Other·March 16, 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 2/27/17 through 3/2/17. Complaint CA00524105 regarding Quality of Care/Treatment was investigated. The Department did not substantiate the complaint. The facility was licensed for 199 beds. The census at the time of the survey was 176 including two bedholds. Representing the California Department of Public Health: 29765, Health Facilities Evaluator Nurse; 29259, Health Facilities Evaluator Nurse; 34383, Health Facilities Evaluator Nurse; 36045, Health Facilities Evaluator Nurse; 36044, Health Facilities Evaluator Nurse; 37409, Health Facilities Evaluator Nurse; 37959, Health Facilities Evaluator Nurse, and 27000, Public Health Pharmacy Consultant. 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: OQB711 Facility ID: CA070000023 If continuation sheet 1 of 50 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: _______________ 056082 (X3) DATE SURVEY COMPLETED 03/02/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON SPRINGS POST-ACUTE 180 N Jackson 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)

F241 DIGNITY AND RESPECT OF INDIVIDUALITY F241 CFR(s): 483.10(a)(1) SS=D ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 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 provide privacy during medication pass for one of 27 sampled residents (2). This failure had the potential to affect the resident's self-esteem and self-worth. Findings: During an observation of the medication pass for Resident 2 on 2/28/17, at 7:45 a. m., licensed vocational nurse C (LVN C) did not pull the curtain to provide privacy. LVN C administered Resident 2's medications through her G-tube (a tube inserted through the abdomen that delivers nutrition and medication directly to the stomach), and part of Resident 2's abdomen was exposed. Resident 2 was not interviewable. During an interview with LVN C, on 2/28/17, at 8:15 a. m., she stated she should pull the curtain to provide privacy for Resident 2 before administering the medications. The facility policy and procedure titled "Quality of Life - Dignity", revision dated 10/2009, indicated "Staff shall promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OQB711 Facility ID: CA070000023 If continuation sheet 2 of 50 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: _______________ 056082 (X3) DATE SURVEY COMPLETED 03/02/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON SPRINGS POST-ACUTE 180 N Jackson 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

F252 SAFE/CLEAN/COMFORTABLE/HOMELIKE ENVIRONMENT CFR(s): 483.10(e)(2)(i)(1)(i)(ii)

F252 SS=D PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 04/06/2017 (e)(2) The right to retain and use personal possessions, including furnishings, and clothing, as space permits, unless to do so would infringe upon the rights or health and safety of other residents. §483.10(i) Safe environment. The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. The facility must provide(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. (i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. (ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft. This REQUIREMENT is not met as evidenced by: Based on observation and interview, the facility failed to secure a wire shelving unit in Resident 11's room. This failure had the potential to pose a safety risk in the event of an earthquake. Findings: During the environmental tour on 2/28/17, at 3:05 p.m., with the maintenance supervisor (MS) in Resident 11's room, a six foot high FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OQB711 Facility ID: CA070000023 If continuation sheet 3 of 50 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: _______________ 056082 (X3) DATE SURVEY COMPLETED 03/02/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON SPRINGS POST-ACUTE 180 N Jackson 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 four-shelf steel wire shelving unit containing personal items was not securely attached to the wall. The unit wobbled from side to side after conducting a mild test shake. During a concurrent interview, the MS confirmed the shelving unit belonged to Resident 11 and had been in the room for a while. He acknowledged the shelving unit should had been anchored to the wall to prevent swaying and falling over in case of an earthquake. The facility policy and procedure titled "Use of Personal Furnishings" dated April 2008, indicated the facility permits residents to use their personal furnishings when such use does not cause a violation of current fire and/or safety code requirements.

F279 SS=D DEVELOP COMPREHENSIVE CARE PLANS CFR(s): 483.20(d);483.21(b)(1)

F279 04/06/2017 483.20 (d) Use. A facility must maintain all resident assessments completed within the previous 15 months in the resident’s active record and use the results of the assessments to develop, review and revise the resident’s comprehensive care plan. 483.21 (b) Comprehensive Care Plans (1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c) (3), that includes measurable objectives and timeframes to meet a resident's medical, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OQB711 Facility ID: CA070000023 If continuation sheet 4 of 50 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: _______________ 056082 (X3) DATE SURVEY COMPLETED 03/02/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON SPRINGS POST-ACUTE 180 N Jackson 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 nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident’s medical record. (iv)In consultation with the resident and the resident’s representative (s)(A) The resident’s goals for admission and desired outcomes. (B) The resident’s preference and potential for future discharge. Facilities must document whether the resident’s desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section. This REQUIREMENT is not met as evidenced FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OQB711 Facility ID: CA070000023 If continuation sheet 5 of 50 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: _______________ 056082 (X3) DATE SURVEY COMPLETED 03/02/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON SPRINGS POST-ACUTE 180 N Jackson 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 care plans were developed and implemented for three of 27 sampled residents (12, 13, and 17). For Resident 12, there was no care plan developed for thyrotoxicosis (a condition that occurs due to excessive thyroid hormone in the body). For Resident 13, the landing pad at the bedside floor was not implemented. For Resident 17, the care plan for psychosocial well-being was not initiated and implemented timely. These failures may affect the quality of care for the residents. Findings: 1. During a record review on 2/28/17, Resident 13's clinical record indicated Resident 13 spoke another language other than English and needed an interpreter for communication. The minimum data set (MDS, an assessment tool) dated 1/12/17 indicated Resident 13 needed supervision for ambulation and had a history of falls on 2/4/17 and 2/28/17. During lunch observation on 2/27/17 at 12:40 p.m., Resident 13 was sitting in bed. The landing pad was propped up against the wall. During observations of Resident 13 on 2/28/17, 3/1/17, and 3/2/17 the landing pad was resting against the wall. During a concurrent interview with certified nursing assistant C (CNA C) on 3/2/17 at 11:50 a.m., using registered nurse E (RN E) to interpret for Resident 13 and a family member who also spoke a language other than English, they acknowledged the landing pad should be on the bedside floor for fall precaution. Review of the facility's policy and procedure on 3/2/17 "Falls and Fall Risk, Managing" FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OQB711 Facility ID: CA070000023 If continuation sheet 6 of 50 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: _______________ 056082 (X3) DATE SURVEY COMPLETED 03/02/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON SPRINGS POST-ACUTE 180 N Jackson Ave San Jose, CA 95116 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE indicated the staff would identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. 2. During the initial tour observation and interview on 2/27/17 at 8:45 a.m., Resident 17 was waiting for her ride to her scheduled dialysis (a procedure that performs many of the normal functions of the kidneys, like filtering waste products from the blood, when the kidneys no longer work adequately). Resident 17 had a right above the knee amputation (AKA) and was legally blind. Resident 17 was alert and oriented to name, place, and time. Resident 17 was also edentulous on both the upper and lower dentures. She stated she could not see and needed a lot of assistance from the CNA. She stated did not want her dentures to get lost in the facility and had a family member (FM) keep it for her at home and used it when FM was able to come to see her in the facility. She stated she appreciated any short visit and conversation with her by anybody from the facility. During a review on 3/1/17 of Resident 17's clinical record, the care plan for psychosocial well-being dated 2/27/17 indicated on 12/16/16, Resident 17 had feelings of sadness due to her condition and a psych consult/psychosocial therapy was one of the approaches. During an interview on 3/2/17 at 9:00 a.m. with licensed vocational nurse A (LVN A), she stated she was not aware a psych consult was done for Resident 17. During a concurrent interview with the social service supervisor (SSS) she acknowledged the psychosocial care plan for a psych consult was not initiated timely. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OQB711 Facility ID: CA070000023 If continuation sheet 7 of 50 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: _______________ 056082 (X3) DATE SURVEY COMPLETED 03/02/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON SPRINGS POST-ACUTE 180 N Jackson 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 on 3/2/17 of the facility's policy and procedure "Care Planning- Interdisciplinary Team" indicated the Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident. 3. Resident 12 was admitted to the facility with diagnoses including thyrotoxicosis. Clinical signs of thyrotoxicosis include weight loss, anxiety, muscle weakness, high blood sugar, abnormal heart rhythms, shortness of breath, irregular heart beat, psychosis (an abnormal condition of the mind that involves a loss of contact with reality) and paranoia (a condition involves intense anxious or fearful feelings). The clinical record review on 2/28/17 indicated there was no care plan developed for Resident 12's thyrotoxicosis diagnosis. During an interview with nursing supervisor F (NS F), on 3/1/17, at 2:40 p. m., she reviewed the clinical record and was unable to find the care plan for Resident 12's thyrotoxicosis condition. The facility policy and procedure titled "Care Planning- Interdisciplinary Team", revision dated 12/2008, indicated "The facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident."

F309 SS=D PROVIDE CARE/SERVICES FOR HIGHEST WELL BEING CFR(s): 483.24, 483.25(k)(l)

F309 04/06/2017 483.24 Quality of life Quality of life is a fundamental principle that applies to all care and services provided to facility residents. Each resident must receive FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OQB711 Facility ID: CA070000023 If continuation sheet 8 of 50 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: _______________ 056082 (X3) DATE SURVEY COMPLETED 03/02/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON SPRINGS POST-ACUTE 180 N Jackson Ave San Jose, CA 95116 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident’s comprehensive assessment and plan of care. 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive personcentered care plan, and the residents’ choices, including but not limited to the following: (k) Pain Management. The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents’ goals and preferences. (l) Dialysis. The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents’ goals and preferences. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to give medication in a timely manner for one of 27 sampled residents (9) when Lorazepam (a medication used for the short-term treatment of anxiety) medication was not available for more than 22 hours for her anxiety (a disease frequently with intense, excessive and persistent worry and fear about FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OQB711 Facility ID: CA070000023 If continuation sheet 9 of 50 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: _______________ 056082 (X3) DATE SURVEY COMPLETED 03/02/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON SPRINGS POST-ACUTE 180 N Jackson 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 everyday situations). This failure had potential to cause the resident distress and health complications. Findings: Resident 9 was admitted with diagnoses including end stage congestive heart failure. Review of Resident 9's clinical record indicated an order for Lorazapam two milligram per milliliter (mg/ml - unit of measurement) every four hours as needed dated 6/18/16 for anxiety, restless and shortness of breath. Review of Resident 9's clinical record indicated an order for Lorazepam two mg/ml, give 0.5ml sublingual (medication placed under the tongue) two times a day as needed for anxiety. Review of Resident 9's clinical record indicated an order for Lorazepam suspension two mg/ml. on 3/1/17. Give one mg per orem (by mouth) two times a day, total of 20 mls. Review of Resident 9's PRN medications flowsheet documented she had taken Lorazapam 16 times for anxiety and restless from 2/5/17 to 2/26/17. During an observation and interview on 3/2/17 at 8 a.m., Resident 9 was lying in bed grimacing. She stated she was waiting for her Lorazapam medication since yesterday noon time (3/1/17) and the facility was not able to give her medication. She also stated she was very uncomfortable. During an interview on 3/2/17 at 9:05 a.m., the acting director of nurses (ADON) stated the prescription orders for Lorazapam were written twice. The first time was on 2/28/17, at 6:30 p.m. and the second time was on 3/1/17, at 12 p.m. This was due to the quantity was written FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OQB711 Facility ID: CA070000023 If continuation sheet 10 of 50 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: _______________ 056082 (X3) DATE SURVEY COMPLETED 03/02/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON SPRINGS POST-ACUTE 180 N Jackson 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 incorrectly on the physician active orders, and the pharmacy was not able to process the order for Lorazapam. During a telephone interview with the pharmacist (Ph) on 3/2/17, at 11:30 a.m., she stated the facility nurse should have notified the (physician) MD and obtained an new order for Lorazapam oral tablet at that time for emergency use. The facility policy and procedure titled "Administering Medications" dated April 2007, indicated medications must be administered in accordance with the orders, including any required time frame.

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

F323 04/06/2017 (d) Accidents. The facility must ensure that (1) The resident environment remains as free from accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. (n) - Bed Rails. The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements. (1) Assess the resident for risk of entrapment from bed rails prior to installation. (2) Review the risks and benefits of bed rails with the resident or resident representative and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OQB711 Facility ID: CA070000023 If continuation sheet 11 of 50 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: _______________ 056082 (X3) DATE SURVEY COMPLETED 03/02/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON SPRINGS POST-ACUTE 180 N Jackson 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 obtain informed consent prior to installation. (3) Ensure that the bed’s dimensions are appropriate for the resident’s size and weight. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to conduct Resident 10's quarterly fall risk assessment (a tool used to identify risk factors for fall and formulate action plan), and failed to implement the intervention of placing the bed in a low position for one of 27 sampled residents (Resident 10). These failures resulted in a fall and a right hip fracture. Findings: Review of Resident 10's facesheet on 2/28/17, indicated the resident was admitted 9/7/15 with diagnoses including history of falling, difficulty in walking, muscle weakness, dementia (memory problem), unsteadiness on feet, and age related osteoporosis (a medical condition in which the bones become brittle and fragile) without current pathological fracture (a fracture caused by disease which led to weakness of the bone structure). Her minimum data set (MDS, an assessment tool) dated 6/10/16 indicated the resident had severe impaired cognition (the activities of thinking, understanding, learning, and remembering), required assistance in bed movements, transfers, walking, and toileting. Review of Resident 10's fall risk assessment dated 6/17/16, indicated under fall risk summary score Resident 10 had a score of 19 which indicated she was at risk for fall. There was no quarterly fall risk assessment done for 9/2016. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OQB711 Facility ID: CA070000023 If continuation sheet 12 of 50 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: _______________ 056082 (X3) DATE SURVEY COMPLETED 03/02/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON SPRINGS POST-ACUTE 180 N Jackson Ave San Jose, CA 95116 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During an interview and record review with the assistant director of nursing (ADON) on 3/1/17 at 11 a.m., he stated Resident 10 was at high risk for falls, and there should be a quarterly fall risk assessment in 9/2016. Review of Resident 10's care plan for fall risk dated 9/17/16, indicated to keep the bed in the lowest position with the brakes locked. Review of Resident 10's event report dated 11/22/16, indicated the resident had an unwitnessed fall at 3:30 p.m., and was found on the floor. Per the body assessment it was suspected there was a fracture or an actual fracture. Review of Resident 10's progress note dated 11/22/16 at 11 p.m., indicated at 3:30 p.m., "a CNA assisting across the hall noted the resident was on the floor with the bed elevated, and was calling for help. [Resident 10] was unable to state what she was doing prior to fall". Review of Resident 10's progress note dated 11/23/16 at 8:19 a.m., indicated receipt of the results of the X-ray (an imaging test used to produced photograph of bones which can be checked for fractures). Results were acute right hip fracture. Resident 10 had an old fracture involving right rami (part of a pubic bone) with modest healing. Resident 10's primary physician was called to report the X-ray result, and he ordered to transfer Resident 10 to the acute hospital. Review of Resident 10's acute hospital discharge summary dated 12/1/16 and the admission dated 11/23/16, indicated Resident 10's discharge diagnoses were right hip fracture with status post (had the procedure) right hip gamma nail fixation (a surgical FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OQB711 Facility ID: CA070000023 If continuation sheet 13 of 50 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: _______________ 056082 (X3) DATE SURVEY COMPLETED 03/02/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON SPRINGS POST-ACUTE 180 N Jackson 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 procedure to stabilize severe fracture of the bone), postoperative (after surgical procedure) anemia (a medical condition in which the red blood cell count is less than normal), status post blood transfusion (a process to replace blood lost), history of osteoporosis, mechanical falls (means slipped, tripped or lost your balance), and high risk for falls. Review of Resident 10's care plan for falls dated 12/2/16, indicated to keep the bed in a low position with an alarm, landing pad, and hip protector. Review of Resident 10's event report dated 12/23/16, indicated the resident had an unwitnessed fall when she was found on the floor while she transferred from the wheelchair to her bed, and lost her balance. During an observation on 2/28/17 at 7:40 a.m. and 3/1/17 at 8:30 a.m., Resident 10 was lying in her bed with her eyes closed. The bed was elevated and was not in a low position. During an observation and interview with licensed vocational nurse C (LVN C) on 3/1/17 at 8:35 a.m., Resident 10 was lying in bed. The bed was not in a low position, and the bed alarm was turned off. LVN C confirmed the bed should have been in a low position and the bed alarm should not be turned off. A review of the facility's 2001 policy, "Fall and Fall Risk, Managing", indicated the staff identify interventions and implement relevant interventions to try to minimize serious consequences of falling.

F329 SS=D DRUG REGIMEN IS FREE FROM UNNECESSARY DRUGS CFR(s): 483.45(d)(e)(1)-(2)

F329 04/06/2017 483.45(d) Unnecessary Drugs-General. Each resident’s drug regimen must be free from unnecessary drugs. An unnecessary drug FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OQB711 Facility ID: CA070000023 If continuation sheet 14 of 50 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: _______________ 056082 (X3) DATE SURVEY COMPLETED 03/02/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON SPRINGS POST-ACUTE 180 N Jackson 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 is any drug when used-(1) In excessive dose (including duplicate drug therapy); or (2) For excessive duration; or (3) Without adequate monitoring; or (4) Without adequate indications for its use; or (5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or (6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section. 483.45(e) Psychotropic Drugs. Based on a comprehensive assessment of a resident, the facility must ensure that-(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record; (2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs; This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure two of 27 sampled residents (12 and 19) were free from unnecessary drugs. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OQB711 Facility ID: CA070000023 If continuation sheet 15 of 50 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: _______________ 056082 (X3) DATE SURVEY COMPLETED 03/02/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON SPRINGS POST-ACUTE 180 N Jackson Ave San Jose, CA 95116 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 1. For Resident 12, the ordered dose of megestrol (an appetite stimulant) may not be effective for the treatment his condition. Also, there were no side effect monitoring for megestrol and methimazole (a drug used to treat hyperthyroidism, a condition that occurs when the thyroid gland begins to produce an excess of thyroid hormone). 2. For Resident 19, the facility did not obtain an ammonia (a gas formed in the body when protein is broken down by bacteria in the intestines) level when he experienced lethargy and confusion while on divalproex sodium (a drug used to treat seizures and manicdepressive illness). High ammonia is one of the serious side effects of divalproex sodium, which can cause symptoms of feeling tired, vomiting, and changes in mental status. These failures had the potential for the physician not to decrease or discontinue the medication, and for the residents to receive unnecessary drugs. Findings: 1. Resident 12 was admitted to the facility with diagnoses including failure to thrive (weight faltering) and thyrotoxicosis (a condition that occurs due to excessive thyroid hormone in the body). His weight was 100 pounds (lbs). The clinical record review on 2/28/17 indicated Resident 12 had physician orders for megestrol 40 milligram (mg) daily, dated 2/15/17, and methimazole 10 mg twice daily, dated 2/7/17. Resident 12's care plan dated 2/15/17 reflected he lost 4 lbs in 7 days, and the 2/21/17 care plan reflected he lost 2.2 lbs in 7 days. According to Lexicomp (www.lexi.com), a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OQB711 Facility ID: CA070000023 If continuation sheet 16 of 50 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: _______________ 056082 (X3) DATE SURVEY COMPLETED 03/02/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON SPRINGS POST-ACUTE 180 N Jackson 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 nationally recognized drug information resource, the effective dose of megestrol to treat appetite was 400 mg daily (10 times the dose Resident 12 was taking). During an interview with nursing supervisor F (NS F), on 3/1/17, at 2:40 p.m., she stated the dose of megestrol for Resident 12 was low and verified there were no side effect monitorings for megestrol and methimazole. During a telephone interview with the consultant pharmacist (CP), on 3/2/17, at 1:50 p. m., she agreed the megestrol dose of 40 mg daily was too low. The Prescribing Information for megestrol indicated it could cause high blood sugar, nervousness, confusion, shortness of breath, fever, chills, sore throat, cough, numbness, seizures, dizziness, headache, and rash. The Prescribing Information for methimazole indicated it could cause dark urine, feeling tired, stomach pain, throwing up, yellow skin or eyes, low blood sugar, bleeding, swelling, fever, chills, sore throat, cough, headache, and rash. 2. Resident 19 was admitted to the facility on 7/9/16 with diagnoses including bipolar (a mental health condition that causes extreme mood swings from depression to mania) and depressive disorder. During an observation on 3/1/17 at 1:25 p.m., Resident 19 was lying in bed, opened his eyes to respond to questions and closed them right away. Resident 19 stated he preferred to stay in bed. Resident 19's nursing weekly summary and progress notes indicated he was alert and had FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OQB711 Facility ID: CA070000023 If continuation sheet 17 of 50 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: _______________ 056082 (X3) DATE SURVEY COMPLETED 03/02/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON SPRINGS POST-ACUTE 180 N Jackson 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 clear speech in July, August, September, and October 2016, but his mental status changed starting in November 2016. Nursing weekly summary dated 11/8/16 stated Resident 19 had "unclear speech". On 11/29/16 weekly summary note indicated "Period of confusion. Orient to reality when awake and while giving care." Weekly summary dated 12/20/16 indicated Resident 19 was "intermittently confused," and on 1/9/17 it indicated Resident 19 was "confused and disoriented most of the time". Nursing progress notes dated 11/29/16, 12/13/16, 12/14/16, 1/10/17, 1/23/17, 2/13/17, and 2/21/17 indicated Resident 19 was "Alert with period of confusion". He also vomited on 3/1/17 and was given Zofran (a drug used to prevent nausea and vomiting). Resident 19's clinical record, reviewed on 3/2/17, indicated he had been on divalproex sodium with the dose ranging from 1500 mg to 2000 mg per day since adminssion in July 2016. There was no laboratory order for ammonia level. During an interview with NS F, on 3/2/17 at 11:40 a.m., she reviewed Resident 19's clinical record and was unable to find his ammonia level laboratory result. According to Lexicomp, "Hyperammonemia (high ammonia level) and/or encephalopathy (a disease that damages the brain), sometimes fatal, has been reported following the initiation of valproate therapy... Ammonia levels should be measured in patients who develop unexplained lethargy and vomiting, or changes in mental status ..."

F332 FREE OF MEDICATION ERROR RATES OF FORM CMS-2567(02-99) Previous Versions Obsolete

F332 Event ID: OQB711 04/06/2017 Facility ID: CA070000023 If continuation sheet 18 of 50 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: _______________ 056082 (X3) DATE SURVEY COMPLETED 03/02/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON SPRINGS POST-ACUTE 180 N Jackson 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) SS=E 5% OR MORE CFR(s): 483.45(f)(1) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (f) Medication Errors. The facility must ensure that its(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 17.2% medication error rate when five medication errors of 29 opportunities were observed during the medication pass for one sampled resident (2) and three non-sampled residents (37, 39, and 40). These failures had the potential to negatively affect the residents' health and wellbeing. Findings: 1. During a medication pass observation on 2/27/17, at 4:15 p.m., licensed vocational nurse H (LVN H) administered multiple medications including a metformin (medication to lower blood sugar level) 500 milligrams (mg - unit dose measurement) to Resident 40. During an interview with LVN H, on 2/27/17, at 5:15 p.m., she stated dinner was at 5:30 p.m. LVN H verified that the pharmacy's instruction on the bubble pack (a blister pack that contained individual medication in each bubble) for metformin was to "take with a meal," and she should administer metformin to Resident 40 at dinner time. To date, the Prescribing Information for metformin indicated to "Administer with a meal (to decrease GI [gastrointestinal] upset)." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OQB711 Facility ID: CA070000023 If continuation sheet 19 of 50 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: _______________ 056082 (X3) DATE SURVEY COMPLETED 03/02/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON SPRINGS POST-ACUTE 180 N Jackson 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 a medication pass observation on 2/27/17, at 4:45 p.m., LVN I administered multiple medications including glimepiride (an oral drug that helps lower blood sugar level) 1 mg to Resident 39. During a concurrent observation, LVN I administered 1 puff of Qvar (a drug used to prevent and control wheezing and shortness of breath) inhalation 40 micrograms (mcg) to Resident 39 and did not instruct him to rinse his mouth. During an interview with LVN I, on 2/27/17, at 4:50 p.m., she stated dinner was at 5:30 p.m. LVN I verified the pharmacy's instruction on the bubble pack for glimepiride was to "take with a meal", and she should administer glimepiride to Resident 39 at dinner time. LVN I also verified per the manufacturer's instruction Resident 39 should rinse his mouth after inhalation of Qvar. During an interview with assistant director of nursing K (ADON K), on 2/28/17, at 10:20 a.m., he stated for the medication with the instruction to take with a meal, it should be given with breakfast, lunch, or dinner. To date, the Prescribing Information for glimepiride indicated to administer with the "main meal" of the day. The clinical record for Resident 39 was reviewed on 2/27/17. The physician order, dated 1/25/17, indicated "Qvar aerosol, 40 mcg/actuation, 1 puff inhalation for wheezing, rinse mouth after use with water." Lexicomp (www.lexi.com), a nationally recognized drug information resource, indicated: "Rinse mouth and throat with water (and spit) after use of Qvar inhalation to prevent Candida infection". FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OQB711 Facility ID: CA070000023 If continuation sheet 20 of 50 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: _______________ 056082 (X3) DATE SURVEY COMPLETED 03/02/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON SPRINGS POST-ACUTE 180 N Jackson 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 3. During a medication pass on 2/28/17, at 7:45 a.m., LVN C prepared three solid and three liquid medications for Resident 2. She put each solid medication in individual 30 millimeters (ml - unit of measurement) cup after crushing them and dissolved each medication with water. She also mixed liquid medication with water. LVN C attached a syringe to Resident 2's gastrostomy tube (G-tube, a tube inserted through the abdomen that delivers nutrition and medication directly to the stomach), flushed the tubing with 30 ml of water, then poured each dissolved medication down the G-tube one after another without flushing between the medications. LVN C did not wait for each individual medication to completely pass through the syringe and Gtube before administering the next one. Shortly after the medication pass, on 2/28/17, at 8:15 a.m., LVN C stated she should flush water between the medications. 4. During a medication pass on 2/28/17, at 8:25 a.m., LVN J prepared five solid and two liquid medications for Resident 37. She put each solid medication in individual 30 ml cup after crushing them and dissolved each medication with water. She also mixed liquid medication with water. LVN J attached a syringe to Resident 37's G-tube, flushed the tubing with 30 ml of water, then poured each dissolved medication down the G-tube one after another without flushing between the medications. LVN J did not wait for each individual medication to completely pass through the syringe and Gtube before administering the next one. Shortly after the medication pass, on 2/28/17, at 8:45 a.m., LVN J stated she should flush water between the medications. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OQB711 Facility ID: CA070000023 If continuation sheet 21 of 50 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: _______________ 056082 (X3) DATE SURVEY COMPLETED 03/02/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON SPRINGS POST-ACUTE 180 N Jackson 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 ADON K, on 2/28/17, at 10:50 a.m., he stated 5ml of water should be flushed between medications administered through a G-tube. The facility policy and procedure titled "Administering Medications through an Enteral Tube", revision dated 3/2015, indicated, "If administering more than one medication, flush with 5 to 15 ml (or prescribed amount) water between medications."

F366 SS=D SUBSTITUTES OF SIMILAR NUTRITIVE VALUE CFR(s): 483.60(d)(4)-(6)

F366 04/06/2017 (d)(4) Food that accommodates resident allergies, intolerances, and preferences; (d)(5) Appealing options of similar nutritive value to residents who choose not to eat food that is initially served or who request a different meal choice; and (d)(6) Drinks, including water and other liquids consistent with resident needs and preferences and sufficient to maintain resident hydration. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to serve food consistent with the preferences of one of 27 sampled residents (Resident 3) and two nonsampled residents. These failures could adversely affect the nutritional status of the residents. Findings: 1. Resident 3's diet card was reviewed and indicated she did not like white sugar. During a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OQB711 Facility ID: CA070000023 If continuation sheet 22 of 50 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: _______________ 056082 (X3) DATE SURVEY COMPLETED 03/02/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON SPRINGS POST-ACUTE 180 N Jackson 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 breakfast observation and interview on 2/28/17, at 7:40 a.m., Resident 3 was eating breakfast. Her breakfast tray included oatmeal and she asked certified nurse assistant L (CNA L), who was assisting her, to put sweetener on her cereal. He proceeded to open two packages of white sugar, which were on her tray, and pour them on her cereal. She ate a few bites of the cereal and then stated she did not want the rest because she did not like the taste. During an interview on 2/28/17, at 7:55 a.m., CNA L stated he poured white sugar on Resident 3's cereal because sugar was the only sweetener included on her tray. During an interview on 3/1/17, at 2 p.m., Resident 3 stated she did not like white sugar. She stated she wanted the sweetener in the pink package (a sugar substitute) and she had advised the kitchen of her preference, but she kept getting sugar. During an interview on 3/1/17, at 2:30 p.m., the dietary supervisor (DS) reviewed Resident 3's diet card and confirmed the card indicated the resident did not like white sugar. She stated she would change the diet card to indicate the resident wanted a sugar substitute. 2. Resident 29's diet card was reviewed and indicated she did not like juice. During a lunch observation and interview on 2/27/17, at 12:20 p.m., Resident 29 was eating lunch. Her lunch tray included juice which she did not drink because she stated she did not like juice. 3. Resident 30's diet card was reviewed and indicated she did not like milk. During a lunch observation and interview on 2/27/17, at 12:25 p.m., Resident 30 was eating lunch. Her lunch tray included milk which she did not drink because she stated she did not like milk. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OQB711 Facility ID: CA070000023 If continuation sheet 23 of 50 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: _______________ 056082 (X3) DATE SURVEY COMPLETED 03/02/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON SPRINGS POST-ACUTE 180 N Jackson Ave San Jose, CA 95116 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During an interview on 2/27/17, at 12:30 p.m., with CNA M, he stated Residents 29 and 30 should not be served food items listed as "dislikes" on their diet cards. During an interview on 3/2/17, at 2:30 p.m., the nutrition consultant (NC) reviewed Residents 29 and 30's diet cards and confirmed Resident 29's card indicated she did not like juice and Resident 30's card indicated she did not like milk. He stated the residents should not be served food items they do not like and he would speak to the kitchen staff. Review of the facility's 2001 policy, "Resident Food Preferences", indicated upon the resident's admission, the dietician or the nursing staff will identify a list of the resident's food preferences and the staff will strive to accommodate those preferences when possible.

F371 SS=D FOOD PROCURE, STORE/PREPARE/SERVE F371 - SANITARY CFR(s): 483.60(i)(1)-(3) 04/06/2017 (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 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OQB711 Facility ID: CA070000023 If continuation sheet 24 of 50 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: _______________ 056082 (X3) DATE SURVEY COMPLETED 03/02/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON SPRINGS POST-ACUTE 180 N Jackson 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 facility. (i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. (i)(3) Have a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to comply with national guidelines and their own policy when food items were unlabeled and undated and some items were stored on the floor. Failure to appropriately label, date, and store food could result in food-borne illnesses. Findings: 1. During the initial tour and accompanied by registered nurse N (RN N) on 2/27/17, at 8 a.m., water bottles were observed stored on the floor in Room 20 and juice bottles were stored on the floor in Room 28. During a concurrent interview, RN N stated the bottles of water and juice had been brought in by the residents' families. However, he stated they should not have been stored on the floor. Review of the Federal Food Code 2013 (Food Code, the standard of practice for food service operations), indicated food items should be stored at least six inches above the floor. 2. During the initial tour on 2/27/17 at 8:40 a.m., Resident 32 had yellow juice in a cup which was unlabelled and undated. During an interview with the assistant director of nursing (ADON) at 8:45 a.m., he stated the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OQB711 Facility ID: CA070000023 If continuation sheet 25 of 50 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: _______________ 056082 (X3) DATE SURVEY COMPLETED 03/02/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON SPRINGS POST-ACUTE 180 N Jackson 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 yellow juice in a cup should have a date and be labelled. 3. During the initial tour on 2/27/17, at 7:40 a.m., Resident 35 had a container of shredded dried fish on the bedside table. The container was labeled with his name and room number, but it had no date. During an observation on 2/28/17, at 9:30 a.m., Resident 35's container of shredded dried fish still had no date. During a concurrent interview with licensed vocational nurse P (LVN P), she stated the container should be dated. 4. During the initial tour on 2/27/17, at 8:20 a.m., Resident 34 had a container of sun flower seeds on the overbed table. The container had no label. During an observation on 2/28/17, at 9:45 a.m., Resident 34's container of sun flower seeds still had no label. During a concurrent interview with LVN P, she stated the container should be labeled with Resident 34's name and dated. The facility policy and procedure titled "Foods Brought by Family/Visitors", revision dated 12/2008, indicated "Containers will be labeled with the resident's name, the item, and the use by date.

F425 SS=D PHARMACEUTICAL SVC - ACCURATE PROCEDURES, RPH CFR(s): 483.45(a)(b)(1)

F425 04/06/2017 (a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OQB711 Facility ID: CA070000023 If continuation sheet 26 of 50 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: _______________ 056082 (X3) DATE SURVEY COMPLETED 03/02/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON SPRINGS POST-ACUTE 180 N Jackson Ave San Jose, CA 95116 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who-(1) Provides consultation on all aspects of the provision of pharmacy services in the facility; This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to meet the needs of non-sampled Resident 37 when he was simultaneously administered two medications with drug-to-drug interaction (situation in which a drug affects the activity of another drug when both are administered together). This interaction may decrease the therapeutic affect of the medications for the resident. Findings: During a medication pass observation on 2/28/17, at 8:25 a.m., licensed vocational nurse J (LVN J) administered seven medications to Resident 37. The medications were Ferrous sulfate (iron, to treat anemia), folic acid (one of the B vitamins), losartan (a drug used to treat high blood pressure), multiple vitamins, oyster shell calcium with vitamin D (a calcium and vitamin D supplement), gabapentin (a drug used to relieve nerve pain and to prevent and control seizures), and metoprolol (a drug used to treat high blood pressure). The clinical record for Resident 37 was reviewed on 3/1/17, and he had physician orders for ferrous sulfate four times daily at 9:00 a.m., 1:00 p.m., 5:00 p.m., and 9:00 p.m. started on 2/22/17; and for oyster shell calcium with vitamin D twice daily at 9:00 a.m. and 5:00 p.m. started on 4/6/16. Thus since 2/22/17 ferrous sulfate and calcium were given daily at the same times, at 9 a.m. and 5 p.m. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OQB711 Facility ID: CA070000023 If continuation sheet 27 of 50 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: _______________ 056082 (X3) DATE SURVEY COMPLETED 03/02/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON SPRINGS POST-ACUTE 180 N Jackson 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 nursing supervisor F (NS F), on 3/1/17, at 3:10 p.m., she verified since 2/22/17, ferrous sulfate and calcium were given daily at the same time at 9 a.m. and 5 p.m. NS F acknowledged these two medications should not be given at the same time due to the drug-to-drug interaction. During a telephone interview with the consultant pharmacist (CP), on 3/2/17, at 1:50 p.m., she confirmed ferrous sulfate and calcium should not be administered at the same time. According to Lexicomp (www.lexi.com), a nationally recognized drug information resource, the concurrent use of calcium and ferrous sulfate led to a drug-drug interaction (DDI) of Risk Rating D, which was a significant interaction and required therapy modification. The effect of the DDI was that the calcium may decrease the absorption of oral preparations of iron salts. It indicated the iron absorption was decreased an average of 60% when given as ferrous sulfate and co-administered with calcium. Lexicomp also indicated to separate the administrations of these medications so it may minimize the potential for significant interaction.

F428 SS=E DRUG REGIMEN REVIEW, REPORT IRREGULAR, ACT ON CFR(s): 483.45(c)(1)(3)-(5)

F428 04/06/2017 c) Drug Regimen Review (1) The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist. (3) A psychotropic drug is any drug that affects brain activities associated with mental FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OQB711 Facility ID: CA070000023 If continuation sheet 28 of 50 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: _______________ 056082 (X3) DATE SURVEY COMPLETED 03/02/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON SPRINGS POST-ACUTE 180 N Jackson 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 processes and behavior. These drugs include, but are not limited to, drugs in the following categories: (i) Anti-psychotic; (ii) Anti-depressant; (iii) Anti-anxiety; and (iv) Hypnotic. (4) The pharmacist must report any irregularities to the attending physician and the facility’s medical director and director of nursing, and these reports must be acted upon. (i) Irregularities include, but are not limited to, any drug that meets the criteria set forth in paragraph (d) of this section for an unnecessary drug. (ii) Any irregularities noted by the pharmacist during this review must be documented on a separate, written report that is sent to the attending physician and the facility’s medical director and director of nursing and lists, at a minimum, the resident’s name, the relevant drug, and the irregularity the pharmacist identified. (iii) The attending physician must document in the resident’s medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident’s medical record. (5) The facility must develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OQB711 Facility ID: CA070000023 If continuation sheet 29 of 50 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: _______________ 056082 (X3) DATE SURVEY COMPLETED 03/02/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON SPRINGS POST-ACUTE 180 N Jackson 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 consultant pharmacist (CP) failed to identify and report to the facility the irregularities during the medication regimen review (MRR) for two sampled residents (6 and 12) and non-sampled Resident 36, and failed to identify expired medications when: 1. The pharmacist did not inspect the central supply (a room where the facility stored overthe-counter medications and supplies) during the monthly visits to the facility. There were 30 expired medications identified in the central supply during the survey; 2. One lorazepam (a drug used to manage restlessness and anxiety) oral concentrate bottle for Resident 36, that should have been refrigerated, was kept in the medication cart since 11/2016. 3. The dose of megestrol (an appetite stimulant) may not be effective for the treatment of Resident 12's condition. Also, there were no side effects monitoring for megestrol and methimazole (a drug used to treat hyperthyroidism, a condition that occurs when the thyroid gland begins to produce an excess of thyroid hormone). 4. The Hepatic Function Panel (a blood test to check how well the liver is working) and Lipid Panel (a blood test that measures fats and fatty substances used as a source of energy by the body) for Resident 6 were not done. These failures had the potential to place residents at risk for receiving expired, ineffective medications, or unnecessary drugs and to compromise the health status of the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OQB711 Facility ID: CA070000023 If continuation sheet 30 of 50 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: _______________ 056082 (X3) DATE SURVEY COMPLETED 03/02/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON SPRINGS POST-ACUTE 180 N Jackson 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 residents. Findings: 1. During an observation on 2/27/17, at 12:15 p.m., in the central supply, 30 expired medication bottles were found: six vitamin B6 50 milligrams (mg - unit dose measurement) (100 counts) expired in 1/2017, five eye vitamins (100 counts) expired in 5/2016, two cranberry 450 mg (100 counts) expired in 1/2017, one cetirazine (a drug used to treat cold or allergy symptoms) 10 mg (90 counts) expired in 5/2016, four saline nasal sprays expired in 12/2016, two aspirin 325 mg (100 counts) expired in 2/2016, seven aspirin bottles expired in 8/2016, and three aspirin bottles expired in 1/2017. During a concurrent interview, the central supply coordinator (CSC) stated these medications were expired and should have been put away. During a telephone interview with the consultant pharmacist (CP), on 3/2/17, at 1:50 p.m., she stated she did not inspect the medications in the central supply during her monthly visits. She stated she should have and would do so moving forward. 2. During an observation of medication cart 4A on 2/27/17, at 2:30 p.m., one unopened bottle of lorazepam oral concentrate (by Hi-Tech Pharmaceutical) 2 mg per milliliter (ml - unit of liquid measurement) for Resident 36 was identified in the locked compartment for the controlled drugs. The instruction on the container indicated to "keep refrigerated." During a concurrent interview with licensed vocational nurse O (LVN O), she verified the instruction "Keep refrigerated" was on the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OQB711 Facility ID: CA070000023 If continuation sheet 31 of 50 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: _______________ 056082 (X3) DATE SURVEY COMPLETED 03/02/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON SPRINGS POST-ACUTE 180 N Jackson 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 medication container. She said since November, 2016, the lorazepam had been kept in the medication cart, at room temperature. The Package Insert (Drug Information) for the lorazepam oral concentrate indicated to: "Store at Cold Temperature - Refrigerate 2 - 8 Celsius degrees (36 - 46 Fahrenheit degrees)." During a telephone interview on 3/2/17 at 1:50 p.m., the CP stated she inspected medications in the medication carts during her monthly visit, but did not identify the lorazepam oral concentrate as not being stored as specified by the manufacturer. The facility policy and procedure titled "Pharmacy Services - Role of the Consultant Pharmacist", revision dated 4/2007, indicated "The Consultant Pharmacist will provide specific activities related to medication regimen review including: ... proper storage and labeling of medications, cleanliness, and expired medications..." 3. Resident 12 was admitted to the facility with diagnoses including failure to thrive (weight faltering) and thyrotoxicosis (a condition that occurs due to excessive thyroid hormone in the body), and his weight was 100 pounds (lbs). The clinical record review on 2/28/17 indicated Resident 12 had physician orders for megestrol 40 mg daily, dated 2/15/17, and methimazole 10 mg twice daily, dated 2/7/17. Resident 12's care plan dated 2/15/17 reflected he lost 4 lbs in 7 days, and the 2/21/17 care plan reflected he lost 2.2 lbs in 7 days. According to Lexicomp (www.lexi.com), a nationally recognized drug information resource, the effective dose of megestrol to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OQB711 Facility ID: CA070000023 If continuation sheet 32 of 50 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: _______________ 056082 (X3) DATE SURVEY COMPLETED 03/02/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON SPRINGS POST-ACUTE 180 N Jackson 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 treat appetite was 400 mg daily (10 times the dose Resident 12 was taking). During an interview with nursing supervisor F (NS F), on 3/1/17, at 2:40 p. m., she stated the dose of megestrol for Resident 12 was low and verified there were no side effect monitoring for megestrol and methimazole. At 4:15 p.m., NS F confirmed there were no CP's recommendation regarding megestrol and methimazole. During a telephone interview with the CP, on 3/2/17, at 1:50 p.m., she agreed the megestrol dose of 40 mg daily was too low. The CP stated her last visit to the facility was on 2/23/17 and she was unable to find her recommendation regarding the dosage of megestrol and the side effect monitoring for megestrol and methimazole. 4. The clinical record for Resident 6 was reviewed on 3/1/17. She was diagnosed with hyperlipidemia (an abnormally high concentration of fats in the blood). The physician's order dated 11/28/14, indicated "Hepatic Function Panel: Lipid Panel once a day on the fifth of December" each year. There were no documented evidence these diagnostic testings were done in December 2016. During an interview with the assistant director of nursing K (ADON K), on 3/2/17, at 2:40 p.m., he stated the last time Hepatic Function Panel and Lipid Panel was done for Resident 6 was in December 2015 and these testings were not done for December 2016. ADON K verified the above physician order was current and should have been carried out. During a telephone interview on 3/2/17 at 1:50 p.m., the CP was asked if she had identified FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OQB711 Facility ID: CA070000023 If continuation sheet 33 of 50 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: _______________ 056082 (X3) DATE SURVEY COMPLETED 03/02/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON SPRINGS POST-ACUTE 180 N Jackson 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 lack of laboratory tests for Resident 6 as an irregularity in her report to the facility. She stated she was unable to find any recommendations, from 12/2016 to 2/2017, regarding these diagnostic testings for Resident 6. The facility policy and procedure titled "Pharmacy Services - Role of the Consultant Pharmacist," revision dated 4/2007, indicated "The Consultant Pharmacist will provide specific activities related to medication regimen review including: ... medication irregularities, and pertinent resident-specific documentation in the medical record..."

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

F431 04/06/2017 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 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OQB711 Facility ID: CA070000023 If continuation sheet 34 of 50 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: _______________ 056082 (X3) DATE SURVEY COMPLETED 03/02/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON SPRINGS POST-ACUTE 180 N Jackson 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 reconciliation; and (3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. (g) Labeling of Drugs and Biologicals. Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. (h) Storage of Drugs and Biologicals. (1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. (2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure medications were stored, logged, and accounted when: 1. Two medications were used from an oral emergency kit (E-kit, medications for emergency use) without being logged, 2. the central supply (a room where the facility FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OQB711 Facility ID: CA070000023 If continuation sheet 35 of 50 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: _______________ 056082 (X3) DATE SURVEY COMPLETED 03/02/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON SPRINGS POST-ACUTE 180 N Jackson 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 stores over-the-counter medications and supplies) had 30 expired medications, and 3. one lorazepam (a drug used to manage restlessness and anxiety) oral concentrate bottle for non-sampled Resident 36, that should have been refrigerated, was kept in the medication cart since 11/2016. These failures had the potential to place residents at risk for receiving expired or ineffective medications, and for the facility not having accurate accountability for the medications in the E-kit. Findings: 1. During an observation on 2/27/17, at 11:45 a.m., in the medication room for Station 1, one oral drug E-kit was opened. Five tablets of prednisone (a drug used to treat allergic disorders) 5 milligrams (mg - unit dose measurement) and four tablets of acyclovir (a drug used to treat infections caused by certain types of viruses) 200 mg were used without being logged. During a concurrent interview with nursing supervisor F (NS F), she was unable to locate the logs for the prednisone and acyclovir tablets. NS F stated every time the medications in the E-kit were used they should be logged. The facility policy and procedure titled "Emergency Medication Supplies," revision dated 1/1/13, indicated "Facility should complete the Interim/Stat/Emergency Box Withdrawal Form to report for which resident the medication was withdrawn." 2. During an observation on 2/27/17, at 12:15 p.m., in the central supply, 30 expired FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OQB711 Facility ID: CA070000023 If continuation sheet 36 of 50 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: _______________ 056082 (X3) DATE SURVEY COMPLETED 03/02/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON SPRINGS POST-ACUTE 180 N Jackson 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 medication bottles were found: six vitamin B6 50 mg (100 counts) expired in 1/2017, five eye vitamins (100 counts) expired in 5/2016, two cranberry 450 mg (100 counts) expired in 1/2017, one cetirazine (a drug used to treat cold or allergy symptoms) 10 mg (90 counts) expired in 5/2016, four saline nasal sprays expired in 12/2016, two aspirin 325 mg (100 counts) expired in 2/2016, seven aspirin bottles expired in 8/2016, and three aspirin bottles expired in 1/2017. During a concurrent interview, the central supply coordinator (CSC) stated these medications were expired and should have been put away. 3. During an observation of medication cart 4A on 2/27/17, at 2:30 p.m., one unopened bottle of lorazepam oral concentrate (by Hi-Tech Pharmaceutical) 2 mg per milliliter (ml - unit of liquid measurement) for Resident 36 was identified in the locked compartment for the controlled drugs. The instruction on the container indicated to "keep refrigerated." During a concurrent interview with licensed vocational nurse O (LVN O), she verified the instruction "Keep refrigerated" was on the medication container. She said since November, 2016, the lorazepam had been kept in the medication cart, at room temperature. The Package Insert (Drug Information) for the lorazepam oral concentrate indicated to: "Store at Cold Temperature - Refrigerate 2 - 8 Celsius degrees (36 - 46 Fahrenheit degrees)."

F441 SS=D INFECTION CONTROL, PREVENT SPREAD, F441 LINENS CFR(s): 483.80(a)(1)(2)(4)(e)(f) 04/06/2017 (a) Infection prevention and control program. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OQB711 Facility ID: CA070000023 If continuation sheet 37 of 50 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: _______________ 056082 (X3) DATE SURVEY COMPLETED 03/02/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON SPRINGS POST-ACUTE 180 N Jackson 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 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: (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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OQB711 Facility ID: CA070000023 If continuation sheet 38 of 50 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: _______________ 056082 (X3) DATE SURVEY COMPLETED 03/02/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON SPRINGS POST-ACUTE 180 N Jackson 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 (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 follow infection control policy and procedure for one of 27 sampled residents (2) and three non-sampled residents (33, 37, and 38). For Resident 2, the wound treatment nurse (WT) and certified nursing assistant B (CNA B) did not perform proper hand hygiene during wound dressing change. Resident 33's oxygen tubing was not changed timely. For Residents 37 and 38, during medication pass, the nurses did not wash hands and change gloves after touching potentially contaminated objects. These failures had the potential for the development and transmission of infection. Findings: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OQB711 Facility ID: CA070000023 If continuation sheet 39 of 50 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: _______________ 056082 (X3) DATE SURVEY COMPLETED 03/02/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON SPRINGS POST-ACUTE 180 N Jackson Ave San Jose, CA 95116 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 1. During an observation on 2/28/17, at 11:20 a.m., of Resident 2's wound dressing change, the WT washed her hands four times before donning gloves. The first two times the handwashing was less than 10 seconds. CNA B did not perform hand hygiene during the first changing of gloves while helping the WT for the dressing change. During an interview with the CNA B on 2/28/17, at 11:40 a.m., she stated there was no need to wash hands in between glove changes especially with the same resident and she did not touch Resident 2's body. During a concurrent interview with the WT, she stated she was in a rush and handwashing should be at least 20 seconds. During an interview with the acting director of nursing (ADON) on 3/2/17, at 9:20 a.m., she stated hands must be washed for 20 seconds everytime one changes gloves. The facility policy and procedure titled "Handwashing/Hand Hygiene" dated October 2009, indicated approximately 20 seconds of handwashing with antimicrobial or nonantimicrobial soap and water must be performed under the following conditions: after removing gloves. The use of gloves does not replace handwashing. 2. During the initial tour on 2/27/17 at 8:25 a.m., Resident 33's oxygen tubing was dated 2/13/17. During an interview with the ADON on 2/27/17 at 8:27 a.m., he stated oxygen tubing should have been change weekly for Resident 33. Review of the facility's 2015 policy, "Respiratory Therapy - Prevention of Infection", indicated to change the oxygen tubing every FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OQB711 Facility ID: CA070000023 If continuation sheet 40 of 50 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: _______________ 056082 (X3) DATE SURVEY COMPLETED 03/02/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON SPRINGS POST-ACUTE 180 N Jackson 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 seven (7) days, or as needed. 3. During medication pass observation on 2/27/17, at 11:30 a.m., registered nurse E (RN E) administered 50 milliliter (ml, unit of liquid measurement) of ceftriaxone (an antibiotic used to treat infection) intravenous (IV, within the vein) 2 grams (g, unit dose measurement) through Resident 38's peripherally inserted central catheter (PICC). RN E washed her hands, put on gloves, wiped the port of the PICC line with alcohol, and flushed the PICC line with 5 ml of normal saline. Then she removed the hanging used IV set, took out a marker from her pocket to blacken Resident 38's name on the used IV bag, and threw it into the trash can. Wearing the same gloves, RN E wiped the PICC line's port with alcohol, and connected the IV tubing to the port. Shortly after the medication pass, on 2/27/17, at 11:40 a.m., RN E stated after touching potentially contaminated objects, the used IV set and the marker, she should have washed her hands and put on new gloves before she continued Resident 38's IV administration. 4. During a medication pass observation on 2/28/17, at 8:25 a.m., licensed vocational nurse J (LVN J) washed her hands, put on gloves, checked the placement of Resident 37's gastrostomy tube (G-tube, a tube inserted through the abdomen that delivers nutrition and medication directly to the stomach), and checked the residual in Resident 37's stomach. Then she pressed the bed control to raise the head of the bed up, flushed 30 ml of water through Resident 37's G-tube, and administered his medications. Shortly after the medication pass, on 2/28/17, at 8:45 a.m., LVN J acknowledged after touching potentially contaminated object, the bed control, she should change gloves before FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OQB711 Facility ID: CA070000023 If continuation sheet 41 of 50 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: _______________ 056082 (X3) DATE SURVEY COMPLETED 03/02/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON SPRINGS POST-ACUTE 180 N Jackson 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 administered medications to Resident 37. The facility policy and procedure titled "Handwashing/Hand Hygiene", revision dated 10/2009, indicated "Use an alcohol-based hand rub for all the following situations: ... After contact with inanimate objects ..."

F463 SS=D RESIDENT CALL SYSTEM ROOMS/TOILET/BATH CFR(s): 483.90(g)(2)

F463 04/06/2017 (g) Resident Call System The facility must be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area (2) Toilet and bathing facilities. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure call lights were accessible and in good working condition for two of 27 sampled residents (3 and 8) and one non-sampled resident (28). These failures may prevent residents' calls from being answered in a timely manner. Findings: 1. Resident 3's clinical record was reviewed. Her Minimum Data Set (MDS, an assessment tool), dated 11/25/16, indicated she was cognitively intact. During an interview on 3/1/17, at 2 p.m., she stated the staff did not FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OQB711 Facility ID: CA070000023 If continuation sheet 42 of 50 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: _______________ 056082 (X3) DATE SURVEY COMPLETED 03/02/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON SPRINGS POST-ACUTE 180 N Jackson 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 answer her call light. Her call light was observed attached to her pillow and within her reach. When asked to activate her call light, she pushed the call light button, but the call light did not work. 2. Resident 8's clinical record was reviewed. Her MDS, dated 1/23/17, indicated she had some difficulty in decision making. During an observation on 3/1/17, at 2:05 p.m., her call light was observed attached to her pillow within her reach. Resident 8 was in the same room as Resident 3. When asked to activate her call light, Resident 8 pushed the call light button, but the call light did not work. During an observation and interview on 3/1/17, at 2:25 p.m., the maintenance assistant (MA) attempted to activate Residents 3 and 8's call lights, but they did not work. He stated the call lights were broken and needed to be replaced. 3. During an observation of Resident 28 on 3/1/17 at 8:20 a.m., Resident 28 was awake and alert in bed. With instruction, Resident 28 could use the call light. The call light was attached with the bed alarm box fastened at the head of the bed. When Resident 28 was asked to use her call light she was unable to locate the call light. A concurrent interview with certified nursing assistant G (CNA G) was conducted. CNA G gave the call light to Resident 28 to use. The call light was not working. During a concurrent interview with the housekeeping assistant (HKA), he acknowledged the call light was defective and needed to be changed. Review of the facility's policy and procedure "Answering the Call light" indicated to report all FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OQB711 Facility ID: CA070000023 If continuation sheet 43 of 50 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: _______________ 056082 (X3) DATE SURVEY COMPLETED 03/02/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON SPRINGS POST-ACUTE 180 N Jackson 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 defective call lights promptly and be sure the call light is within easy reach of the resident.

F492 SS=D COMPLY WITH FEDERAL/STATE/LOCAL LAWS/PROF STD CFR(s): 483.70(b)(c)

F492 04/06/2017 (b) Compliance with Federal, State, and Local Laws and Professional Standards. The facility must operate and provide services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards and principles that apply to professionals providing services in such a facility. (c) Relationship to Other HHS Regulations. In addition to compliance with the regulations set forth in this subpart, facilities are obliged to meet the applicable provisions of other HHS regulations, including but not limited to those pertaining to nondiscrimination on the basis of race, color, or national origin (45 CFR part 80); nondiscrimination on the basis of disability (45 CFR part 84); nondiscrimination on the basis of age (45 CFR part 91); nondiscrimination on the basis of race, color, national origin, sex, age, or disability (45 CFR part 92); protection of human subjects of research (45 CFR part 46); and fraud and abuse (42 CFR part 455) and protection of individually identifiable health information (45 CFR parts 160 and 164). Violations of such other provisions may result in a finding of non-compliance with this paragraph. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to comply with state law when FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OQB711 Facility ID: CA070000023 If continuation sheet 44 of 50 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: _______________ 056082 (X3) DATE SURVEY COMPLETED 03/02/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON SPRINGS POST-ACUTE 180 N Jackson 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 informed consents (a voluntary agreement of a patient or the responsible party [RP, a person empowered to make medical decisions for the patient]) were not obtained prior to the administration of psychotropic medications (medication used for mood stabilization) for two of 27 sampled residents (Residents 8 and 19). Failure to obtain informed consents potentially limited the residents' rights to accept or refuse treatments. Findings: 1. Resident 8's clinical record was reviewed and indicated she was admitted to the facility on trazadone (medication used to treat depression). On 7/20/16, her physician obtained an informed consent for the administration of trazadone from Resident 8's RP in compliance with the state regulations. On 7/22/16, Resident 8's physician ordered Remeron (medication used to treat depression). No informed consent form could be found. During an interview on 3/1/17, at 1:35 p.m., with the director of medical records (DMR), he reviewed Resident 8's clinical record and was able to find documentation of the informed consent for trazadone, dated 7/20/16. He stated he was unable to find an informed consent for Remeron. DMR said the Facility Verification of Resident Informed ConsentPsychotropic Meds should have been dated and signed by the RP and the physician. 2. A review of Resident 19's clinical record on 3/2/17 indicated he was started on divalproex (a drug used to treat seizures and manicdepressive illness) 1500 milligrams (mg, unit dose measurement) per day on 7/9/16 and on 10/19/16 the dose was increased to 2000 mg per day on 10/19/16. The only informed consent found was for divalproex 1000 mg FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OQB711 Facility ID: CA070000023 If continuation sheet 45 of 50 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: _______________ 056082 (X3) DATE SURVEY COMPLETED 03/02/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON SPRINGS POST-ACUTE 180 N Jackson 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 dated 10/20/16. Resident 19 was also on Zoloft (a drug used to treat depression, panic disorder, anxiety disorder, and post-traumatic stress disorder) 50 mg daily started on 7/9/16 and the dose was increased to 100 mg daily on 10/19/16. The only informed consent found was for Zoloft 100 mg daily dated 10/20/16. During an interview with the acting director of nursing (ADON), on 3/2/17, at 3:50 p.m., she reviewed Resident 19's clinical record and was unable to find any other informed consents for divalproex and Zoloft. The facility policy and procedure titled "Questions and Answers Regarding Informed Consent" dated 4/12/11, indicated informed consent for psychotherapeutic drugs must be verified prior to the administration of the medication and include documentation by the prescribing healthcare practitioner indicating there was a voluntary agreement between the resident or the resident's authorized representative to accept treatment after receiving information material to a decision concerning the administration of a psychotherapeutic drug. The material information includes the reason for the treatment; the probable degree and duration expected with and without the treatment; the degree, duration, and probability of side effects; reasonable alternative treatments; and the resident's right to accept or refuse treatment. Review of the California Code of Regulations, Title 22, Section 72528 indicated the attending licensed healthcare practitioner must obtain informed consent from the resident or the resident's RP prior to administering psychotherapeutic drugs and must provide the resident or the RP with enough information to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OQB711 Facility ID: CA070000023 If continuation sheet 46 of 50 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: _______________ 056082 (X3) DATE SURVEY COMPLETED 03/02/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON SPRINGS POST-ACUTE 180 N Jackson 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 make an informed decision. The necessary information includes the reason for the treatment; the probable degree and duration expected with and without the treatment; the degree, duration, and probability of side effects; reasonable alternative treatments; and the resident's right to accept or refuse treatment.

F502 SS=D ADMINISTRATION CFR(s): 483.50(a)(1)

F502 04/06/2017 (a) Laboratory Services (1) The facility must provide or obtain laboratory services to meet the needs of its residents. The facility is responsible for the quality and timeliness of the services. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to meet the standards of care when physician orders for Hepatic Function Panel (a blood test to check how well the liver is working) and Lipid Panel (a blood test that measures fats and fatty substances used as a source of energy by the body) for one of 27 sampled resident (6) were not carried out. These failures had the potential to compromise the health status of the resident. Findings: The clinical record for Resident 6 was reviewed on 3/1/17. She was diagnosed with hyperlipidemia (an abnormally high concentration of fats in the blood). The physician's order dated 11/28/14, indicated "Hepatic Function Panel: Lipid Panel once a day on the fifth of December" each year. There were no documented evidence these FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OQB711 Facility ID: CA070000023 If continuation sheet 47 of 50 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: _______________ 056082 (X3) DATE SURVEY COMPLETED 03/02/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON SPRINGS POST-ACUTE 180 N Jackson 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 diagnostic testings were done in December 2016. During an interview with assistant director of nursing K (ADON K), on 3/2/17, at 2:40 p.m., he stated the last time Hepatic Function Panel and Lipid Panel done for Resident 6 was in December 2015 and these testings were not done for December 2016. ADON K verified the above physician order was current and should have been carried out.

F514 SS=D RES RECORDSCOMPLETE/ACCURATE/ACCESSIBLE CFR(s): 483.70(i)(1)(5)

F514 04/06/2017 (i) Medical records. (1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are(i) Complete; (ii) Accurately documented; (iii) Readily accessible; and (iv) Systematically organized (5) The medical record must contain(i) Sufficient information to identify the resident; (ii) A record of the resident’s assessments; (iii) The comprehensive plan of care and services provided; (iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State; FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OQB711 Facility ID: CA070000023 If continuation sheet 48 of 50 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: _______________ 056082 (X3) DATE SURVEY COMPLETED 03/02/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON SPRINGS POST-ACUTE 180 N Jackson 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 (v) Physician’s, nurse’s, and other licensed professional’s progress notes; and (vi) Laboratory, radiology and other diagnostic services reports as required under §483.50. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to maintain accurate clinical records for two of 27 sampled residents (4 and 18). For Resident 18, the medication flowsheet was incomplete for charting in February 2017, January 2017, and December 2016. Resident 4 had an unnecessary podiatry order in the list of physician orders. These failures had the potential to continue incorrect information for resident care. Findings: 1. Resident 18's clinical record was reviewed and indicated her medication flowsheet was not documented for giving medication folic acid (a type of B vitamin) on 2/12//17, at 5 p.m. and for giving medication atorvastatin (a medication to lower the level of cholesterol and triglycerides in the blood) on 1/5/17, at 9 p.m., and for giving the medication Renvela (a medication for dialysis patient to prevent dangerous increases in phosphates), on 1/5/17, at 7 a.m. and 12 p.m. and 1/6/17, at 12 p.m. Also there were no documents for blood pressure and heart rate checks when withheld metoprolol tartrate (a medication used to treat high blood pressure) on 12/20/16, at 9 a.m. During an interview with the acting director of nursing (ADON) on 3/2/17, at 9 a.m., she reviewed the medication flowsheet and was unable to find medication notes for administration information. She stated if medications were not charted on the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OQB711 Facility ID: CA070000023 If continuation sheet 49 of 50 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: _______________ 056082 (X3) DATE SURVEY COMPLETED 03/02/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON SPRINGS POST-ACUTE 180 N Jackson 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 medication flowsheet, it was considered those medications were not given. 2. Resident 4's clinical record was reviewed and indicated he was admitted to the facility with diagnoses of type 2 diabetes mellitus, acquired absence of left leg below knee and right foot. The physician order report dated 2/2/17 had an order for podiatry (a branch of medicine devoted to the medical and surgical treatment of disorders of the foot, ankle and lower extremity) consult PRN (as needed) for mycotic/hypertrophic nails and/or keratotic lesions. During an interview with the social services director (SSD), on 3/2/17, at 10:40 a.m., she stated all diabetic residents were seen routinely by the podiatrist. She confirmed the podiatrist only deals with the toenails. SSD acknowledged Resident 4's podiatry order was a standing order and should be removed from the physician order. During a review of the clinical record for Resident 4, the history and physical from an acute hospital dated 1/19/17 indicated the resident had a left below-knee amputation stump and right transmetatarsal amputation stump (a method used for long-term limb preservation for patients with diabetes). The facility policy and procedure titled "Charting and Documentation dated" April 2008", indicated all observations,medications,administered, services performed, etc., must be documented in the resident's clinical records. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OQB711 Facility ID: CA070000023 If continuation sheet 50 of 50