Other·December 24, 2019

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 on 12/19/19. The facility was licensed for 99 beds. The census at the time of the survey was 89. The sample size was 18. Also, Class "B" citations were issued (see F689 and F759). For Facility Reported Incident CA00666848 regarding Resident Rights, the Department substantiated the complaint allegation but did not violate the State and/or Federal regulations. Representing the California Department of Public Health: 26295, District Administrator; 33651, Health Facilities Evaluator Supervisor; 29258, Health Facilities Evaluator Supervisor, and 39949, Health Facilities Evaluator Nurse.

F550 SS=D Resident Rights/Exercise of Rights CFR(s): 483.10(a)(1)(2)(b)(1)(2)

F550 01/18/2020 §483.10(a) Resident Rights. The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section. §483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the 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: O7HP11 Facility ID: CA070000009 If continuation sheet 1 of 34 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 12/19/2019 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 §483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source. §483.10(b) Exercise of Rights. The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States. §483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility. §483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to ensure to provide privacy and dignity for two of 10 residents (Residents 346 and 65) during medication administration. This failure had potential to exposed residents to the public view and lower residents' self-esteem. Findings: 1.During a medication administration observation on 12/16/19 at 11:52 a.m., licensed vocational nurse C (LVN C) did not close Resident 346's door while LVN C FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O7HP11 Facility ID: CA070000009 If continuation sheet 2 of 34 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 12/19/2019 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 administered insulin injection (medication to lower blood sugar level) to the resident's upper arm. Resident 346 was facing the hallway and exposed to the public view. During an interview with LVN C on 12/16/19 at 12:34 p.m., she stated she should have closed the door to provide privacy to the resident while administering the injection to Resident 346. 2. During a medication administration observation on 12/16/19 at 5:18 p.m., LVN D did not pull the curtain or close the door for Resident 65 while LVN D administer medication to the resident via gastrostomy tube (GT, a soft tube surgically inserted from the abdomen area into stomach for medication and nutrition use) Resident 65's uncovered abdomen was exposed in public view in the hallway. During an interview with LVN D on 12/16/19 at 5:46 p.m., LVN D sated he should have pulled the curtain and closed the door for Resident 65 for the privacy during medication administration. Review of the facility's policy, "Dignity", dated June 16, 2016, indicated "...Residents' privacy space and property shall be respected at all times ..."

F689 SS=D Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) 01/18/2020 §483.25(d) Accidents. The facility must ensure that §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O7HP11 Facility ID: CA070000009 If continuation sheet 3 of 34 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 12/19/2019 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 This REQUIREMENT is not met as evidenced by: Based on interview, and record review, the facility failed to ensure interventions to prevent further fall incidents for two out of 18 sampled residents (64 and 73) when: 1. For Resident 64, fall interventions were not implemented to prevent falls. 2. For Resident 73, fall interventions were not reevaluated for effectiveness and implementation. This failure had resulted in repeated falls which could cause further decline in the resident's physical function. Findings: 1. For Resident 64, fall interventions were not implemented to prevent falls. During a review of Resident 64's "Record of Admission", indicated Resident 64 was admitted on 1/14/19 with diagnoses of presence of right artificial hip joint, abnormalities of gait, mobility and posture. During a review of Resident 64's "Minimum Data Set (MDS)", dated 10/30/19, indicated Resident 64's mental cognition was severely impaired. During a review of Resident 64' "Change in Condition Report - Post Fall Interdisciplinary (IDT) Review and Recommendation", indicated the following: 1. On 4/24/19 at 1:05 a.m., Resident 64 was found kneeling on the floor and stated he was trying to get up from his wheelchair to go to bed but lost his balance. The IDT recommended to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O7HP11 Facility ID: CA070000009 If continuation sheet 4 of 34 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 12/19/2019 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 put "colored tape" on the wheelchair and staff to take Resident 64 for toileting before and after meals and as needed. 2. On 4/29/19 at 6:45 a.m., Resident 64 was found sitting on the floor and stated he wanted to sit on the sofa but his legs "gave out." New fall intervention included cordless alarm in the wheelchair. 3. On 5/1/19 at 8:30 a.m., Resident 64 was found sitting on the floor with his back against the bed. New fall interventions included room change closer to the nursing station and infrared alarm (used to detect presence of movement) in the room to alert staff. 4. On 5/16/19 at 2:55 p.m., Resident 64 was found sitting on the floor and stated he was trying to go to the restroom and lost his balance. New fall intervention included toileting assessment and check to determine bladder and bowel patterns. 5. On 9/23/19 at 3:05 p.m., Resident 64 was found on the floor in a sitting position. Resident was found wet at the time of the incident. 6. On 9/23/19 at 6:00 p.m., Resident 64 slid on the floor from his wheelchair when staff tried to assist him opening the door. New fall interventions included providing non-skid matt on the wheelchair to prevent Resident 64 from sliding and remove washable cloth on the wheelchair seat. 7. On 9/29/19 at 7:10 p.m., Resident 64 was found on the floor and stated he was trying to get up because he was already late for breakfast. New fall interventions included providing digital clock, night light, and vitamin D supplement. 8. On 10/3/19 at 5:00 p.m., Resident 64 had a witnessed fall in the lobby as he tried to transfer himself from wheelchair to a chair and Resident 64 slid from the edge of the wheelchair down to the floor. Per post fall assessment "patient was sitting on the wheelchair and has nonskid mat at the bottom FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O7HP11 Facility ID: CA070000009 If continuation sheet 5 of 34 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 12/19/2019 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 seat and cushion on top with folded washable cloth that has a slippery side attach to the cushion that may possibly cause the patient to slide easily." New fall interventions included to rearrange wheelchair seat, provide extra nonskid mat on top of the wheelchair seat and to remove the washable cloth. During an interview on 12/17/19 at 11:34 a.m., with the assistant director of nursing (ADON), he stated the washable cloth was already removed from the last fall incident on 9/23/19. However, he confirmed the IDT found the same non skid cloth that could possibly cause Resident 64 from sliding on the fall incident on 10/3/19. 2. For Resident 73, fall interventions were not reevaluated for effectiveness and implementation. During a review of Resident 73's clinical record dated 11/21/16, indicated Resident 73 had diagnoses including anxiety (intense, excessive, and persistent worry and fear about everyday situations), depression (mood disorder that causes persistent feeling of sadness), and dementia (memory loss). During a review of Resident 73's Minimum Data Set (MDS, an assessment tool) dated 11/21/19, indicated Resident 73 had long and short memory problem and was dependent in decision-making. He was totally dependent with his activities of daily living (ADL's) including bed mobility, transfer, and ambulation and required one-person assistance. During a review of Resident 73's Change in Condition- Post Fall Interdisciplinary (IDT) review and recommendation indicated the following: 1. On 1/24/19 at 6:30 p.m., Resident 73 was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O7HP11 Facility ID: CA070000009 If continuation sheet 6 of 34 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 12/19/2019 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 found sitting on the floor, near his bed, IDT recommended 2:00 p.m. snacks and to feed resident on time. 2. On 2/16/19 at 4:20 p.m., Resident 73 was found lying on the floor on his back, he sustained a small bump at the back of his head with minimal bleeding. IDT recommended a fall mattress, low bed, half side rails for mobility and transfer, and medication review. 3. On 4/27/19 at 9:45 a.m., Resident 73 was found sitting on the floor near the bathroom. IDT recommended out of bed daily, non-skid socks, incontinent care every two hours and as needed. 4. On 5/23/19 at 11:30 a.m., Resident 73 had a witnessed fall, he fell from bed to the floor. IDT recommended to monitor bowel and bladder (B/B) pattern every two hours. 5. On 6/18/19 at 10:15 a.m., Resident 73 had a witnessed fall, he fell on the floor, on his side. IDT recommended psychological evaluation and medication review. 6. On 9/13/19 at 2:50 p.m., Resident 73 was found on the floor on his left side, wet and naked. IDT to review current medications, resident's behavior, and B/B pattern monitoring. 7. On 10/2/19 at 3:30 p.m., Resident 73 was found sitting on the floor. IDT recommendation to place him in the wheelchair when awake and place him close to the nurse's station for extra supervision. 8. On 12/3/19 at 7:00 a.m., Resident 73 was found sitting on the floor next to his bed. Resident 73 was wet. IDT review indicated, Resident 73 under the care of new staff and was not yet fully aware and oriented with resident's routine and activity. IDT recommendation to re-educate and in service the staff. During an interview on 12/18/19 at 10:30 a.m. with the ADON, he acknowledged Resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O7HP11 Facility ID: CA070000009 If continuation sheet 7 of 34 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 12/19/2019 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 73's multiple fall incidents. He stated Resident 73 should not be assigned to a new staff that did not know the his routine. During a review of the facility's policy, "Falls Clinical Protocol", revised on 4/2007, indicated based on the preceding assessment the staff/IDT will identify pertinent interventions to try to prevent subsequent falls and to address risk of serious consequences of falling. Furthermore, underlying causes cannot be readily identified or corrected, staff will try various and relevant interventions, based on assessment of the nature or category of falling, until falling reduces or stops or until a reason is identified for its continuation.

F755 SS=D Pharmacy Srvcs/Procedures/Pharmacist/Records CFR(s): 483.45(a)(b)(1)-(3)

F755 01/18/2020 §483.45 Pharmacy Services The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse. §483.45(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. §483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who§483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O7HP11 Facility ID: CA070000009 If continuation sheet 8 of 34 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 12/19/2019 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 in the facility. §483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and §483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure the controlled substance medications (medication with a high potential for abuse and addiction) was disposed properly for Resident 56. This failure had the potential to result in residents not getting medications per physician's order and potential to cause controlled medication misuse and abuse. Findings: Review of Resident 56's physician order dated 11/30/19, indicated to administer one tablet of Xanax 0.25 milligrams (medication for anxiety; mg, measure unit) every 8 hours as needed for anxiety. Review Resident 56's controlled drug record dated 12/12/19, indicated registered nurse B (RN B) signed to dispose one tablet of Xanax by herself. There was no evidence that Xanax was disposed with two licensed nurses. During an interview with RN B on 12/18/19 at 10:14 a.m., RN B reviewed Resident 56's control drug record and stated she disposed the Xanax on 12/12/19 with another nurse. However, she forgot to ask the other nurse to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O7HP11 Facility ID: CA070000009 If continuation sheet 9 of 34 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 12/19/2019 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 co-sign for the disposition. RN B stated two nurses should dispose and sign the control medications. Review of the facility's policy, "DISPOSAL OF MEDICATIONS AND MEDICATION-RELATED SUPPLIES", dated January 2013, indicated "...When a dose of a controlled medication is removed from the container for administration but refused by the resident or not giving for any reason, it is not placed back in the container. It is destroyed in the presence of two licensed nurses, and the disposal is documented on the accountability record on the line representing that dose..."

F759 SS=E Free of Medication Error Rts 5 Prcnt or More CFR(s): 483.45(f)(1)

F759 01/18/2020 §483.45(f) Medication Errors. The facility must ensure that its§483.45(f)(1) Medication error rates are not 5 percent or greater; This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility had a 42.86% medication error rate with 12 medication errors during 28 opportunities were observed during the medication passes (med pass, licensed nurses administer medication to residents) for seven of 10 observed residents (Residents 4, 13, 16, 24, 34, 65 and 196). Seven of nine observed licensed nurses made medication errors during the med pass. These failures had the potential to jeopardize residents' medical condition and health. Findings: 1a. During a med pass observation on 12/16/19 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O7HP11 Facility ID: CA070000009 If continuation sheet 10 of 34 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 12/19/2019 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 9:40 a.m., registered nurse E (RN E) administered total five medications to Resident 196. These medications included Lumigan 0.01% eye drop (eye medication for glaucoma, a kind of eye disease) and Pazeo 0.7% eye drops (eye medication for glaucoma). RN E administered these two different eye drops within one minute. During an interview with RN E on 12/16/19 at 9:55 a.m., RN E stated she gave Resident 196's two different eye drop medications within one minute. She stated one minute between two different eye drop administration was a good time management for her. Review of the physician's order dated 12/13/19, indicated to give lumigan 0.01% one drop to each eye for glaucoma and Pazeo 0.7% one drop to each eye for glaucoma. Review of the facility's policy, "EYE DROP ADMINISTRATION", dated April 2008, indicated "...Wait at least five 5 minutes before applying additional medication to the eye ..." 1b. During the med pass with RN E on 12/16/19 at 9:40 a.m., RN E did not give the lidocaine patch (medication for pain) for the resident. During an interview with RN E on 12/16/19 at 10 a.m., she stated Resident 196 should get the lidocaine patch medication for the back pain in the morning. However, the medication was not available. Therefore, she did not give the resident his lidocaine medication as the physician ordered. RN E further stated Resident 196 did not get the lidocaine patch on 12/14/19, 12/15/19 and 12/16/19 as ordered. RN E stated she worked on 12/15/19 and did not follow up with the pharmacy regarding the lidocaine. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O7HP11 Facility ID: CA070000009 If continuation sheet 11 of 34 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 12/19/2019 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 the physician's order dated 12/13/19, indicated to give lidocaine patch 4% transdermal to the most painful area on the back. 2. During a med pass observation on 12/16/19 at 11:45 a.m., licensed vocational nurse C (LVN C) checked Resident 4's finger stick blood sugar level (FSBG, obtain a drop of blood from the fingertip to check blood sugar level). Resident 4's FSBG was 219, which indicated the resident needed two units of Admelog insulin (injection medication to lower the blood sugar) per order. LVN C stated Resident 4's Admelog insulin was not available and would check with the physician. Then LVN C wheeled Resident 4 to the dining room for lunch. During an observation at dining room on 12/16/19 at 12:25 p.m., Resident 4 was sitting in the wheelchair and eating his lunch. Resident 4 ate lunch without insulin as doctor ordered. Review Resident 4's physician order dated 12/15/19, indicated to check the resident's FSBG before meals and give Admelog insulin two units if FSBG was 201-250 before meals. Review of the facility's revised policy, "Administering Medications", dated April 2007, indicated " ...Medications must be administered in accordance with the orders, including any required time frame ..." 3. During a med pass observation on 12/16/19 at 1:15 p.m., LVN F administered 3 milliliters (ml, measure unit) of Duoneb (breathing medication, ipratropium bromide and Albuterol 05mg/3 mg) to Resident 34 via nebulizer (device to administer mist inhaler medication). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O7HP11 Facility ID: CA070000009 If continuation sheet 12 of 34 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 12/19/2019 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 the physician's order dated 8/3/19, indicated to administer Duoneb 1.5 ml via nebulizer for short of breath and wheezing. During an interview with LVN F on 12/16/19 at 1:40 p.m., she stated the physician's order indicated to administer 1.5 ml Duoneb to Resident 34. However, she administered 3 ml Duoneb. LVN F stated she did not administer the correct dose of Duoneb to the resident. 4. During a med pass observation on 12/16/19 at 4:27 p.m., LVN G administered the mixture of water and calcium (medication for supplement for the bones and the muscles) to Resident 24 via gastrostomy tube (GT, a soft tube surgically inserted from the abdomen area into stomach for medication and nutrition use). After LVN G finished med pass for Resident 24, observed white particles residue of Calcium remained on the bottom and side of the medication cup. During an interview with LVN G on 12/16/19 at 4:35 p.m., he stated there was some white particles of Calcium residue still inside the medication cup. LVN G stated he did not give the full dose of Calcium to Resident 24. Review of Resident 24's physician's order dated 10/29/19, indicated to give Calcium Carbonate 500 milligrams (mg: measure unit) via GT for supplement. 5. During a med pass observation on 12/16/19 at 5:18 p.m., LVN H mixed water with half tablet of 25 mg of metoprolol (medication for blood pressure) and administered the mixture of the metoprolol to Resident 65 via GT. After LVN H finished med pass for Resident 65, white particles of metoprolol residue remained on the bottom and side of the medication cup. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O7HP11 Facility ID: CA070000009 If continuation sheet 13 of 34 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 12/19/2019 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 LVN H on 12/16/19 at 5:46 p.m., he stated a small amount of metoprolol remained inside the medication cup and he did not dissolve the metoprolol completely. LVN H stated he did not give Resident 65 the full dose of metoprolol. Review of the Resident 65's physician order indicated to give half tablet of 25 mg of metoprolol (12.5 mg) for high blood pressure. 6. During a med pass observation on 12/17/19 at 8:06 a.m., RN I administered a total of six oral tablet medications with 80 ml of the water and one eye drop medication to Resident 13. These oral medications included one tablet of 2.5 mg Metolazone (same as Zaroxolyn, medication for edema) and one tablet of 20 millequivalent (mEq, measure unit) potassium (important mineral for heart, kidney and other organs). One drop of artificial tears eye drop (eye medication for dry eyes) to both eyes. Review of Resident 13's physician's order dated 2/26/19 indicated to administer one tablet of Zaroxolyn 2.5 mg with one banana on Monday, Wednesday and Friday for edema; Potassium 20 meq one tablet daily for supplement. Physician's order date 10/16/19 indicated to administer one drop of artificial tears to the left eye for dry eye. During an interview with RN I on 12/17/19 at 8:25 a.m., she stated she gave total 80 ml water to Resident 13 for the resident's six oral tablet medications. RN I stated she normally gave 30 ml for the potassium medication to the resident. "Lexi-comp" online (www.lexi.com), a nationally recognized drug information resource, indicated oral form of potassium should be FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O7HP11 Facility ID: CA070000009 If continuation sheet 14 of 34 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 12/19/2019 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 taken with meals and a full glass of water (equals to 240 ml) or other liquid to minimize the risk of gastrointestinal (GI: stomach, small and large intestine) irritation. During an interview with RN I on 12/17/19 at 2:50 p.m., she stated the order of Zaroxolyn was confusing and she thought to give Zaroxolyn daily and "only" gave a banana on Monday, Wednesday and Friday. RN I stated she gave Zaroxolyn to Resident 13 on the wrong date because 12/17/19 was Tuesday. RN I stated she gave the artificial tear drop to the wrong eye. 7. During a med pass observation for Resident 16 on 12/17/19 at 9:07 a.m., RN J crushed one tablet of Carvedilol (medication for high blood pressure), one tablet of Multaq (medication for abnormal heart rhythms), and one tablet of Losartan (medication for high blood pressure). RN J put each tablet in an individual medication cup without mixing with water prior to medication administration. During med pass, RN J poured some water into one crushed tablet cup with her left hand and swirled the cup of the mixture into the syringe barrel that connect to Resident 16's GT tube. The mixture of the tablet medication stuck in the GT tube. RN J squeezed the GT tube in order to let the mixture tablet medication going down through GT tube. RN J continued the same technique to administer the second and third tablet medication for Resident 16 via GT. After RN J finished med pass for Resident 16, white lump of tablet residue observed at the bottom and side of the medication cups for two tablets medication mixture, white particle residue observed on the bottom of the third tablet cup. During an interview with RN J on 12/17/19 at 9:27 a.m., she stated she "forgot" to mix the three tablet medications with water prior to the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O7HP11 Facility ID: CA070000009 If continuation sheet 15 of 34 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 12/19/2019 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 med pass for Resident 16. RN J stated the three tablet medications did not dissolve completely. Therefore, she did not give the full dose for the three tablet medications to Resident 16. Review of the facility's revised policy, "Administering Medications through an Enteral Tube", dated March 2015, indicated "...Dilute the crushed or split medication with 5 to 15 mL of water (or prescribed amount ...)

F761 SS=D Label/Store Drugs and Biologicals CFR(s): 483.45(g)(h)(1)(2)

F761 01/18/2020 §483.45(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. §483.45(h) Storage of Drugs and Biologicals §483.45(h)(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. §483.45(h)(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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O7HP11 Facility ID: CA070000009 If continuation sheet 16 of 34 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 12/19/2019 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 This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to properly store medications in a safe and sanitary condition when: 1. Medication Cart 1 (MC 1) had multi-color substances and sticky substance; expired medication stored in MC 1. 2. MC 2 had multi-color substances and sticky substances; pill crusher (device to crush tablet medication into powder) had multi-color substances. Eye drop medication stored with oral medication. Expired medication stored in MC2. 3. MC 3 had multi-color substance; pill crusher had multi-color substances. Expired eye drop medication stored in MC 3. Eye drops stored with oral and cream medication. Insulin (medication to lower high blood sugar level) injection pens had no open or expiration date. 4. MC 4 had multi-color substance and sticky substances. Pill crusher had multi-color substances, medication pill spilled inside MC 4, ripped paper and rubber bands noted inside MC 4. Pill divider (device to cut the pill into half or small pieces) had white substance and half white pill was inside pill divider. 5. Medication room 1 (MR 1) refrigerator stored one resident's spoiled strawberry. 6. Two of two emergency medication carts (crash cart) stored expired medical supplies. These failures had the potential for the residents to receive contaminated and/or deteriorated medications. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O7HP11 Facility ID: CA070000009 If continuation sheet 17 of 34 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 12/19/2019 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 Findings: 1. During a MC 1 inspection with registered nurse A (RN A) on 12/16/19 at 11:20 a.m.: 1a. Black, brown, and white substances noted inside MC 1; 1b. Pink and yellow sticky substances noted on the liquid medication bottles; 1c. A bottle of liquid protein medication had an expiration date of 11/28/19 inside MC 1. 2. During a MC 2 inspection with RN A on 12/16/19 at 2:52 p.m.: 2a. A pill crusher had white and black sticky substances; 2b. Black, brown, and white substances noted inside MC 2; 2c. White, pink and yellow sticky substances noted on the liquid medication bottles; 2d. Two opened bottles of eye drops stored with one bottle of oral medication; 2e. Resident 20's blood pressure medication (Amlodipine, four tablets) had an expiration date of 12/13/19 inside MC 2. 3. During an MC 3 inspection with RN A on 12/16/19 at 2:21 p.m.: 3a. A pill crusher had white and black sticky substances; 3b. Black, brown and white substance noted inside MC 3; 3c. White, pink, and yellow sticky substances noted on the liquid medication bottles; 3d. Resident 15's opened eye drop bottle had no open or expiration date. RN A stated nurse staff should label with open and expiration date once it opened. RN A stated the opened eye drop medication was good for 28 days; 3e. Resident 1's two opened eye drops bottles stored with two bottles of oral medications and one tube of topic cream medication. RN A stated eye drop medication should not be stored with oral or topical medication; FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O7HP11 Facility ID: CA070000009 If continuation sheet 18 of 34 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 12/19/2019 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 3f. Resident 85's lantus insulin (injection medication to lower blood sugar level) pen had no open or expiration date; RN A stated lantus pen was good for 28 days it opened; 3g. Resident 48's Novolog Flexpen (injection insulin medication) had a date of 11/25/19, which was unclear if it was open date or expiration date or other date. 4. During an MC 4 inspection with RN A on 12/6/19 at 1:50 p.m.: 4a. A pill crusher had black, white, and brown substance; 4b. A pill divider inside MC noted with a half white pill and with white substance; 4c. White, black, and brown substances noted inside MC 4; 4d. Pink and yellow sticky substance noted on the liquid medication bottles; 4e. Ripped paper, rubber bands, and one pink pill spilled inside MC 4. During an interview with RN A on 12/16/19 at 3 p.m., she stated medication carts should maintain the clean and sanitary condition, expired medication should not be stored in the medication carts, medication should be labeled with open and expiration date once it opened, and eye drops should not be stored with oral or topic medications. "Lexi-comp" online (www.lexi.com), a nationally recognized drug information resource, indicated a Novolog Flexpen and Lantus pen a could be used for up to 28 days at room temperature storage. 5. During an MR 1 inspection with RN A on 12/16/19 at 10:45 a.m., the top refrigerator stored with a box of resident's strawberry. One strawberry noted with hairy white and black substance and the color changed into black. RN A stated the spoiled strawberry should not FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O7HP11 Facility ID: CA070000009 If continuation sheet 19 of 34 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 12/19/2019 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 store in the refrigerator in the medication room. 6a. During a crash cart 1 inspection with RN A on 12/18/19 at 2 p.m., a bottle of alcohol gel (hand sanitizer) had an expiration date of 02/2019 inside the cart. 6b. During a crash cart 2 inspection with RN A on 12/18/19 at 2:15 p.m., four suction connecting tubes had expiration date of 3/10/18 inside the cart. A bottle of bleach germicidal wipes (sanitizer wipes) with an expiration of 8/16/19 stored in the cart. During an interview with RN A on 12/18/19 at 2:18 p.m., she stated the expired emergency medical supplies should not store in the crash cart. Review of the facility's revised policy, "Storage of Medications", dated April 2007, 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... Drugs for external use ...shall be separately from other medications ..."

F802 SS=D Sufficient Dietary Support Personnel CFR(s): 483.60(a)(3)(b)

F802 01/18/2020 §483.60(a) Staffing The facility must employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.70(e). §483.60(a)(3) Support staff. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O7HP11 Facility ID: CA070000009 If continuation sheet 20 of 34 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 12/19/2019 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 The facility must provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. §483.60(b) A member of the Food and Nutrition Services staff must participate on the interdisciplinary team as required in § 483.21(b)(2)(ii). This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to employ staff with the appropriate competencies and skills to carry out the functions of the food and nutrition service when: 1. Dietary staff did not know how to check thermometer accuracy correctly during the calibration process; 2. Dietary staff did not know how to correctly check the dishwasher's sanitizer and quaternary sanitizer (sanitizer used to clean kitchen counters, tables and surfaces, and used to manually sanitize dishes). The lack of knowledge regarding food and nutrition services had the potential for dietary staff not being able to carry out their job functions properly and ensure sanitary conditions in the kitchen. Findings: 1a. During an observation on 12/17/19 at 11:42 p.m., Cook Q demonstrated how to check the thermometer during the calibration process. Cook Q put the thermometer probe (tip) on the bottom of the ice water container and read the temperature. He stated if the thermometer's temperature reached to 32 Fahrenheit (F), then it was okay to use thermometer to check the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O7HP11 Facility ID: CA070000009 If continuation sheet 21 of 34 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 12/19/2019 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 food temperature. 1b. During an observation on 12/17/19 at 1:06 p.m., Cook R demonstrated how to check the thermometer during the calibration process. Cook R put the thermometer probe on the bottom of the ice water cup and read the temperature. 1c. During an observation on 12/17/19 at 1:09 p.m., dietary aide P (DA P) demonstrated how to check the thermometer during the calibration process. DA P put the thermometer probe on the bottom of the ice water cup and read the temperature. DA P stated the facility used only a digital thermometer. He further stated, if the thermometer's temperature was not 32F during the calibration process, then the facility should discard the thermometer because the digital thermometer could not be calibrated. During an interview with the dietary supervisor (DS) on 12/17/19 at 1:15 p.m., he stated the probe of the thermometer should not touch the bottom of the ice water container or cups. The DS stated the thermometer's probe should be between ice. 2a. During an observation on 12/17/19 at 1:31 p.m., DA P demonstrated how to check the dishwasher's sanitizer concentration. He took out one test strip and quickly dipped the strip into the sanitizer solution and then took the strip out and immediately compared the test strip with the color chart on the strip bottle. The test strip had expiration date of 04/19. The instructions for checking the sanitizer posted on the wall next to the dishwasher indicated to dip the test strip into the sanitizer solution, immediately remove it and let the test strip sit (wait) for at least 5 seconds but not more than 10 seconds before reading the strip. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O7HP11 Facility ID: CA070000009 If continuation sheet 22 of 34 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 12/19/2019 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 DA P on 12/17/19 at 1:35 p.m., he stated he did not check the expiration date of the test strip and he did not know he should wait for 5-10 seconds before he checked the strip to the color chart. At 1:36 p.m., DA P continue to demonstrate how to check the quaternary sanitizer. DA P took one piece of test strip without checking the expiration date (two rolls of test strips with expiration dates of Aug 1, 2019 and Sep 15, 2019). DA P quickly dipped the strip into the sanitizer and immediately removed it and then compared the strip with the color chart on the strip box. The instructions for the quaternary sanitizer check on the strip box indicated to dip the test strip into the the sanitizer solution for 10 seconds, remove it and then compare the strip with the color chart immediately. During an interview with DA P on 12/17/19 at 1:38 p.m., he stated he did not check the test strip expiration date and did not know he needed to dip the test strip into the solution for 10 seconds. 2b. During an observation on 12/17/19 at 1:46 p.m., Cook R demonstrated how to check the dishwasher's sanitizer. She took one strip out without checking the expiration date and dipped the strip into the solution, removed it, and then immediately compared the strip with the color chart on the strip bottle. Cook R stated she did not check the test strip expiration date and did not know she should wait for 5-10 seconds before she checked strip with the color chart. During an observation on 12/17/19 at 1:42 p.m., Cook R checked the quaternary sanitizer. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O7HP11 Facility ID: CA070000009 If continuation sheet 23 of 34 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 12/19/2019 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 She took a piece of test strip without checking the expiration date and quickly dipped the test strip into the solution, immediately removed it, and then compared the test strip with the color chart on the test strip box. Cook R stated she did not check the test strip expiration date and did not know she should dip the strip into the solution for 10 seconds before removing it to compare it with the color chart. 3a. During an observation on 12/17/19 at 1:52 p.m., DA M demonstrated how to check the dishwasher's sanitizer. She took one test strip out of the strip bottle without checking the expiration date. She dipped the strip into the solution for 5 seconds and removed the strip and immediately compared the strip with the color chart. DA M stated she did not check the strip expiration date and did not know she should dip the strip in the solution and immediately remove it, and then wait for 5-10 seconds before reading the results. During an observation on 12/17/19 at 1:54 p.m., DA M checked the quaternary sanitizer. She took one piece of strip from the test strip roll and dipped the test strip into the sanitizer for 5 seconds, removed the strip and compared the strip with color chart. DA M stated she did not know the test strips were already expired and did not know she should have dipped the strip into the sanitizer solution for 10 seconds before removing it to check the results. During an interview with the DS on 12/17/19 at 2 p.m., he stated the staff should check the test strip expiration date and should follow the instructions regarding checking the sanitizer.

F812 SS=E Food Procurement,Store/Prepare/ServeSanitary CFR(s): 483.60(i)(1)(2) FORM CMS-2567(02-99) Previous Versions Obsolete

F812 Event ID: O7HP11 01/18/2020 Facility ID: CA070000009 If continuation sheet 24 of 34 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 12/19/2019 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 §483.60(i) Food safety requirements. The facility must §483.60(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 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. §483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to maintain a sanitary condition when: 1. Dietary staff did not cover their hair completely with a hairnet; 2. The interior of the ice machine door and ice bin (the bin inside the ice machine where the ice is collected) had multi-color substance; The portable ice container had brown substance inside the container wall; 3. The can opener had multi-color substances; 4. Food items past use by date stored in Freezer 1; 5. There was no air gap ( no space in-between drain spout and the in-floor drain inlet) for the coffee machine and ice machine drain system; 6. Open bags of food items were not sealed or closed in Freezer 2; 7. Expired food items stored in Refrigerator 1; FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O7HP11 Facility ID: CA070000009 If continuation sheet 25 of 34 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 12/19/2019 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 8. Ready-to-eat Jello stored next to the fruits in Refrigerator 2; 9. Dishwasher sanitizer test strips was expired; sanitizer of multi-Quat (sanitizer for manual dishwasher and kitchen surfaces) test strips were expired. These failures had the potential to cause forborne illness for residents. Findings: 1. During an initial kitchen tour with the dietary supervisor (DS) on 12/16/19 at 7:50 a.m., the DS did not completely cover his hair on the sides and back with a hairnet. The dietary aide K (DA K), Cook L, DA M, and DA N were working in the prepared food area and their hair on the sides and back were not completely covered with a hairnet. During an observation on 12/16/19 at 8:30 a.m., the registered dietitian (RD), maintenance supervisor (MS), and Cook O were at the kitchen prepared food area and their hair on the side and back were not completely covered with a hairnet. During an interview with the DS on 12/16/19 at 8:40 a.m., the DS stated all staff in the kitchen should have fully covered their hair with a hair net. Review of the facility's undated policy "Employee Sanitary Practices", indicated all kitchen employees should wear hair restraints (hairnet, hat, beard restrain) to prevent hair from contacting exposed food. 2. During an initial kitchen tour with the DS on 12/16/19 at 8:12 a.m., the interior of the ice machine door (the side of the ice machine door that is closed to the ice bin) and ice bin walls FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O7HP11 Facility ID: CA070000009 If continuation sheet 26 of 34 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 12/19/2019 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 had black, brown and orange substances. One portable ice container had brown substance inside the container walls and interior of container cover. During an interview with the DS on 12/16/19 at 8:15 a.m., he stated the ice machine and ice container should have been kept clean. The DS stated the facility had only one ice machine. Review of the facility's undated policy, "Cleaning Instructions: Ice Machine and Equipment", indicated "...The ice machine and equipment (scoops, etc.) will be cleaned on a regular basis to maintain a clean, sanitary condition ..." 3. During an initial kitchen tour with the DS on 12/16/19 at 8:16 a.m., a can opener had sticky black and orange substances. The DS stated the can opener should be cleaned after each use and cleaned daily. Review of the facility's undated policy "Cleaning Instructions: Can Opener", indicated "...The can opener will be cleaned after each use ..." 4. During an initial kitchen tour with the DS on 12/16/19 at 8:25 a.m., Freezer 1 had a bag of muffins stored with used by date of 12/14/19; a bag of ram muffin with a date of 11/3/19, (unclear what the date meant); one bag of cranberry muffin with used by date of 12/7/19. The DS stated the food stored past the used by date, should not be in the freezer. Review of the facility's undated policy, "Food Storage", indicated "...All foods should be covered, labeled and dated. All foods will be checked to assure that foods will be consumed by their safe use by dates or discarded ..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O7HP11 Facility ID: CA070000009 If continuation sheet 27 of 34 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 12/19/2019 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 5. During an initial kitchen tour with the DS on 12/16/19 at 8:35 a.m., the coffee machine drain sprout was 1.5 inches to 2 inches below the infloor drain inlet, there was no air gap. The ice machine drain sprout was at the in-floor drain level, there was no air gap. The DS stated there should be an air gap between the coffee machine/ice machine drain sprout and the infloor drain inlet. According to the Federal Food Code (2017), there is to be an air gap between the water supply inlet and the flood level rim of the plumbing fixture, equipment, or nonfood equipment that was at least twice the diameter of the water supply inlet and may not be less that one inch. 6. During an initial kitchen tour with the DS on 12/16/19 at 8:45 a.m., Freezer 2 had one opened bag of hamburger paddy, one opened bag of beef steak and two bags of diner loaves, and one opened box of chicken. The DS stated the opened food bags should be sealed and closed. 7. During an initial kitchen tour with the DS on 12/16/19 at 8:50 a.m., Refrigerator 1 had a container of heavy cream with an expiration date of 12/15/19. The DS stated the expired food item should not be stored in the refrigerator. 8. During an initial kitchen tour with the DS on 12/16/19 at 8:52 a.m., Refrigerator 2's top shelf had a tray of ready-to-eat Jello covered with a thin food wrap stored next to two bags of grapes, one box of blackberries and one box of strawberries. The middle shelf had a tray of ready-to-eat Jello stored next to a box of limes. One lime had a black and soft area. The DS stated the Jello should not be stored next to the fruits. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O7HP11 Facility ID: CA070000009 If continuation sheet 28 of 34 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 12/19/2019 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 9. During a kitchen inspection on 12/17/19 at 1:31 p.m., DA P demonstrated how to check the sanitizer for the dishwasher, he used a test strip with an expiration date of 04/19. At 1:35 p.m., DA P used the test strip with expiration dates of 8/1/19 and 9/15/19 for the multi-quat sanitizer check. DA P stated he did not know both test stripes were expired. During an interview with the DS on 12/17/19 at 2 p.m., he stated dietary staff should check the sanitizer test strips before use.

F880 SS=E Infection Prevention & Control CFR(s): 483.80(a)(1)(2)(4)(e)(f)

F880 01/18/2020 §483.80 Infection Control The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. §483.80(a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: §483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards; §483.80(a)(2) Written standards, policies, and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O7HP11 Facility ID: CA070000009 If continuation sheet 29 of 34 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 12/19/2019 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 procedures for the program, which must include, but are not limited to: (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; (iv)When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and (vi)The hand hygiene procedures to be followed by staff involved in direct resident contact. §483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility. §483.80(e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. §483.80(f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary. This REQUIREMENT is not met as evidenced FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O7HP11 Facility ID: CA070000009 If continuation sheet 30 of 34 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 12/19/2019 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 by: Based on observation, interview, and record review, the facility failed to ensure nurse staff follow proper infection control practices during medication passes (med pass: nurse administered the medications to residents per physician's order) for seven of 10 observed residents (Residents 4, 13, 16, 24, 65, 196 and 346 ) and one resident with catheter out of 18 sampled residents (18). These failures had the potential to result in cross-contamination and the spread of infections. Findings: 1. During the med pass observation for Resident 196 on 12/16/19 at 9:40 a.m., registered nurse E (RN E) put the medication tray (oral medications and eye drop in the cup) in Resident 196's bed sheet, then RN E put the same tray back to the medication cart after oral med pass. At 9:46 a.m., after RN E administered one type of eye drops to the resident, the eye drop cap dropped on the floor. RN E's gloved hand picked up the cap from the floor. RN E did not perform hand hygiene and/or change into a new pair of gloves. RN E continued to administer the second type of eye drops to Resident 196. During an interview with RN E on 12/16/19 at 10 a.m., she stated she should have not put the med tray on Resident 196's bed; should have washed her hands after she picked up the eye drop cap from the floor; and should have washed her hands prior to administering eye drops to Resident 196. Review of the facility's policy, "EYE DROP ADMINISTRATION", dated April 2008, indicated staff should wash hands prior to eye drop administration. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O7HP11 Facility ID: CA070000009 If continuation sheet 31 of 34 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 12/19/2019 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 2. During an observation for Resident 4 on 12/16/19 at 11:45 a.m., licensed vocational nurse C (LVN C) cleaned Resident 4's middle finger with an alcohol pad prior to pricking the resident's finger to obtain a blood drip for finger stick blood sugar (FSBG, check blood drop from fingertip) check. LVN C moved her gloved hand back and forth over Resident 4's clean finger to dry the alcohol. 3. During an observation for Resident 346 on 12/16/19 at 11:50 a.m., LVN C used an alcohol pad to clean Resident 346's finger for FSBG. LVN C's gloved hand moved back and forth over the resident's clean finger in order to dry the alcohol. During an interview with LVN C on 12/16/19 at 12:34 p.m., she stated during FSBG, she should have let Resident 346's clean finger air dry after sanitizing with an alcohol pad. 4. During med pass for Resident 24 on 12/16/19 at 4:27 p.m., LVN G wore the same pair of gloves to pull the resident's bed up, pulled the curtain, and continued to administer the medication to Resident 24 via gastrostomy tube (GT, a soft tube surgically inserted from the abdomen area into stomach for medication and nutrition use). During an interview with LVN G on 12/16/19 at 4:35 p.m., he stated he should have performed hand hygiene after his gloved hand touch Resident 24's bed, curtain and before administering the medication. 5. During med pass observation for Resident 65 on 12/16/19 at 4:35 p.m., LVN H wore the same pair of gloves to administer the GT medications, touched the GT pump to start the GT feeding, charted, and opened the medication cart. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O7HP11 Facility ID: CA070000009 If continuation sheet 32 of 34 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 12/19/2019 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 LVN H on 12/16/19 at 5:46 p.m., he stated he should have performed hand hygiene between different tasks. 6. During med pass observation for Resident 13 on 12/17/19 at 8:06 a.m., RN I prepared medications for the resident and forgot to check the resident's blood pressure. RN I put the uncovered medication cup (three tablet medications in the cup) into her scrub pocket and then she went into the resident's room. After RN I returned from the resident's room, RN I took the uncovered med cup out of her pocket and continued to put the rest of the tablets in the cup. At 8:14 a.m., RN I did not perform hand hygiene prior to administering oral medications. RN I wore the same pair of gloves and continued to administer the eye drops to both eyes for Resident 13. After the med pass, RN I wore gloves to care for both of Resident 13 legs and continued to push the resident's breakfast table with the same pair of gloves. During an interview with RN I on 12/27/19 at 8:25 a.m., she stated she should have performed hand hygiene prior to administering the oral and eye drop medications. She stated she should have not put the uncovered medication cup in her scrub pocket. 7. During a med pass observation for Resident 16 on 12/17/19 at 9:05 a.m., RN J carried a chain of keys (seven keys) at her left elbow area during the GT med pass for Resident 16. The keys touched the resident's bed, blanket, the resident's gown and RN J's clothes. Then RN J brought the chain of the keys back to the medication cart to open the medication cart. During an interview with RN J on 12/17/19 at 9:27 a.m., she stated she should not carry the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O7HP11 Facility ID: CA070000009 If continuation sheet 33 of 34 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 12/19/2019 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 chain of keys to the resident's room during med pass. Review of the facility's revised policy, "Handwashing /Hand Hygiene", dated August 2015, indicated " ...All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors ..." 8. For Resident 81, the tip of the catheter bag was exposed and not covered. During a concurrent observation with licensed vocational nurse B (LVN B) on 12/17/19 at 11:02 a.m., LVN B confirmed Resident 81's catheter tubing's tip was exposed and not covered. During a concurrent observation with registered nurse A (RN A) on 12/17/19 at 11:07 a.m., RN A confirmed Resident 81's catheter tubing's tip was exposed and not covered. RN A further stated if catheter was disconnected the tubing with the catheter bag should be covered to prevent infections. During a review of facility policy titled "Catheter Urinary" revised 10/2010 indicated, maintain clean technique when handling or manipulating the catheter, tubing or drainage bag. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O7HP11 Facility ID: CA070000009 If continuation sheet 34 of 34