, item F done on 8/15/17 scored zero and when the assessment was repeated on 11/13/17 the score was two . The Fall Risk Evaluation total score was 15 . Fall risk score of 10 or above represented high risk. During an interview with the registered nurse D (RN D), the MDS Coordinator/Supervisor on 11/13/17 at 2:50 p.m., the "Fall Risk" evaluations were done upon admission, quarterly, annually and after fall incidents. During a follow-up interview with RN D, with the director of nursing (DON) on 11/13/17 at 3:05 p.m., the DON concurred that the nurses' procedure of measuring the orthostatic blood pressure in relation to Fall risk evaluation, section F were done incorrectly. Per the DON, to check for orthostatic BP, compare the systolic BP readings between lying and standing positions or if unable to stand, compare lying and sitting. In an interview with the director of staff development (DSD) on 11/14/17 at 8:20 a.m., she stated to check orthostatic blood pressure, staff must take the resident's BP in lying, sitting FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2R4D11 Facility ID: CA070000009 If continuation sheet 10 of 26 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555483 (X3) DATE SURVEY COMPLETED 11/16/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VISTA MANOR NURSING CENTER 120 Jose Figueres Ave San Jose, CA 95116 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE or standing and then compare the BP readings. Per the DSD, the DON gave in-service to staff on 11/13/17 on the correct procedure to check the orthostatic BP. She said, if the assessment is incorrect or inaccurate, then the safety of the resident is at stake. During a follow-up interview with the DON on 11/14/17 at 11:35 a.m., she stated, all residents had their orthostatic BP rechecked on 11/13/17 because the previously completed orthostatic BP assessments were inaccurate. The Fall Risk evaluation of all the residents were documented to reflect the correct orthostatic score. 3. Review of Resident 10's clinical record indicated admission on 9/9/03 with admitting diagnoses including major depressive disorder, Parkinson's disease (a neurodegenerative disorder which leads to progressive deterioration of motor function due to loss of dopamine-producing brain cells), dementia (loss of memory and other mental abilities severe enough to interfere with daily life) without behavioral disturbance. Resident 10's physician's order dated 10/17/16 included, to monitor episodes of depression manifested by crying every shift and monitor episodes of hitting, kicking staff every shift. Resident 10's Medication Administration Record (MAR) for the months of October and November 2017 indicated, no monitoring done for episodes of hitting and kicking staff every shift from October 1-November 13, 2017. The monitoring of episodes of depression manifested by crying every shift for October 131, 2017 did not indicate the episodes but rather the nurses initials every shift were documented. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2R4D11 Facility ID: CA070000009 If continuation sheet 11 of 26 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555483 (X3) DATE SURVEY COMPLETED 11/16/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VISTA MANOR NURSING CENTER 120 Jose Figueres Ave San Jose, CA 95116 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During an interview and concurrent record review done with the licensed vocational nurse Q (LVN Q) on 11/14/17 at 8:15 a.m., she confirmed that documentation for kicking, hitting and crying episodes were missing. Per LVN, the monitoring should have been done and documented. The facility's revised 12/2016 policy on "Behavioral Assessment, Intervention and Monitoring", indicated, interventions and approaches in the management of behavior is based on detailed assessment of the behavioral symptoms that include the frequency, duration, intensity, etc. 3. Review of Resident 11's clinical record indicated admission on 8/15/17 with admitting diagnoses including dementia (loss of memory and other mental abilities severe enough to interfere with daily life ) without behavioral disturbance, hypertension (HTN- abnormally high blood pressure), hemiplegia (a total or partial paralysis of one side of the body that results from disease of or injury to the motor centers of the brain) and hemiparesis (partial paralysis affecting one side of the body). Resident 11's Pressure Ulcer Risk Evaluation dated 8/15/17 indicated a score of 10. A score of 8 or above represented high risk. Resident 11's physician's order dated 9/15/17 included, to turn every 2 hours for repositioning/better circulation, and low bed to prevent injury from fall. During multiple observations done on 11/3/17 at 10:30 a.m., and 1:40 p.m., on 11/14/17 at 7:20 a.m., 9:25 a.m. and 11:15 a.m., the resident was noted to be lying on his back, his bed was not in a low position. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2R4D11 Facility ID: CA070000009 If continuation sheet 12 of 26 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555483 (X3) DATE SURVEY COMPLETED 11/16/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VISTA MANOR NURSING CENTER 120 Jose Figueres Ave San Jose, CA 95116 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During an interview with the licensed vocational nurse Q (LVN Q) on 11/14/17 at 11:15 a.m., she verified the above observations. LVN Q repositioned the bed to lowest position using the bed remote control right away and stated, she was busy and will tell the CNA to reposition the resident. During an interview with the assistant director of nursing (ADON) on 11/14/17 at 11:30 a.m., she stated staff should follow doctor's orders. Per ADON, if the order was low bed, then the bed should be in lowest position and the resident's repositioning helps prevent skin breakdown and promote circulation. Review of the California Board of Registered Nursing website, California Business and Professions Code, Division 2, Chapter 6, Article 2, Section 2725(b)(2), indicated RNs should ensure the safety, protection of residents; administration of medications, and therapeutic agents, necessary to implement a treatment, disease prevention, ordered by and within the scope of the licensure of a physician. 4. Review of Resident 2's Physician Orders dated on 8/10/17, indicated to place low bed with fall mattress on the floor to prevent injury from fall every shift. During an observation on 11/13/17 at 12:15 p.m., 11/14/17 at 9:00 a.m., and 11/15/17 at 8:02 a.m., Resident 2 was lying in his bed asleep with no fall mattress and not in a low bed. During an observation and interview with LVN B on 11/15/17 at 8:05 a.m., LVN B acknowledged Resident 2 was lying on his bed with no fall mattress on the floor and not in a low bed position. She also stated the physician order should have been followed to prevent injury from fall. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2R4D11 Facility ID: CA070000009 If continuation sheet 13 of 26 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555483 (X3) DATE SURVEY COMPLETED 11/16/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VISTA MANOR NURSING CENTER 120 Jose Figueres Ave San Jose, CA 95116 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

F323 FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES CFR(s): 483.25(d)(1)(2)(n)(1)-(3)

F323 SS=G PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 01/03/2018 (d) Accidents. The facility must ensure that (1) The resident environment remains as free from accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. (n) - Bed Rails. The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements. (1) Assess the resident for risk of entrapment from bed rails prior to installation. (2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation. (3) Ensure that the bed’s dimensions are appropriate for the resident’s size and weight. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to provide two-person assistance during a change of her incontinent pads for one of 18 sampled residents (Residents 3). This failure resulted in Resident 3's fall with a fracture of the right femur (the bone located within the human thigh extending FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2R4D11 Facility ID: CA070000009 If continuation sheet 14 of 26 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555483 (X3) DATE SURVEY COMPLETED 11/16/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VISTA MANOR NURSING CENTER 120 Jose Figueres Ave San Jose, CA 95116 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE from the hip to the knee) and an open reduction internal fixation (ORIF-is a type of surgery used to stabilize and heal a broken bone). Findings: Review of Resident 3's clinical record indicated she was admitted on 12/1/16 with diagnoses including abnormal posture, hypertension (HTN-abnormally elevated blood pressure), Diabetes mellitus (DM-a condition in which the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine), malignant neoplasm (abnormal growth of tissue) of bladder. Resident 3's Minimum Data Set (MDS, an assessment tool) dated 12/07/16, indicated the resident BIMS (Brief Interview for Mental Status- an assessment tool for cognition) score of 13 indicating cognitively intact and was totally dependent that required two or more persons physical assistance with bed mobility and toilet use. Review of Resident 3's Fall Risk Assessment dated 12/1/16 indicated she had a score of 13. A score of 10 or more indicated high risk for fall. Review of Resident 3's Resident Data Collection dated 12/1/16 indicated she was dependent on personal hygiene and grooming. Resident 3's ADL records for the months of February and March 2017, indicated Resident 3 was dependent with two-person assistance for bed mobility and toilet use. Review of Resident 3's ADL impairment care plan dated 12/5/16, indicated she was dependent and required two-person assistance with activities of daily living (ADLs, such as bed mobility, transfer, toileting and personal FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2R4D11 Facility ID: CA070000009 If continuation sheet 15 of 26 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555483 (X3) DATE SURVEY COMPLETED 11/16/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VISTA MANOR NURSING CENTER 120 Jose Figueres Ave San Jose, CA 95116 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE hygiene) related to bilateral knee contractures, history of left shoulder fracture, gall bladder cancer (CA - is a group of diseases involving abnormal cell growth with the potential to invade or spread to other parts of the body), DM, HTN, depression, hydrocephalus (a condition in which there is an accumulation of cerebrospinal fluid (CSF - a clear fluid that surrounds the brain and spinal cord) within the brain. Review of Resident 3's Interdisciplinary team's (IDT, composed of different disciplines like nursing, social service, activities, rehabilitation, maintenance, who work together toward a common goal) care conference summary and quarterly review of bowel and bladder evaluation plan dated 3/8/17 indicated, she was totally dependent, incontinent with bladder and bowel and dependent from the staff for toileting needs. Review of Resident 3's toileting needs care plan dated 12/5/16, indicated Resident 3 was incontinent (unable to voluntarily control retention) of both bowel and bladder that required total assistance. Review of the potential for fall care plan dated 12/5/16 indicated Resident 3 was dependent for toileting status and had the potential to fall related to history of fracture left shoulder, right arm, and right foot osteomyelitis (inflammation of bones), narcotic and analgesic (pain medication) use, antihypertensives (medications to treat high blood pressure), hypoglycemia (low blood sugar level) that required assistance with ADLs PRN (as needed). Review of Resident 3's Nurses notes dated 3/16/17 indicated the resident was found sitting on the floor, complained of pain on legs FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2R4D11 Facility ID: CA070000009 If continuation sheet 16 of 26 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555483 (X3) DATE SURVEY COMPLETED 11/16/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VISTA MANOR NURSING CENTER 120 Jose Figueres Ave San Jose, CA 95116 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE and thigh upon assessment and was given pain medication. The doctor was notified and an Xray (procedure that creates imaging pictures of the inside of the body) was done. The physician's order dated 3/16/17 at 9:00 p.m. indicated X-ray of right and left leg, and right and left thigh STAT (immediately) due to complaint of pain. Review of Resident 3's Change in Condition Post Fall report dated 3/16/17 indicated the resident was seen sitting on the floor on the left side of her bed. Per report, the certified nursing assistant (CNA) while changing the resident's diaper turned the resident to the left side, the CNA tried to prevent the fall but because the resident's weight was too much she put the resident to sit on the floor. Review of Resident 3's Change in Condition Post- fall IDT done on 3/17/17 indicated, during an interview with the resident, she stated a CNA was helping her turn to her left side during incontinent care when she suddenly started to slip slowly out of bed. The CNA tried to put her back to bed but because of the resident's weight the CNA eased her down to the floor. The IDT post fall recommendation included two-person assistance for ADLs, educate and train CNA for proper technique during ADL care. Review of Resident 3's findings of the X-ray of the right femur (two views) done on 3/17/17 indicated, there was a relatively acute angulated and moderately displaced supracondylar (a round part at the end of a bone where it fits into another bone) fracture of the distal right femur. Review of Resident 3's nurses notes dated 3/17/17 indicated, the attending doctor was notified of Resident 3's X-ray findings with FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2R4D11 Facility ID: CA070000009 If continuation sheet 17 of 26 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555483 (X3) DATE SURVEY COMPLETED 11/16/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VISTA MANOR NURSING CENTER 120 Jose Figueres Ave San Jose, CA 95116 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE order to transfer Resident 3 to the acute hospital for further evaluation and management of right distal (situated away from the center of the body) fracture. Resident 3 was transferred to the acute hospital on 3/18/17 at 1:20 p.m. Review of the acute hospital's diagnostic imaging report done on 3/18/17 indicated, right femoral shaft fracture (a break of the long, straight part of the thigh bone) of uncertain age. The imaging report done on 3/19/17 after the surgery indicated fluoroscopic (an imaging technique that uses X-rays to obtain real-time moving images of the interior of an object) spot images for intramedullary rod (also known as an intramedullary nail (IM nail) is a metal rod forced into the medullary cavity of a bone used to treat fractures of long bones of the body) placement right femur. Review of Resident 3's readmission to the facility on 3/22/17, included diagnoses of HTN, hyperlipidemia (elevated lipid level), DM, s/p (status post) right knee surgery with ORIF. During Resident 3's observation and concurrent resident interview done on 11/14/17 at 8:30 a.m., Resident 3 stated, the fall happened when only one CNA assisted her to turn to her left side to change her diaper. She slipped out of bed after being turned to her left side, and fell on her right knee. Per resident, the CNA was alone at that time. The CNA should have asked for another staff for help which they usually do. During an interview with registered nurse F (RN F) on 11/15/17 at 7:42 a.m., she validated Resident 3 needed two-person assistance with all her ADLs. During a phone interview with registered nurse H (RN H) on 11/15/17 at 10:30 a.m., she FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2R4D11 Facility ID: CA070000009 If continuation sheet 18 of 26 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555483 (X3) DATE SURVEY COMPLETED 11/16/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VISTA MANOR NURSING CENTER 120 Jose Figueres Ave San Jose, CA 95116 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE confirmed that the CNA worked by herself when changing Resident 3's diaper. During an interview with licensed vocational nurse I (LVN I ) on 11/15/17 at 1:50 p.m., she stated that the CNA repoted working by herself when the resident was turned in bed while changing her diaper and fell on the floor. Per LVN, the CNA stated, she did not follow the two-person assistance needed during the ADL care. During an interview and record review with the assistant director of nursing (ADON) on 11/15/17 at 2:10 p.m., she stated Resident 3 was a high risk for falls and required twoperson assistance during ADLs. Per the ADON, if the CNA followed the care plan indicating two-person assistance during the ADL care, the fall could have been prevented. Review of the facility's 10/14/15 revised policy on "Falls Management", indicated a fall is an unintentional change in position coming to rest on the ground, floor or onto the next lower surface. Each resident must be assessed on admission using the Fall Risk Assessment form for potential risk for falls in order to take preventive approach. Identify the reason and/or risk factors for the fall in order to prepare a plan of care to reduce the potential for future falls.

F371 SS=F FOOD PROCURE, STORE/PREPARE/SERVE F371 - SANITARY CFR(s): 483.60(i)(1)-(3) 01/03/2018 (i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities. (i) This may include food items obtained directly from local producers, subject to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2R4D11 Facility ID: CA070000009 If continuation sheet 19 of 26 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555483 (X3) DATE SURVEY COMPLETED 11/16/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VISTA MANOR NURSING CENTER 120 Jose Figueres Ave San Jose, CA 95116 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE applicable State and local laws or regulations. (ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. (iii) This provision does not preclude residents from consuming foods not procured by the facility. (i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. (i)(3) Have a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to follow manufacturer's recommendation for chlorine sanitizer (chemical substance to kill the germs) test procedures for the low-temperature dish machine. This failure created a potential for food-borne illnesses. Findings: During a kitchen observation on 11/13/17 at 7:50 a.m., accompanied by the executive cook (EC), a dietary aide (DA) demonstrated on how to test the dish machine using chlorine sanitizer. The DA took one test strip (a strip contains sensitized material that is used to expose to the sanitizer for vary length of time to check the proper sanitizer concentration in order to kill the germ) , dipped it into chlorine sanitizer solution for 5 seconds and immediately compared the test strip to the color FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2R4D11 Facility ID: CA070000009 If continuation sheet 20 of 26 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555483 (X3) DATE SURVEY COMPLETED 11/16/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VISTA MANOR NURSING CENTER 120 Jose Figueres Ave San Jose, CA 95116 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE chart. During a concurrent interview with the EC, he stated the DA did not follow the manufacturer's guidelines. The EC stated the DA should dip the test strip into the sanitizer solution and remove it immediately and wait for at least 5 seconds before comparing it to the color chart. During an interview with the dietary supervisor (DS) on 11/13/17 at 8:10 a.m. she stated they should follow the manufacturer's recommendations to ensure accurate measurement. According to the facility's undated "Chlorine Sanitizer Test Procedures for LowTemperature Dish Machine", test trip should be dipped into solution and removed immediately... After dipping, let sit for at least 5 seconds but not more than 10 seconds before reading the strip. Match the test strip to the color chart to determine chlorine concentration.

F431 SS=D DRUG RECORDS, LABEL/STORE DRUGS & BIOLOGICALS CFR(s): 483.45(b)(2)(3)(g)(h)

F431 01/03/2018 The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g) of this part. The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse. (a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2R4D11 Facility ID: CA070000009 If continuation sheet 21 of 26 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555483 (X3) DATE SURVEY COMPLETED 11/16/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VISTA MANOR NURSING CENTER 120 Jose Figueres Ave San Jose, CA 95116 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who-(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and (3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. (g) Labeling of Drugs and Biologicals. Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. (h) Storage of Drugs and Biologicals. (1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. (2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2R4D11 Facility ID: CA070000009 If continuation sheet 22 of 26 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555483 (X3) DATE SURVEY COMPLETED 11/16/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VISTA MANOR NURSING CENTER 120 Jose Figueres Ave San Jose, CA 95116 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE review, the facility failed to establish a procedure in monitoring medication room temperature to maintain safe drug storage and ensure accurate labeling for one non-sampled resident (19). This failure could result to unsafe medication storage and created a potential for medication error. Findings: 1. During medication room A (MR A) inspection with the assistant director of nursing (ADON) on 11/13/17 at 8:14 a.m., there was no thermometer inside the room. The ADON stated she saw one last week hanging on the wall but she was unsure what happened. During an interview with the maintenance director (MD) on 11/14/17 at 10:07 a.m., he stated he was not aware that the wall thermometer was missing nor broken in MR A. The MD stated licensed nurses usually inform him if there was any maintenance issues. However, the MD stated licensed nurses were the ones monitoring the temperature in the medication rooms. During an interview with the director of nursing (DON) on 11/14/17 at 1:25 p.m. she stated it was the MD who was responsible for checking the medication room temperature. During another interview with the DON on 11/15/17 at 1:37 p.m., she stated that she conducted a few interviews and it was still unclear who was responsible for monitoring the medication room temperature. The DON stated the medication should be stored at the right temperature in order to maintain its integrity. The DON stated she would streamline the process and would assign licensed nurses to monitor both the medication room and medication refrigerator temperatures. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2R4D11 Facility ID: CA070000009 If continuation sheet 23 of 26 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555483 (X3) DATE SURVEY COMPLETED 11/16/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VISTA MANOR NURSING CENTER 120 Jose Figueres Ave San Jose, CA 95116 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Review of facility's 4/2007 "Storage of Medications" policy indicated "the facility shall store all drugs and biologicals in a safe, secure, and orderly manner. The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. 2. During a medication pass observation on 11/14/17 at 8:25 a.m., registered nurse A (RN A) prepared Resident 19's medications including sertraline (anti-depressant medication) 50 milligrams (mg, unit of measurement). The medication label indicated to administer sertraline 50 mg by mouth during bedtime. During a concurrent interview with RN A, she stated there was a change of physician order, however, the licensed nurse who received the order forgot to put a sticker to indicate such a change. During an interview with the DON on 11/14/17 at 1:25 p.m. she stated it was the facility's policy to put a "Directions Changed, Refer to Chart" sticker if there was a change in the physician's medication order. Review of the facility's 4/2007 "Storage of Medications" policy indicated drugs that have a change in directions will have a change of directions label applied and pharmacy to be notified of change.

F456 SS=D ESSENTIAL EQUIPMENT, SAFE OPERATING CONDITION CFR(s): 483.90(d)(2)(e) FORM CMS-2567(02-99) Previous Versions Obsolete

F456 Event ID: 2R4D11 01/03/2018 Facility ID: CA070000009 If continuation sheet 24 of 26 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555483 (X3) DATE SURVEY COMPLETED 11/16/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VISTA MANOR NURSING CENTER 120 Jose Figueres Ave San Jose, CA 95116 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (d)(2) Maintain all mechanical, electrical, and patient care equipment in safe operating condition. (e) Resident Rooms Resident rooms must be designed and equipped for adequate nursing care, comfort, and privacy of residents. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to ensure the Wanderguard (signaling device) attached in wheelchair for Residents 6 and 22 were not expired. These failures could potentially lead to harm when Residents 6 and 22 go out of the facility undetected. Findings: 1. A review of Resident 6's clinical record indicated he had a physician's order dated 11/29/16 for wanderguard in wheelchair to alert staff of wandering out of the facility unattended. His Wanderer/elopement risk evaluation dated 11/21/16 indicated at risk for wandering due to cognitive impairment. His care plan dated 11/29/16 indicated on wanderguard in wheelchair to alert staff of wandering out of the facility. His medication administration record dated 11/29/16 indicated wanderguard in wheelchair to alert staff of wandering out of the facility unattended. During an observation and concurrent interview, on 11/14/17, at 10:55 a.m., with LVN Q and CNA S, they both stated the wanderguard attached on Resident 6's wheelchair had a warranty expiration date of 6/2017. 2. A review of Resident 22's clinical record FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2R4D11 Facility ID: CA070000009 If continuation sheet 25 of 26 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555483 (X3) DATE SURVEY COMPLETED 11/16/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VISTA MANOR NURSING CENTER 120 Jose Figueres Ave San Jose, CA 95116 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE indicated her wanderer/elopement risk evaluation dated 9/5/17 indicated Resident 22 expressed desire to leave the facility and expressed anger at being placed in a nursing home. Her physician order dated 9/15/17 indicated wanderguard in wheelchair to alert staff when trying to go out of the facility, monitor and check placement of wanderguard every shift and monitor attempts to absent without leave (AWOL, abbreviation for absent without leave) every shift. During an observation and concurrent interview, on 11/14/17, at 11:40 a.m., the maintenance supervisor (MS) stated the wanderguard attached to Resident 22's wheelchair also had a warranty expiration date of 11/2016. According to the General Information provided by the facility titled "Wandering Management Transmitters User: Warranty Expiration Date " indicated if the warranty period has expired, discard the transmitter immediately. The warning sign indicated using a transmitter beyond the printed expiration date can result in system failure and /or abduction. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2R4D11 Facility ID: CA070000009 If continuation sheet 26 of 26