Other·March 29, 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 3/13/17 through 3/16/17. The facility was licensed for 59 beds. The census at the time of the survey was 50. The sample size was 13. For Entity Reported Incident CA00524348 regarding Quality of Care/Treatment, a federal deficiency was identified (see F281). A Class "B" citation was issued for F281. Representing the California Department of Public Health: 37686, Health Facilities Evaluator Nurse; 29258, Health Facilities Evaluator Supervisor; 32892, Health Facilities Evaluator Nurse; 36044, Health Facilities Evaluator Nurse; 38174, Health Facilities Evaluator Nurse; and 37329, Health Facilities Evaluator Nurse.

F241 SS=D DIGNITY AND RESPECT OF INDIVIDUALITY F241 CFR(s): 483.10(a)(1) 04/06/2017 (a)(1) A facility must treat 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. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to ensure dignity was maintained for one of 13 sampled residents (3) 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: 9L0E11 Facility ID: CA070000012 If continuation sheet 1 of 22 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: _______________ 555363 (X3) DATE SURVEY COMPLETED 03/16/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LINCOLN GLEN SKILLED NURSING 2671 Plummer Ave San Jose, CA 95125 (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 when the urine collection bag for Resident 3's indwelling catheter (a flexible tube inserted and left in the bladder to provide drainage of urine) was not concealed from public view. This failure had the potential to negatively affect the resident's psychosocial well-being. Findings: During an observation on 3/13/17 at 9:15 a.m., Resident 3 was lying in bed. The indwelling catheter's collection bag was attached to the side of her bed. The collection bag was not covered and its contents were visible. Resident 3's clinical record was reviewed and indicated she was admitted with left hemiplegia (weakness), hypertension, atrial fibrillation (abnormal heart rhythm), and chronic obstructive pulmonary disease. Her minimum data set (MDS, an assessment tool) dated 2/27/17, indicated she had no cognitive impairment. An indwelling catheter was inserted due to neurogenic bladder (bladder dysfunction due to disease of the central nervous system). During an interview with registered nurse B (RN B) on 3/14/17 at 8:05 a.m., she stated urine collection bags for indwelling catheters should be covered. During an observation on 3/15/17 at 8:00 a.m., Resident 3 was lying in bed. The urine collection bag for her indwelling catheter was attached to the side of her bed. The collection bag was not covered. A privacy bag (a cover intended to discreetly hide a urine collection bag from public view) was attached to Resident 3's wheelchair, which was in the hallway outside her room. During an interview with the assistant director FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9L0E11 Facility ID: CA070000012 If continuation sheet 2 of 22 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: _______________ 555363 (X3) DATE SURVEY COMPLETED 03/16/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LINCOLN GLEN SKILLED NURSING 2671 Plummer Ave San Jose, CA 95125 (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 of nursing (ADON) on 3/15/17 at 1:20 p.m., she stated urine collection bags for indwelling catheters must be covered when attached to the side of residents' beds.

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

F281 04/14/2017 (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 provide services according to professional standards of clinical practice for two sampled residents (5 and 7) when: 1. A nurse inserted a rectal tube (a long slender tube inserted into the rectum to relieve gas) for Resident 5 without removing the cap, and 2. a nurse crushed an enteric coated tablet (tablet intended to delay release of the medication until the tablet has passed through the stomach to prevent the drug from being destroyed by stomach juices and to prevent stomach irritation) and administered it to Resident 7. These practices resulted in Resident 5 needing to be hospitalized and undergo a procedure to remove the retained rectal tube cap from his rectum, and had the potential to negatively FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9L0E11 Facility ID: CA070000012 If continuation sheet 3 of 22 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: _______________ 555363 (X3) DATE SURVEY COMPLETED 03/16/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LINCOLN GLEN SKILLED NURSING 2671 Plummer Ave San Jose, CA 95125 (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 affect Resident 7's health and well-being. Findings: 1. Resident 5's clinical record indicated he was admitted on 1/28/14 with diagnoses of transverse myelitis (inflammation of the spinal cord), paraplegia (paralysis of the legs and lower body), ogilvie syndrome (distension of the colon in the absence of obstruction), and neurogenic bladder (bladder dysfunction due to disease of the central nervous system). Resident 5's risk for constipation care plan, dated 12/9/16, indicated, "Administer rectal tubes as ordered by MD". A physician's order, dated 2/27/17 at 1:30 p.m., indicated Resident 5 was to have a rectal tube inserted for abdominal girth (measurement of distance around the abdomen) greater than 120 centimeters (cm, a unit of measurement). A physician's order, dated 2/27/17 at 4:00 p.m., indicated Resident 5 was to be sent to the hospital for evaluation and treatment. A nurse's note, dated 2/27/17 at 6:44 p.m., signed by licensed vocational nurse D (LVN D), indicated Resident 5 was sent to the hospital because the cap of the rectal tube was dislodged in his rectum. During an interview with LVN D on 3/14/17 at 3:35 p.m., she confirmed she inserted the rectal tube for Resident 5. She stated there was a "blue part" on the tip of the rectal tube that she did not realize was a cap. LVN D stated she inserted the rectal tube, including the cap, and when she pulled the tube out, the cap remained in the resident's rectum. During the same interview, LVN D stated she FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9L0E11 Facility ID: CA070000012 If continuation sheet 4 of 22 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: _______________ 555363 (X3) DATE SURVEY COMPLETED 03/16/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LINCOLN GLEN SKILLED NURSING 2671 Plummer Ave San Jose, CA 95125 (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 never inserted a rectal tube before attempting it on Resident 5. She also stated she did not have any formal training on how to do it. LVN D explained that on the day of the incident, she asked nurses on the other units if they knew how to insert a rectal tube, but they told her they did not. LVN D stated that after the incident, the assistant director of nursing (ADON) instructed her not to perform any procedures she did not feel comfortable with. During an interview with registered nurse H (RN H) on 3/16/17 at 10:55 a.m., she stated she was working on the day of the incident involving Resident 5's rectal tube. She stated LVN D asked her if she had ever inserted a rectal tube for Resident 5, to which RN H replied, "No". During a telephone interview with RN G on 3/16/17 at 12:55 p.m., she stated she was also working on the date of the incident involving Resident 5's rectal tube. She stated LVN D asked her if she knew how to insert a rectal tube, and RN G replied, "No". RN G stated she had not received any in-service (training) about rectal tubes prior to the incident involving Resident 5. During an interview with the ADON on 3/15/17 at 1:20 p.m., she stated she was in the facility when LVN D inserted Resident 5's rectal tube. She explained that LVN D did not tell her about the rectal tube until after the incident occurred. The ADON stated LVN D should have informed her before attempting to insert the rectal tube, because LVN D had never done it before. The ADON stated, "I could have helped her". According to the ADON, she has instructed staff to ask for assistance with procedures they are unfamiliar with. During an interview with LVN F on 3/15/17 at FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9L0E11 Facility ID: CA070000012 If continuation sheet 5 of 22 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: _______________ 555363 (X3) DATE SURVEY COMPLETED 03/16/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LINCOLN GLEN SKILLED NURSING 2671 Plummer Ave San Jose, CA 95125 (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 3:50 p.m., she stated the same incident occurred with Resident 5 once in the past. She stated that "a couple of years ago", another nurse inserted a rectal tube without removing the cap, and the cap remained in the resident's rectum. During an interview with the ADON on 3/16/17 at 8:25 a.m., she confirmed the same incident happened to Resident 5 once in the past. She stated she gave an in-service on rectal tubes "a couple of years ago", but did not give any rectal tube in-services during the time between the first incident and the most recent incident involving Resident 5. A history and physical (H&P) from the hospital, dated 2/27/17, indicated Resident 5 had a "dislodged plastic rectal tube left in his colon/rectum". The H&P indicated manual retrieval (removal using the hands) of the dislodged rectal tube could not be done. A consultation report from the hospital, dated 2/28/17, indicated Resident 5 had a computerized tomography scan (CT scan, a computerized X-ray image) done, which showed a 12 cm "foreign body" about 8 cm from the anus. The consultation report also indicated the resident would have a sigmoidoscopy (insertion of a flexible tube through the anus into part of the large intestine) to remove the "foreign body". A physician progress note from the hospital, dated 2/28/17, indicated Resident 5 had "discrete superficial ulcerations" of the rectum, and that the retained "foreign body" was removed with a roth net (a foreign body retrieval device). 2. During an observation on 3/15/17 at 8:30 a.m., registered nurse B (RN B) administered FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9L0E11 Facility ID: CA070000012 If continuation sheet 6 of 22 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: _______________ 555363 (X3) DATE SURVEY COMPLETED 03/16/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LINCOLN GLEN SKILLED NURSING 2671 Plummer Ave San Jose, CA 95125 (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 aspirin (medication used to reduce the risk of heart attack or stroke) 81 milligrams (mg, a unit of dose measurement) to Resident 7. The label on the bottle of aspirin indicated the medication was an enteric coated tablet. RN B crushed the enteric coated aspirin, mixed it in water, and administered it to Resident 7 through a gastrostomy tube (GT, a tube inserted through the abdomen into the stomach). During an interview with RN B on 3/15/17 at 9:00 a.m., she confirmed she crushed the enteric coated aspirin she administered to Resident 7. RN B acknowledged she should not have crushed this medication. The facility's 5/2016 policy entitled "Medication Administration Enteral Tubes" indicated, "Do not crush the following types of medication: enteric coated, buccal or sublingual formulations, or sustained/extended release products". According to Lexicomp (lexi.com, an online nationwide source for drug information), enteric coated aspirin may reduce stomach irritation and/or stomach disturbances. Lexicomp further indicated enteric coated aspirin must be taken whole and not crushed or chewed.

F315 SS=D NO CATHETER, PREVENT UTI, RESTORE BLADDER CFR(s): 483.25(e)(1)-(3)

F315 04/14/2017 (e) Incontinence. (1) The facility must ensure that resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9L0E11 Facility ID: CA070000012 If continuation sheet 7 of 22 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: _______________ 555363 (X3) DATE SURVEY COMPLETED 03/16/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LINCOLN GLEN SKILLED NURSING 2671 Plummer Ave San Jose, CA 95125 (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)For a resident with urinary incontinence, based on the resident’s comprehensive assessment, the facility must ensure that(i) A resident who enters the facility without an indwelling catheter is not catheterized unless the resident’s clinical condition demonstrates that catheterization was necessary; (ii) A resident who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident’s clinical condition demonstrates that catheterization is necessary and (iii) A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible. (3) For a resident with fecal incontinence, based on the resident’s comprehensive assessment, the facility must ensure that a resident who is incontinent of bowel receives appropriate treatment and services to restore as much normal bowel function as possible. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to implement interventions consistent with resident's assessed needs and current standards of practice for one of 13 sampled residents (3). This practice could lead to complications and would affect the resident's health. Findings: During the initial tour on 3/13/17 at 9:15 a.m., FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9L0E11 Facility ID: CA070000012 If continuation sheet 8 of 22 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: _______________ 555363 (X3) DATE SURVEY COMPLETED 03/16/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LINCOLN GLEN SKILLED NURSING 2671 Plummer Ave San Jose, CA 95125 (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 3 was lying in bed. The urine collection bag for her indwelling catheter (a flexible tube inserted and left in the bladder to provide drainage of urine) was attached to the side of her bed and draining cloudy urine. Resident 3's clinical record was reviewed and indicated she was admitted with left hemiplegia (weakness), hypertension, atrial fibrillation (abnormal heart rhythm), and chronic obstructive pulmonary disease. Her minimum data set (MDS, an assessment tool) dated 2/27/17, indicated she had no cognitive impairment. An indwelling catheter was inserted due to neurogenic bladder (bladder dysfunction due to disease of the central nervous system). There was a care plan initiated on 5/24/16 "Potential for UTI (urinary tract infection) due to indwelling catheter". Interventions included: encourage up to 2 liters of fluid per day, monitor intake and output (I & O), and notify physician if there were signs and symptoms of UTI like abdominal discomfort and cloudy urine. During an interview with Resident 3 on 3/14/17 at 8:40 a.m., she complained of lower abdominal discomfort. She stated she wanted to go to the hospital if the facility would not be able to figure it out. Resident 3's urine was still cloudy in appearance. During an interview with certified nursing assistant K (CNA K), on the same day at 2:10 p.m., she stated that for the past few days, Resident 3 had low urine output and she informed licensed nurses about it. She confirmed that Resident 3's urine was still cloudy. During an interview and record review with licensed vocational nurse I (LVN I) on 3/14/17 at 10:10 a.m., he confirmed there were FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9L0E11 Facility ID: CA070000012 If continuation sheet 9 of 22 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: _______________ 555363 (X3) DATE SURVEY COMPLETED 03/16/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LINCOLN GLEN SKILLED NURSING 2671 Plummer Ave San Jose, CA 95125 (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 discrepancies in the daily I & O's from 3/6/17 to 3/13/17, ranging from 250 mL (milliliters = a unit of liquid measurement) to 740 mL. On 3/13/17, there was 1370 mL input and only 800 mL output, a difference of 570 mL. There was no documentation that the physician was contacted. LVN I stated he would notify the physician right away due to fluid retention. LVN I also stated he was unsure if the evening shift or the night shift nurse would tally the daily I & O's. During an interview with registered nurse J (RN J) on 3/15/17 at 7:50 a.m., he stated he was not aware of I & O discrepancies for the past week. He stated he never received any report from evening nurses about it. RN J was surprised of the discrepancies and stated he would notify the physician if there was a 500 mL discrepancy. During an interview with the director of nursing (DON) on 3/15/17 at 4:38 p.m., she stated the facility would address the issue with intake and output monitoring of all concerned residents, including Resident 3. A review of the facility's undated "Hydration Protocol " policy indicated residents should be provided sufficient fluid intake to maintain hydration and health. Monitoring of I & O is an essential part of assessing residents' hydration status. A review of 2013 Mosby's Nursing Interventions and Clinical Skills, indicated measuring and recording I & O is necessary to assess fluid balance and requires critical thinking and knowledge application of a nurse. I & O is an important tool for nurses to assess signs and symptoms of dehydration and fluid overload.

F334 INFLUENZA AND PNEUMOCOCCAL FORM CMS-2567(02-99) Previous Versions Obsolete

F334 Event ID: 9L0E11 03/13/2017 Facility ID: CA070000012 If continuation sheet 10 of 22 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: _______________ 555363 (X3) DATE SURVEY COMPLETED 03/16/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LINCOLN GLEN SKILLED NURSING 2671 Plummer Ave San Jose, CA 95125 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) SS=D IMMUNIZATIONS CFR(s): 483.80(d)(1)(2) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (d) Influenza and pneumococcal immunizations (1) Influenza. The facility must develop policies and procedures to ensure that(i) Before offering the influenza immunization, each resident or the resident’s representative receives education regarding the benefits and potential side effects of the immunization; (ii) Each resident is offered an influenza immunization October 1 through March 31 annually, unless the immunization is medically contraindicated or the resident has already been immunized during this time period; (iii) The resident or the resident’s representative has the opportunity to refuse immunization; and (iv) The resident’s medical record includes documentation that indicates, at a minimum, the following: (A) That the resident or resident’s representative was provided education regarding the benefits and potential side effects of influenza immunization; and (B) That the resident either received the influenza immunization or did not receive the influenza immunization due to medical contraindications or refusal. (2) Pneumococcal disease. The facility must develop policies and procedures to ensure that(i) Before offering the pneumococcal immunization, each resident or the resident’s representative receives education regarding FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9L0E11 Facility ID: CA070000012 If continuation sheet 11 of 22 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: _______________ 555363 (X3) DATE SURVEY COMPLETED 03/16/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LINCOLN GLEN SKILLED NURSING 2671 Plummer Ave San Jose, CA 95125 (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 benefits and potential side effects of the immunization; (ii) Each resident is offered a pneumococcal immunization, unless the immunization is medically contraindicated or the resident has already been immunized; (iii) The resident or the resident’s representative has the opportunity to refuse immunization; and (iv) The resident’s medical record includes documentation that indicates, at a minimum, the following: (A) That the resident or resident’s representative was provided education regarding the benefits and potential side effects of pneumococcal immunization; and (B) That the resident either received the pneumococcal immunization or did not receive the pneumococcal immunization due to medical contraindication or refusal. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to follow their policy and procedure to offer the influenza vaccine (flu shot, an annual vaccine intended to protect against the influenza virus) for one of 13 sampled residents (8) and one non-sampled resident (14). These failures had the potential to increase the residents' chances of acquiring the flu and spreading the infection to others. Findings: 1. Review of Resident 8's clinical record FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9L0E11 Facility ID: CA070000012 If continuation sheet 12 of 22 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: _______________ 555363 (X3) DATE SURVEY COMPLETED 03/16/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LINCOLN GLEN SKILLED NURSING 2671 Plummer Ave San Jose, CA 95125 (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 she was admitted on 2/2/11 with diagnoses including age-related cognitive decline and type 2 diabetes mellitus (a long term metabolic disorder characterized by high blood sugar). The influenza vaccine was refused and the consent form was signed by the responsible party (RP, individual empowered to make medical decisions) on 2/2/11. During an interview with registered nurse A (RN A) on 3/14/17 at 4:50 p.m., she reviewed Resident 8's clinical record and was unable to find any documentation to show the influenza vaccine had been offered, or education had been provided, from 2012 to 2017. 2. Review of Resident 14's clinical record indicated she was admitted on 5/10/06 with diagnoses including dementia (a disease that affects memory, personality, and reasoning) and type 2 diabetes mellitus. The influenza vaccine was refused and the consent form was signed by the responsible party on 5/10/06. Review of Resident 14's clinical record indicated there was no documentation to show the influenza vaccine had been offered, or education had been provided, from 2007 to 2016. During an interview with the assistant director of nursing (ADON) on 3/16/17 at 10:10 a.m., she stated the influenza vaccine should have been offered on an annual basis and the licensed nurses should have documented offering the vaccine, including education on the risks and benefits, in the clinical record. The facility's policy and procedure entitled "Influenza/Pneumoccal Immunization Guideline policy", dated 2/2006, indicated if a resident and/or responsible party refuses the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9L0E11 Facility ID: CA070000012 If continuation sheet 13 of 22 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: _______________ 555363 (X3) DATE SURVEY COMPLETED 03/16/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LINCOLN GLEN SKILLED NURSING 2671 Plummer Ave San Jose, CA 95125 (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 administration of the vaccine, they will be contacted on an annual basis and be reeducated on the risks and benefits of the immunization so that another informed consent or refusal may be obtained.

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

F431 04/14/2017 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. (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 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9L0E11 Facility ID: CA070000012 If continuation sheet 14 of 22 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: _______________ 555363 (X3) DATE SURVEY COMPLETED 03/16/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LINCOLN GLEN SKILLED NURSING 2671 Plummer Ave San Jose, CA 95125 (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. (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 review, the facility failed to ensure medications were stored and labeled properly when: 1. There was a medication with an altered label in one of three medication rooms, and 2. there were expired medications in one of three medication rooms. These failures had the potential to result in medications being administered to the wrong residents, and residents receiving expired medications with reduced potency. Findings: 1. During an observation on 3/13/17 at 4:15 p.m., accompanied by licensed vocational nurse C (LVN C), there was one bottle of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9L0E11 Facility ID: CA070000012 If continuation sheet 15 of 22 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: _______________ 555363 (X3) DATE SURVEY COMPLETED 03/16/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LINCOLN GLEN SKILLED NURSING 2671 Plummer Ave San Jose, CA 95125 (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 nyamyc powder (medication applied to the skin to treat fungal infections) in medication room A (MR A). The name of the resident the medication was intended for had been crossed off the label with a black marker. This was confirmed by LVN C. During an observation and concurrent interview with the director of nursing (DON) on 3/13/17 at 4:25 p.m., she looked at the bottle of nyamyc powder and confirmed the resident's name was crossed off the label. The DON stated the medication needed to be "thrown out". She explained the medication should have either been thrown away or placed in a container designated for discontinued medications. According to the facility's 5/2016 "Medications and Medication Labels" policy, medication labels can only be modified by the dispensing pharmacy. The policy further indicates, "Medication labels are not altered, modified, or marked in any way by nursing personnel". 2. During an observation on 3/13/17 at 4:40 p.m., accompanied by the DON, there were two bottles of omeprazole (medication used to treat acid reflux) in MR B. Both bottles of omeprazole belonged to Resident 15. The label on the first bottle indicated the medication was supposed to be discarded in 10/2016. The label on the second bottle had an expiration date of 11/30/16. These dates were confirmed by the DON. During an interview with the DON on the same date and time, she stated the two bottles of omeprazole should have been placed either in a container designated for discontinued medications, or in a container designated for medication waste. According to the facility's 9/2010 "Storage of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9L0E11 Facility ID: CA070000012 If continuation sheet 16 of 22 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: _______________ 555363 (X3) DATE SURVEY COMPLETED 03/16/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LINCOLN GLEN SKILLED NURSING 2671 Plummer Ave San Jose, CA 95125 (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 Medication" policy, outdated medications must be removed from stock immediately.

F441 SS=D INFECTION CONTROL, PREVENT SPREAD, F441 LINENS CFR(s): 483.80(a)(1)(2)(4)(e)(f) 04/14/2017 (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: (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 (facility assessment implementation is Phase 2); (2) Written standards, policies, and 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: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9L0E11 Facility ID: CA070000012 If continuation sheet 17 of 22 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: _______________ 555363 (X3) DATE SURVEY COMPLETED 03/16/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LINCOLN GLEN SKILLED NURSING 2671 Plummer Ave San Jose, CA 95125 (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) 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. (4) A system for recording incidents identified under the facility’s IPCP and the corrective actions taken by the facility. (e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. (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 by: Based on observation, interview, and record review, the facility failed to ensure infection prevention practices were followed for one of 13 sampled residents (7) and one non-sampled resident (16). For Resident 16, staff did not perform hand hygiene before handling medications. For Resident 7, staff did not disinfect medical equipment before and after use. These failures had the potential to spread FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9L0E11 Facility ID: CA070000012 If continuation sheet 18 of 22 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: _______________ 555363 (X3) DATE SURVEY COMPLETED 03/16/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LINCOLN GLEN SKILLED NURSING 2671 Plummer Ave San Jose, CA 95125 (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 infections in the facility. Findings: 1. During an observation on 3/14/17 at 8:35 a.m., registered nurse B (RN B) was preparing to administer medications to Resident 16. With ungloved hands, RN B took Resident 16's blood pressure using an electronic blood pressure cuff (BP cuff, a flexible cuff applied to the arm that is used to measure blood pressure). After obtaining Resident 16's blood pressure, RN B removed the BP cuff and prepared the medications. RN B did not wash or sanitize (to make clean) her hands before handling Resident 16's medications. During an interview with RN B on 3/14/17 at 9:00 a.m., she confirmed she did not wash or sanitize her hands after taking Resident 16's blood pressure and before handling her medications. RN B stated she should have washed her hands. According to the facility's 1/2010 "Hand Hygiene Program" policy, hand hygiene (washing or sanitizing the hands) is required "upon and after coming in contact with a resident's intact skin (e.g., when taking a pulse or blood pressure, and lifting a resident)". 2. During an observation on 3/15/17 at 8:30 a.m., RN B was preparing to administer medications to Resident 7. RN B took Resident 7's blood pressure using an electronic BP cuff. RN B did not disinfect (to clean something in order to destroy bacteria) the electronic BP cuff before or after taking resident 7's blood pressure. During an interview with RN B on 3/15/17 at 9:00 a.m., she stated the electronic BP cuff was used for multiple residents in the facility. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9L0E11 Facility ID: CA070000012 If continuation sheet 19 of 22 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: _______________ 555363 (X3) DATE SURVEY COMPLETED 03/16/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LINCOLN GLEN SKILLED NURSING 2671 Plummer Ave San Jose, CA 95125 (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 RN B confirmed she did not disinfect the BP cuff before or after taking Resident 7's blood pressure, and acknowledged that she should have. According to the facility's 4/2015 "Cleaning Vitals Machine" policy, blood pressure cuffs must be wiped "with a damp cloth moistened with the facility all-purpose cleaner". The policy indicated, "The cleaning procedure will be completed once daily by the housekeeping staff and as needed by the nursing staff".

F517 SS=F WRITTEN PLANS TO MEET EMERGENCIES/DISASTERS CFR(s): 483.75(m)(1)

F517 04/12/2017 The facility must have detailed written plans and procedures to meet all potential emergencies and disasters, such as fire, severe weather, and missing residents. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure they were prepared for emergencies when there were ten boxes of expired water purification tablets (tablets intended to disinfect water by killing bacteria, viruses, and fungi) in their emergency disaster kit. This failure had the potential to compromise the health and safety of the residents, visitors, and staff members who would need drinking water from the facility's emergency water supply in the event of a disaster. Findings: The facility's 5/2015 "Disaster Kit" document indicated their emergency disaster kit was to have ten boxes of water purification tablets. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9L0E11 Facility ID: CA070000012 If continuation sheet 20 of 22 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: _______________ 555363 (X3) DATE SURVEY COMPLETED 03/16/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LINCOLN GLEN SKILLED NURSING 2671 Plummer Ave San Jose, CA 95125 (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 observation of the supply room on 3/15/17 at 11:30 a.m., accompanied by the assistant director of nursing (ADON), the facility's emergency disaster kit was inspected. The kit contained ten boxes of Ef-Chlor water purification tablets. A manufacture date of 6/2013 was printed on all ten boxes. An expiration date of 5/2016 was also printed on all ten boxes. The ADON confirmed these dates. During an observation and concurrent interview with the ADON on 3/15/17 at 1:10 p.m., there were five blue tanks of emergency water located outside the facility near the kitchen. The ADON stated this water would be used for personal use, including drinking, in the event of an emergency. The ADON further explained that if water was taken from the tanks for drinking, it would need to be disinfected with the water purification tablets before being consumed. During an interview with the dietary supervisor (DS) on 3/15/17 at 1:15 p.m., he stated he did not have emergency bottled drinking water in the kitchen. The DS confirmed that in the event of an emergency or disaster, drinking water would be obtained from the tanks located outside the facility near the kitchen. The U.S. Food and Drug Administration's 2013 Food Code indicates that drinking water systems shall be disinfected after emergency situations that may contaminate the system. An undated informational printout, provided by the facility for Ef-Chlor Water Purification Tablets, indicated the product is intended for fast treatment of water during emergencies and disasters. The printout also indicated Ef-Chlor Water Purification Tablets have a three year FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9L0E11 Facility ID: CA070000012 If continuation sheet 21 of 22 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: _______________ 555363 (X3) DATE SURVEY COMPLETED 03/16/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LINCOLN GLEN SKILLED NURSING 2671 Plummer Ave San Jose, CA 95125 (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 shelf life (the length of time an item remains usable or fit for consumption). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9L0E11 Facility ID: CA070000012 If continuation sheet 22 of 22