Other·March 26, 2018

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 exited on 3/9/18. The facility was licensed for 199 beds. The census at the time of the survey was 162. The sample size was 32.

F689, 483.25(d)(1)(2) Accidents had a scope and severity of "G". A Class "B" Citation was also issued. Representing the California Department of Public Health: 36624, Health Facilities Evaluator Nurse; 35091, Health Facilities Evaluator Nurse; 38573, Health Facilities Evaluator Nurse; 35302, Health Facilities Evaluator Nurse; 37329, Health Facilities Evaluator Nurse; 35386, Health Facilities Evaluator Nurse; and 33651, Health Facilities Evaluator Supervisor.

F623 SS=D Notice Requirements Before Transfer/Discharge CFR(s): 483.15(c)(3)-(6)(8)

F623 04/02/2018 §483.15(c)(3) Notice before transfer. Before a facility transfers or discharges a resident, the facility must(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State LongTerm Care Ombudsman. (ii) Record the reasons for the transfer or discharge in the resident's medical record in 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: D33H11 Facility ID: CA070000023 If continuation sheet 1 of 39 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 03/09/2018 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 accordance with paragraph (c)(2) of this section; and (iii) Include in the notice the items described in paragraph (c)(5) of this section. §483.15(c)(4) Timing of the notice. (i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged. (ii) Notice must be made as soon as practicable before transfer or discharge when(A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section; (B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section; (C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section; (D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or (E) A resident has not resided in the facility for 30 days. §483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following: (i) The reason for transfer or discharge; (ii) The effective date of transfer or discharge; (iii) The location to which the resident is transferred or discharged; (iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D33H11 Facility ID: CA070000023 If continuation sheet 2 of 39 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 03/09/2018 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 submitting the appeal hearing request; (v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman; (vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and (vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act. §483.15(c)(6) Changes to the notice. If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available. §483.15(c)(8) Notice in advance of facility closure In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at § 483.70(l). This REQUIREMENT is not met as evidenced by: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D33H11 Facility ID: CA070000023 If continuation sheet 3 of 39 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 03/09/2018 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 Based on interview and record review, the facility failed to ensure the Office of the LongTerm Care Ombudsman was notified before transfer to an acute care hospital for two residents (101 and 124). This failure had the potential to compromise the residents' admission, transfer, and discharge rights. Findings: 1. A review of Resident 101's clinical record indicated she had a diagnosis of urinary tract infection (UTI, infection in part of the urinary system). Review of a change of condition report dated 12/28/17 indicated Resident 101 presented with a low grade fever and became lethargic (lack of energy), was hard to wake up and was transferred to an acute care hospital for further evaluation and treatment. Review of a bedhold informed consent signed and dated 1/4/18, indicated on admission to hold bed upon transfer to acute hospital. 2. Review of Resident 124's clinical record indicated he had a diagnosis of retention of urine with lower urinary tract symptoms. On 12/14/17, Resident 124 complained of abdominal pain, had decreased urine output form the suprapubic catheter (surgically created connection between the urinary bladder and the skin used to drain urine from the bladder)and was transferred to an acute care hospital. Review of a bedhold informed consent signed and dated, 12/18/17, indicated on admission to hold bed upon transfer to acute hospital. Review of clinical records for Residents 101 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D33H11 Facility ID: CA070000023 If continuation sheet 4 of 39 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 03/09/2018 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 andf 124 indicated there was no documentation the Ombudsman was notified of the transfer to acute care hospital. During an interview with the social service director (SSD) on 3/9/18, at 3:27 p.m., she acknowledged the Ombudsman was not notified of Residents 101 and 124 transfer to the hospital. SSD also stated once residents are discharged to an acute care hospital, Ombudsman should be notified, but it has not been done. Review of the facility's 12/2008 policy, "Notice of a Transfer and/or Discharge", indicated the facility must notify in writing the Office of the State Long-Term Care Ombudsman as soon as practicable before transfer or discharge.

F637 SS=D Comprehensive Assessment After Signifcant Chg CFR(s): 483.20(b)(2)(ii)

F637 04/02/2018 §483.20(b)(2)(ii) Within 14 days after the facility determines, or should have determined, that there has been a significant change in the resident's physical or mental condition. (For purpose of this section, a "significant change" means a major decline or improvement in the resident's status that will not normally resolve itself without further intervention by staff or by implementing standard disease-related clinical interventions, that has an impact on more than one area of the resident's health status, and requires interdisciplinary review or revision of the care plan, or both.) This REQUIREMENT is not met as evidenced FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D33H11 Facility ID: CA070000023 If continuation sheet 5 of 39 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 03/09/2018 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 a comprehensive assessment was done after a significant change of condition for sampled Resident 125. This failure had the potential to compromise the resident's care. Findings: Review of Resident 125's clinical record indicated she had a diagnosis of encounter for palliative care (medical care for serious illness providing relief from symptoms), and was admitted under hospice (end of life care provided to the terminally ill) care on 1/18/18. During an observation, on 3/5/18 at 12:42 p.m., Resident 125 was seated in her wheelchair in the dining room, and was fed by nurse assistant. Review of the nursing progress notes dated 1/17/18 indicated Resident 125's physician and responsible party had been contacted regarding her deteriorating condition. It further indicated Resident 125 now required total care and required to be completely fed. Review of the minimum data set (MDS, an assessment tool) dated 2/1/18 indicated in process. Review of the activity of daily living report (ADL report) dated 1/11/18 through 1/18/18 indicated declined in two or more ADL areas. During an interview with assistant director of nursing G (ADON G), on 3/7/18 at 8:54 a.m., she acknowledged the MDS dated 2/1/18 indicated in process and Resident 125 was now on hospice which indicated a significant change of condition. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D33H11 Facility ID: CA070000023 If continuation sheet 6 of 39 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 03/09/2018 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 certified nursing assistant D (CNA D) on 3/7/18 at 10:33 a.m., Resident 125 was totally dependent on staff now with dressing, eating, bathing, and transferring. During a concurrent review of Resident 125's ADL report and interview with licensed vocational nurse E (LVN E) on 3/7/18 at 10:46 a.m., he acknowledged Resident 125 had declined in ADL's in two or more areas. During an interview with the minimum data set coordinator (MDSC) on 3/7/18 at 10:46 a.m., he acknowledged the comprehensive assessment had not been completed within 14 days after the facility determined there had been a significant change of condition. He stated it should have been completed by day 14 or 2/1/18 because the resident had declined in two or more ADL's and was admitted to hospice. Review of the facility's 7/2015 policy, "Clinical policy and Procedure Manual", indicated the coordinator of the MDS Department has overall responsibility for ensuring timely completion of the MDS.

F638 SS=E Qrtly Assessment at Least Every 3 Months CFR(s): 483.20(c)

F638 03/28/2018 §483.20(c) Quarterly Review Assessment A facility must assess a resident using the quarterly review instrument specified by the State and approved by CMS not less frequently than once every 3 months. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to timely complete the minimum FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D33H11 Facility ID: CA070000023 If continuation sheet 7 of 39 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 03/09/2018 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 data set (MDS, an assessment tool) assessments when the quarterly review was completed more in more then 92 days for 13 residents (3, 4, 6, 13, 15, 17, 18, 19, 20, 22, 23, 35, and 76). This failure could potentially delay in monitoring the gradual change in resident status and the appropriate care plan would not be in-place in a timely manner. Findings: Review of Resident 3's clinical record indicated she was admitted 10/18/17. Her next quarterly assessment was due for 1/11/18, but it was completed on 2/23/18. Resident 4's clinical record indicated his quarterly assessment was on 10/2/17. His next quarterly assessment was due last 12/26/17, but it was completed on 2/22/18. Resident 6's clinical record indicated her admission assessment was on 10/25/17. Her next quarterly assessment was due 1/18/18 and it was completed 2/28/18. Resident 13's clinical record indicated his quarterly assessment was on 10/20/17. His next annual assessment was due on 1/14/18 and it was completed 2/27/18. Resident 15's clinical record indicated his quarterly assessment was on 10/13/17. His next annual assessment was due on 1/9/18 and it was completed 2/23/18. Resident 17's clinical record indicated his annual assessment was done on 10/17/17. His next quarterly assessment was due 1/10/18 and it was completed 2/23/18. Resident 18's clinical record indicated her annual assessment was done 5/17/17. Her FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D33H11 Facility ID: CA070000023 If continuation sheet 8 of 39 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 03/09/2018 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 next quarterly assessment was due 7/25/17 and it was completed 8/8/17. Resident 19's clinical record indicated his quarterly assessment was done 10/21/17. His next quarterly assessment was due 1/15/18 and it was completed 2/27/17. Resident 20's clinical record indicated her next (annual) assessment was due on 10/19/17 and it was completed 11/7/17. Resident 22's clinical record indicated her quarterly assessment was done 10/26/17. Her next assessment was an annual assessment which was due on 1/19/18 and it was completed 3/6/18. Resident 23's clinical record indicated his next assessment was an annual assessment which was due on 1/20/18 and upon review on 3/9/18 the MDS assessment was still not complete. Resident 35's clinical record indicated her quarterly assessment was due on 2/1/18 and upon record review on 3/9/18 the MDS assessment was still not completed. Resident 76's clinical record indicated his quarterly assessment was due on 2/5/18 and upon record review on 3/9/18 the MDS assessment was still not completed. During an interview, on 3/9/18, at 8 a.m. with the minimum data set coordinator (MDSC), he stated for Residents 3, 4, 6, 13, 15, 17, 18, 19, 20, and 22 the MDS assessments were completed beyond 92 days. For Residents 23, 35, and 76 the MDS were still in progress. Review of the Centers for Medicare & Medicaid Services (CMS, oversees federal healthcare programs) website FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D33H11 Facility ID: CA070000023 If continuation sheet 9 of 39 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 03/09/2018 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 (https://www.cms.gov/Medicare/QualityInitiatives-Patient-Assessment Instruments/NursingHomeQualityInits/downloa ds/MDS20rai1202ch2.pdf) indicated a quarterly assessment must be completed every 92 days.

F656 SS=D Develop/Implement Comprehensive Care Plan F656 CFR(s): 483.21(b)(1) 03/30/2018 §483.21(b) Comprehensive Care Plans §483.21(b)(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, 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D33H11 Facility ID: CA070000023 If continuation sheet 10 of 39 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 03/09/2018 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) 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 by: Based on interview and record review, the facility failed to develop a comprehensive care plan for one of three closed sample residents (169) and one of 32 residents (55). 1. For Resident 169, the facility did not develop a care plan for diabetes (a disease that affect body to produce or use insulin, can result in high blood sugar level) management and a care plan for non-compliance for blood sugar checks and insulin (medication for diabetes) administration. 2. For Resident 55, there was no care plan developed for contracture prevention. This failure had the potential to not meet the residents' needs. Resident 169 was transferred to the acute hospital on 2/26/18 due to a high blood sugar level. Findings: 1. Review of Resident 169's clinical record indicated he was admitted to the facility on 2/3/18 with diagnoses including diabetes and long-term insulin use. There was no diabetes management care plan. Resident 169 was sent to an acute hospital on 2/26/18 due to hyperglycemia (high blood sugar level). Review Resident 169's physician's order dated 2/3/18 indicated nursing staff should check blood sugar daily at 6:30 a.m., 11:30 a.m., 4:30 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D33H11 Facility ID: CA070000023 If continuation sheet 11 of 39 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 03/09/2018 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 p.m., and 9 p.m. before meals and at bed time. Review of Resident 169's physician's order dated 2/3/18 indicated Resident 169 received humalog insulin (name of the medication for diabetes) 4 units before meals daily for the diabetes. Review of Resident 169's medical administration record (MAR) in February 2018 indicated resident refused blood sugar check four times and refused insulin before meals three times. There was no documentation indicating facility notified the physician regarding Resident 169's episodes of refusing blood sugar checks and insulin administration. There was no non-compliance care plan regarding Resident 169's refusal for blood sugar check and insulin administration. During an interview with assistant of director of nursing A (ADON A) on 3/9/18 at 10:29 a.m., ADON A stated facility should have developed care plans for diabetes management and for non-compliance regarding refusal of blood sugar check and insulin administration for Resident 169. Review of the facility's 9/1/2008 policy, "Care Planning- IDT Care Planning Conference", indicated all the residents will have a comprehensive care plan to meet their individual needs that is prepared by an Interdisciplinary Team with 7 days after the completion of the comprehensive assessment and periodically reviewed and revised after subsequent assessments. 2. Review of Resident 55 clinical record indicated she had a diagnosis including dementia (decline in mental status affecting daily function). Her minimum data set (MDS, an assessment tool) dated 11/27/17 indicated she was cognitively impaired. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D33H11 Facility ID: CA070000023 If continuation sheet 12 of 39 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 03/09/2018 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 of Resident 55's therapy-rehab screening form dated 2/23/18 indicated contracture was present, bilateral knees had baseline rigidity. The was no intervention in placed to prevent Resident 55's further development of contracture. During an observation on 3/6/18 at 12:00 p.m., Resident 55 was seated in his wheelchair in the dining room with both knees bended. On 3/6/18 at 1:20 p.m., Resident 55 was placed in bed on a side lying position with both knees bended. There were no pillows in between her legs. During an observation on 3/7/18 at 8:15 a.m., Resident 55 was laid in bed with both knees bended. During an observation on 3/9/19 at 9:55 a.m. with certified nursing assistant S (CNA S), Resident 55 was laid in bed with both of her knees bended. During an observation and interview with rehabilitation manager (RM) on 3/9/18 at 10:15 a.m., Resident 55 knees were bended. RM extended the legs and she stated Resident 55's muscles were tight. RM stated staff could stretch and could do exercise to extend Resident 55's lower extremities. She stated staff could also placed pillows in between the legs. During an interview with CNA S at 10:30 a.m., she stated she was one of the regular CNA's and she only placed pillows on the sides of the resident and not in between legs. When asked if she was instructed to place a pillow in between legs and do some stretching exercises and/or if she was given instructions on contractor prevention, she just smiled and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D33H11 Facility ID: CA070000023 If continuation sheet 13 of 39 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 03/09/2018 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 refused to answer. During an interview with licensed vocational nurse B (LVN B ) on 3/9/18 at 11:20 a.m., she stated there was no care plan developed and there was no identified intervention in placed to prevent contracture. Review of the facility's 1/25/18 policy, "Contracture Prevention", indicated the facility should implement intervention to prevent the onset of contractor and to provide intervention to prevent worsening of contractor for resident admitted with contracture.

F657 SS=D Care Plan Timing and Revision CFR(s): 483.21(b)(2)(i)-(iii)

F657 03/26/2018 §483.21(b) Comprehensive Care Plans §483.21(b)(2) A comprehensive care plan must be(i) Developed within 7 days after completion of the comprehensive assessment. (ii) Prepared by an interdisciplinary team, that includes but is not limited to-(A) The attending physician. (B) A registered nurse with responsibility for the resident. (C) A nurse aide with responsibility for the resident. (D) A member of food and nutrition services FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D33H11 Facility ID: CA070000023 If continuation sheet 14 of 39 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 03/09/2018 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 staff. (E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan. (F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident. (iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review the facility failed to revise care plan and implement intervention according to their plan of care. 1. For Resident 55, the wedge pillow was not in-placed as a fall intervention. 2. For Resident 97, care plan was not revised when resident had another fall and the landing pad was not in-placed in both sides of the bed . This failure had the potential of not able to identify intervention to prevent fall or minimize complications from falling . Findings: 1. Review of Resident 55's clinical record indicated she had a diagnosis including dementia (decline in mental status affecting daily function). Her minimum data set (MDS, an assessment tool) dated 11/27/17 indicated she was cognitively impaired. Review of Resident 55 progress notes dated 12/23/17 indicated she fell while she was up in the wheelchair. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D33H11 Facility ID: CA070000023 If continuation sheet 15 of 39 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 03/09/2018 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 Her care plan after the fall indicated a new intervention which was to apply wedge pillow (prevents sliding and helps in maintaining proper position) when resident was up in the wheelchair. During an observation on 3/6/18 at 12 p.m. and on 3/8/18 at 11 a.m., Resident 55 was up in the wheelchair and there was no wedge pillow. During an observation on 3/9/18 at 11:20 a.m., with licensed vocational nurse B and occupational therapist (OT) Resident 55 was sitting on the wheelchair with no wedge pillow. Resident 55 was sliding in her wheelchair. LVN B and OT had to pull her up so she can sit upright. During an interview on 3/9/18 at 11:25 a.m., OT stated wedge pillow should be in placed to prevent resident from sliding off the wheelchair. LVN B and OT were searching for the wedge pillow on the activity room, lounge area, and and in the resident's room and they were not able to find the wedge pillow. During an interview with certified nurse assistant O (CNA O) on 3/9/18 at 11:30 a.m., she stated she was the regular CNA for the resident and whenever she placed the resident up in the wheelchair and there was no wedge pillow. During an interview with LVN B on 3/9/18 at 11:40 a.m., she stated using a wedge pillow was one of the intervention for fall prevention. It should be used whenever the resident was up in the wheelchair. Review of Resident 97's clinical record indicated she had multiple falls which happened on 1/21/18, 2/11/18, and 2/24/18. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D33H11 Facility ID: CA070000023 If continuation sheet 16 of 39 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 03/09/2018 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 Resident 97's revised care plan dated 3/3/18 indicated she was at risk for fall related to altered mentas status, visual impairment, unsteady gait, altered balance, and decrease muscular coordination. Resident 97's fall care plan dated 2/12/18 indicated staff would placed a landing pad in both sides of her bed as an intervention to prevent injury during fall. Resident 97's clinical record indicated there was no new intervention identified and there was no indication fall care plan was revised on 2/24/18 fall and there was also no post-fall assessment done. During multiple observations on 3/5/18 at 9 a. m., 3/6/18 at 4:20 p.m., 3/8/18 at 11:15 a.m., 3/8/18 at 2:30 p.m., and on 3/8/18 at 5:55 p.m., Resident 97 was laid in bed with landing pad only placed on the left side of her bed. There was no landing pad on the right side. During an interview with CNA Q he stated, Resident 97 has fallen several times when she stood up by herself and felt dizzy. CNA Q stated a landing pad was only placed on one side of the bed. During an interview with LVN B on 3/9/18 at 9:20 a.m., she stated landing pad should be placed on both sides of resident's bed to decrease fall injury. She stated there was no fall assessment when Resident 97 fell on 2/11/18 . Whenever there was fall, a rehabilitation therapist should conduct a post fall assessment . During an interview with LVN R on 3/9/18 at 9:34 a.m., she stated when Resident 97 fell on 2/24/18 staff did not update her fall care plan. There was no identified new intervention to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D33H11 Facility ID: CA070000023 If continuation sheet 17 of 39 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 03/09/2018 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 prevent future fall. Review of the facility's 12/2017 policy, "Fall and Fall Risk , Managing", indicated staff should identify and implement additional or different intervention to try to minimize serious consequences of falling. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D33H11 Facility ID: CA070000023 If continuation sheet 18 of 39 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 03/09/2018 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

F658 Services Provided Meet Professional Standards CFR(s): 483.21(b)(3)(i)

F658 SS=E PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 03/31/2018 §483.21(b)(3) Comprehensive Care Plans The services provided or arranged by the facility, as outlined by the comprehensive care plan, must(i) Meet professional standards of quality. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to ensure nursing staff: 1. Followed the physician's order to administer the correct oxygen rate for 14 of 18 residents (67, 158, 16, 22, 37, 48, 77, 84, 99, 155, 161, 242, 538, and 589) who were actively receiving oxygen treatment during inspection; 2. Followed the physician's order to administer the insulin (medication to treat high blood sugar) for Resident 184; 3. Followed the physician's order to administer one medication for Resident 393; 4. Followed the registered dietitian's (RD) nutrition recommendations for Resident 158, and 5. Followed facility's policy and procedure regarding GT medication administration for Resident 93. These failures had the potential to jeopardize the residents' health. Findings: 1a. During an observation on 3/7/18 at 3:10 p.m. in Resident 242's room, Resident 242 was lying in the bed receiving oxygen through a nasal cannula (NC, plastic tubing inserted into the nostrils and attached to an oxygen source). The oxygen concentrator (device used to deliver oxygen) was set at 3.5 liters per FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D33H11 Facility ID: CA070000023 If continuation sheet 19 of 39 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 03/09/2018 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 minutes (LPM, the amount of oxygen being delivered to the resident). Review of Resident 242's physician's order dated 1/29/18 indicated Resident 242 received 2 LPM oxygen via NC continuously for chronic obstructive pulmonary disease exacerbation (COPD: lung disease). During an interview with Licensed Vocational Nurse B (LVN B) at 3/7/18 at 3:13 p.m., she checked Resident 242's oxygen rate and confirmed Resident received oxygen at 3.5 LPM. She stated the resident should receive oxygen at 2 LPM per physician's order. During an observation with the LVN C (LVN C) on 3/8/18 from 9:06 a.m. to 9:50 a.m. for the following residents: 1b. Resident 161 received oxygen at 1.5 LPM via NC. Resident 161's physician order dated 3/5/18 indicated Resident 161 received oxygen at 2 LPM via NC continuously for pneumonia (lung disease). 1c. Resident 538 received oxygen at 1.5 LPM via NC. Resident 538's physician order dated 3/8/18 indicated the resident received oxygen at 2 LPM continuously via NC. 1d. Resident 16 received oxygen at 1.5 LPM via NC. Resident 16's physician order dated 1/10/18 indicated the resident received oxygen at 2 LPM continuously via NC for short of breath. 1e. Resident 48 received oxygen at 1.5 LPM via NC. Resident 48's physician order dated 3/4/18 indicated the resident received oxygen at 2 LPM continuously via NC for COPD. 1f. Resident 77 received oxygen at 1.5 LPM via FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D33H11 Facility ID: CA070000023 If continuation sheet 20 of 39 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 03/09/2018 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 NC. Resident 77's physician order dated 2/5/18 indicated the resident received oxygen at 2 LPM continuously via NC for COPD. 1g. Resident 67 received oxygen between 1.52 LPM via NC. Resident 67's physician order dated 12/18/18 indicated the resident received oxygen at 2 LPM continuously via NC for COPD and short of breath. 1h. Resident 155 received oxygen at 2.5 LPM via NC. Resident 155's physician order dated 1/7/18 indicated the resident received oxygen at 3.5 LPM continuously via NC for COPD exacerbation. 1i. Resident 158 received oxygen at 1.5 LPM via NC. Resident 158's physician order dated 1/3/18 indicated the resident received oxygen at 2 LPM continuously via NC. for bronchial asthma (lung disease). 1j. Resident 84 received oxygen at 1.5 LPM via NC. Resident 84's physician order dated 6/28/17 indicated the resident received oxygen at 2 LPM via NC for short of breath. 1k. Resident 589 received oxygen between 22.5 LPM via NC. Resident 589's physician order dated 3/6/18 indicated the resident received oxygen at 3 LPM continuously via NC for short of breath. 1l. Resident 99 received oxygen between 1.5-2 LPM via NC. Resident 99's physician order dated 1/23/18 indicated the resident received oxygen at 2 LPM as needed via NC for COPD and short of breath. 1m. Resident 22 received oxygen at 1.5 LPM via NC. Resident 22's physician order dated 9/30/17 indicated the resident received oxygen at 2 LPM as needed via NC for COPD. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D33H11 Facility ID: CA070000023 If continuation sheet 21 of 39 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 03/09/2018 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 1n. Resident 37 received oxygen at 1.5 LPM via NC. Resident 538's physician order dated 7/26/17 indicated the resident received oxygen at 0.5-2 LPM continuously via NC. Sup C stated the physician's oxygen order was not clear, nursing staff should clarify with physician for the clear oxygen rate order. She stated the oxygen rate should be one rate number. During an interview with licensed vocational nurse C, on 3/8/18, at 9:50 a.m., she stated the staff should follow the physician's order for oxygen rate for above residents. Review of the California Board of Registered Nursing Website, California Business and Professions Code, Division 2, Chapter 6, Article 2, Section 2725(b)(2), indicated RNs should follow the physician orders for a medication regimen necessary to implement a treatment per the physician's order. 2. Review of Resident 184's clinical record indicated she had a diagnosis of end stage renal disease (ESRD, chronic irreversible kidney failure) and type 2 diabetes mellitus (disease in which the body's ability to produce or respond to insulin is impaired resulting in elevated levels of glucose). Review of physician's order dated 11/29/17 indicated dialysis once a day on Monday, Wednesday, and Friday, send out with pack of snack and lunch. Review of physician's order dated 8/22/17 indicated humolog (insulin) per sliding scale before meals. Review of medication administration record (MAR, patient's permanent record ) dated 1/1/18 through 1/31/18 indicated insulin was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D33H11 Facility ID: CA070000023 If continuation sheet 22 of 39 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 03/09/2018 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 not administered on 1/3/18, 1/5/18, 1/8/18, 1/10/18, 1/12/18, 1/15/18, 1/17/18, 1/19/18, 1/22/18, 1/24/18, 1/26/18, 1/29/18 and 1/31/18/18. Review of MAR dated 2/1/18 through 2/28/18 indicated the dates insulin not given: 2/2/18, 2/5/18, 2/7/18, 2/9/18, 2/12/18, 2/14/18, 2/21/18, 2/23/18, 2/26/18 and 2/28/18. Review of MAR dated 3/1/18 through 3/8/18 indicated insulin was not given on 3/2/18 and 3/5/18. The MAR indicated insulin was not administered due to "Resident 184's was unavailable and went to dialysis. During a concurrent record review and interview with LVN E on 3/8/18 at 2:48 p.m., he acknowledged insulin was not administered on 2/28/18 because Resident 184 went to dialysis. He also stated residents should get their medications prior to going to dialysis. He also stated he should have checked her blood sugar and given her insulin as needed prior to her going to dialysis. During a concurrent review of the MAR and interview with LVN F on 3/8/18 at 3:00 p.m., she acknowledged insulin was not administered on 3/5/18 and stated Resident 184 left early that day for dialysis. She also stated she should have checked Resident 184's blood sugar and administered her insulin as needed prior to her going to dialysis. During a MAR review and interview with LVN C on 3/8/18 at 3:27 p.m., on 1/1/18 to 1/31/18, 2/1/18 to 2/28/18 and 3/1/18 to 3/8/18, she acknowledged insulin was not given as ordered and stated if there's an order for sliding scale insulin we should check blood sugar and administer insulin as needed to cover the blood sugar. She also stated the physician should have been notified the insulin was not given because she was at dialysis and obtained a clarification of the order. She then stated that FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D33H11 Facility ID: CA070000023 If continuation sheet 23 of 39 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 03/09/2018 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 was not done. During an interview with LVN E on 3/8/18 at 3:35 p.m., he stated he did not notify the doctor about the missed insulin and he should have notified the doctor and have gotten a clarification order. Review of the facility 4/2007's policy, "Administering Medications", indicated medications must be administered in accordance with the orders, including any required time frames. Review of the facility's undated policy, "Care of a Resident with End-Stage Renal Disease", indicated residents with ESRD will be cared for according to currently recognized standards of care. It also indicated staff caring for residents with ESRD, including residents receiving dialysis care outside the facility, shall be trained in the care and special needs of these residents. It further indicated education and training of staff includes timing and administration of medications, particularly those before and after dialysis. 3. During a medication pass observation with LVN L on 3/5/18 at 8:50 a.m., LVN L prepared and administered Metformin (diabetic medication that lowers blood sugar) F/C 500 miligram (mg, unit of measurement) by mouth to Resident 393. A review of Resident 393's physician order dated 3/5/18, indicated Metformin 1000 mg by mouth twice a day. During an interview on 3/5/18 at 9:14 a.m., LVN L stated she administered Metformin 500 mg instead of 1000 mg to Resident 393. She stated she reviewed the physician's order, dated 3/5/18 and indicated Metformin 1000 mg FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D33H11 Facility ID: CA070000023 If continuation sheet 24 of 39 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 03/09/2018 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 mouth twice a day. Review of the facility's 4/2007 policy, "Administering Medications", indicated medications must be administered in accordance with the orders, including any required time frames. Findings: 4. A review of Resident 158's clinical record indicated she had diagnoses including parkinsons's disease (PD, is a long-term degenerative disorder of the central nervous system that mainly affects the motor system. The most obvious are shaking, rigidity, slowness of movement, and difficulty with walking), chronic contracted extremities (tightening or shortening of muscles) with pressure ulcers (injuries to skin and underlying tissue) on the feet and gastrostomy status (GT, artificial external opening into the stomach for nutritional support) and peripheral arterial disease (PAD, Circulatory problem in which narrowed arteries reduce blood flow to the limbs). A review of the physician's order dated 1/11/18 indicated "flush with a minimum of 200 cc water every four hours, enteral feeding (delivery of a nutritionally complete feed, containing protein, carbohydrate, fat, water, minerals and vitamins, directly into the stomach) Jevity via GT method at 55 cc/ hour x 22 hours. A review of the registered dietitian's (RD, food and nutrition expert) change of condition (COC, sudden, clinically important deviation from a resi dent baseline in physical, cognitive, behavioral, or functional domains) nutrition assessment dated 3/1/18 indicated nutritional interventions included: juven (unique blend of key ingredients to help support wound healing) 1 packet via GT twice a day; prostat (ready-todrink medical food for wounds and protein FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D33H11 Facility ID: CA070000023 If continuation sheet 25 of 39 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 03/09/2018 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 energy malnutrition) 30 cc (cubic centimeter, unit of measurement) via GT every day; increase enteral order to Jevity (Fiber-fortified tube-feeding formula) 1.0 via GT at 70 cc/hour x 20 hours; decrease flush order to 200 cc every 6 hours, and request basic metabolic panel (BMP, to check the status of person's kidneys and electrolyte and acid/base balance, and blood glucose level related to a person's metabolism). A review of the nurses notes dated 3/1/18 indicated the medical doctor (MD) was notified via fax of the RD's nutrition recommendations. During multiple observations on 3/5/18 at 8:51 a.m., 3/6/18 at 8:36 a.m., 3/7/18 at 9:21 a.m. and 12:34 p.m., 3/8/18 at 3:23 p.m. and 4:54 p.m., Resident 158 was in bed, on GT feeding, head of bed (HOB) elevated, GT was running at 55 cc per minute, flushed water was 200 ml every four hours. GT syringe was clean and dated. GT formula was dated. GT was running via GT pump. Resident 158 was covered with clean blanket, with slight grimaced and moaned, both hands were contracted. During an observation, interview and record review on 3/8/18 at 5:54 p.m., inside Resident 158's room, assistant director of nursing G (ADON G) observed and stated the GT feeding remained 55 cc/minute, and the flushed water was 200 ml every four hours. ADON G also reviewed Resident 158's clinical record and stated the RD nutrition recommendation was not carried out. 5. During a medication pass observation on 3/5/18 at 8:51a.m., with registered nurse N (RN N) for resident 93, RN N prepared and administered Tamsulosin (medication for enlarged prostate) 0.4 milligrams (mg, unit of dose measurement), Eliquis (blood thinner) 5 mg, and Metoprolol tartrate (blood pressure medication) 12.5 mg FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D33H11 Facility ID: CA070000023 If continuation sheet 26 of 39 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 03/09/2018 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 via gastrostomy tube (GT, an opening into the stomach from the abdominal wall, made surgically for the introduction of medication and food). RN N used a syringe plunger and pushed the medication into Resident 93's stomach. He did not administer the medication by gravity flow (pour diluted medication into the barrel of syringe while holding the tubing slightly above the level of insertion,open the clamp and deliver medication slowly). During an interview on 3/5/18 at 5:50 p.m., RN N stated medications should not be given via gravity except formula feedings. RN N stated during his clinical experience, medications were not given by gravity except formula feeding. The facility's revised 4/2007 policy and procedure, "Administering Medications through an enteral tube", indicated for gastrostomy tube, reattached syringe (without plunger) to the end of the tubing and administer medication by gravity flow. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D33H11 Facility ID: CA070000023 If continuation sheet 27 of 39 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 03/09/2018 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)

F689 Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) SS=G ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 04/05/2018 §483.25(d) Accidents. The facility must ensure that §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to provide adequate assistance for one of three residents (20) when certified nurse assistant H (CNA H) transferred resident 20 from shower chair to bed by herself. This failure resulted in Resident 20's sustained ankle fracture (common injuries that are most often caused by the ankle rolling inward or outward). Findings: A review of Resident 20's clinical record indicated she was admitted on 11/15/13 with the diagnoses including hemiplegia (paralysis of one side of the body), hemiparesis (a slight paralysis or weakness on one side of the body) following unspecified cerebrovascular disease (CVA, conditions that affect the blood vessels of the brain and the cerebral circulation) affecting unspecified side, left knee contracture (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints), and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D33H11 Facility ID: CA070000023 If continuation sheet 28 of 39 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 03/09/2018 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 generalized muscle weakness (is a decrease in the strength in one or more muscles or muscle group exclusively. A review of Resident 20's fall care plan dated 11/15/13 indicated "at risk for falls related to altered mental status (changes in brain function), antidepressants (to treat depression), antipsychotic (to treat mental disorders), antihypertensive (to treat hypertension), cardiovascular disease (heart disease), seizure disorder (sudden, uncontrolled electrical disturbance in the brain), and poor trunk control (ability to hold the body upright when sitting or moving). Her contractures care plan dated 10/16/17 indicated loss of muscle tone to left lower extremity (LLE) related to disease process. A review of the physical therapist (PT, allied health professionals that, by using mechanical force and movements, remediates impairments and promotes mobility and function) evaluation and plan of treatment dated 10/16/17 indicated Resident 20's prior level of function (PLOF, status of functional abilities prior to the condition causing the need for rehabilitation services) for transfer was maximum assist and functional mobility assessment for transfer indicated total dependence without attempts to initiate and pivot (rotate or turn) indicated total dependence without attempts to initiate. A review of Resident 20's minimum data set (MDS, an assessment tool) dated 10/19/2017 Section G letter B. Transfer (how resident moves between surfaces including to or from bed, chair, wheelchair, standing position (excludes to/from bath/toilet) indicated 7 (activity occurred only once or twice) and support indicated 3 (two + person physical assist). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D33H11 Facility ID: CA070000023 If continuation sheet 29 of 39 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 03/09/2018 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 A review of Resident 20's fall risk assessment dated 11/7/2017, indicated fall risk summary score was 14 with predisposing factor including seizure (sudden attack of illness, especially a stroke or an epileptic fit) disorder. A review of the nurse's notes dated 12/4/17 indicated at 16:50 p.m., CNA H transferred Resident 20 from shower chair to bed with one person assist. Resident 20 accidentally slid down on her left side. Resident 20 was noted with skin redness on the left elbow. On the same date at 21:00 p.m., Resident 20 was noted with swelling and skin discoloration on left lower leg and foot and Resident 20 complained of pain. A review of the acute care hospital discharge document indicated Resident 20 was admitted and discharged on 12/5/17 with a tibia (larger bone of the lower leg, on the big toe side of the ankle, where injury often happened when the ankle was twisted strongly, which tears ankle ligaments) fracture (break in a bone) with nonweight bearing instruction for left ankle. A review of the interdisciplinary team (IDT, a group of health care professionals from diverse fields who work in a coordinated fashion toward a common goal for the patient) post-fall assessment (Accident: Event-Fall) notes completed on 12/8/17 indicated CNA H performed a one-person assist transfer, lifted Resident 20 off the shower chair to do a pivot transfer (to move patients with decreased weight-bearing ability, despite its high risk causing injury to both patient and caregiver), to bed when Residents 20's foot got caught on one of the shower chair legs. CNA H lost her balance and fell along with Resident 20 who landed on the floor next to CNA H. A review of the physician's order dated 12/7/17, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D33H11 Facility ID: CA070000023 If continuation sheet 30 of 39 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 03/09/2018 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 non-weight bearing (NWB, do not place actual weight on the affected leg) left lower leg until cleared by orthopedics (branch of medicine branch of medicine dealing with the correction of deformities of bones or muscles) doctor. A review of the physician's order dated 12/14/17, indicated brace controlled ankle movement (CAM, are foot braces to allow minimal or no movement for the hinge of the ankle in order to rest/protect the damaged area) boot type on LLE to protect from displacement and also to avoid any sore around the extremity. Monitor left leg (distal tibia fracture,) for signs of skin breakdown every shift. During an interview with CNA H on 3/8/18 at 6:09 p.m., with the presence of the assistant director of nursing G (ADON G), she stated the fall happened on 12/4/17 when she transferred Resident 20 from shower chair to bed. CNA H stated she lifted Resident 20 off the shower chair to do a pivot transfer to bed. CNA H stated she suddenly lost balance and she really was not sure what happened. CNA H also stated Resident 20's left foot probably got caught at the shower chair leg. Although she stated Resident 20 needed extensive help with two-person assist (when more than one person is required for safe transfers) for transfer, CNA H stated she transferred Resident 20 by herself and did not call for assistance. During an interview on 3/7/18 at 9:58 a.m., Resident 20 stated in Spanish (interpreted by LVN J), she had a fall and staff now use a Hoyer lift (an assistive medical device) to transfer her. Resident 20 then showed her left arm with splint and her left foot with the CAM boot on. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D33H11 Facility ID: CA070000023 If continuation sheet 31 of 39 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 03/09/2018 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 on 3/8/18 at 8:43 a.m., ADON G stated the fall incident happened on 12/4/17 when CNA H transferred Resident 20 from shower chair to the bed with one-person assist (by herself). ADON G also stated on the MDS, Section G (Functional Status) under letter B (Transfer) dated 10/19/2017 indicated support was coded 3 (two +persons physical assist). In another interview on 3/9/18 at 2:03 p.m., LVN I stated Resident 20 needed two-person assist even prior to her fall on 12/4/17. LVN I stated after the fall, CNAs use a Hoyer lift due to Resident 20's NWB status until her orthopedics doctor follow-up. A review of the facility's revised 12/2007 policy, "Falls and Fall Risk, Managing", indicated the staff will identify interventions related to resident's specific risks and causes and try to prevent the resident from falling and to try to minimize complications from falling.

F758 SS=D Free from Unnec Psychotropic Meds/PRN Use F758 CFR(s): 483.45(c)(3)(e)(1)-(5) 03/30/2018 §483.45(e) Psychotropic Drugs. §483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental 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 Based on a comprehensive assessment of a resident, the facility must ensure that--§483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D33H11 Facility ID: CA070000023 If continuation sheet 32 of 39 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 03/09/2018 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 specific condition as diagnosed and documented in the clinical record; §483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs; §483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and §483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in §483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. §483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure residents were free from unnecessary psychotropic drugs (medications that are capable of affecting the mind, emotions, and behavior) for two residents (24 and 65). Both residents had no physicians' rationale for continued psychotropic medication therapy beyond 14 days. These failures resulted in the unnecessary use of psychotropic medications for Resident 24 and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D33H11 Facility ID: CA070000023 If continuation sheet 33 of 39 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 03/09/2018 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 65. Findings: 1. Review of Resident 24's clinical record indicated Resident 24 was admitted with diagnoses including major depressive disorder and dementia (disease that impaired memory and reasoning) without behavior disturbance. Review Resident 24's physician's order dated 11/7/17 indicated clonazepam (medication for anxiety) 0.25 milligrams (mg, a unit of measurement) by mouth twice a day as needed for anxiety manifested by combative behavior such as hitting and kicking. The medication order was discontinued on 2/8/18. Another physician's order dated 2/8/18 indicated clonazepam 0.25 mg by mouth twice a day as needed for 14 days. Then the order was discontinued on 2/23/18. There was no physician's documents indicating the rationale for continued clonazepam use beyond 14 days from 11/28/17 (when new Federal regulations were implemented) to 2/22/18. During an interview with assistant director of nursing A (ADON A) on 3/8/18 at 2:41 p.m., ADON A reviewed Resident 24's clinical record and stated there was no physician's notes indicating the rationale for continued clonazepam therapy beyond 14 days for Resident 24 from 11/27/17 to 2/22/18. 2. Review Resident 65's clinical record indicated Resident had diagnose including anxiety disorder. Review Resident 65's physician's order dated 12/7/17 indicated the resident had lorazepam (medication for anxiety) 0.5 mg oral as needed every six hours for anxiety manifested by terminal restlessness. Lorazepam was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D33H11 Facility ID: CA070000023 If continuation sheet 34 of 39 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 03/09/2018 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 discontinued on 2/7/18. During an interview with ADON A on 3/9/18 at 3:43 p.m., she reviewed Resident 65's clinical record and stated there was no physician's notes indicating the rationale for continued clonazepam use beyond 14 days from 12/7/17 to 2/6/18. The facility had no policy and procedure for unnecessary drug usage.

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

F761 03/30/2018 §483.45(g) Labeling of Drugs and Biologicals Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. §483.45(h) Storage of Drugs and Biologicals §483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. §483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D33H11 Facility ID: CA070000023 If continuation sheet 35 of 39 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 03/09/2018 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 readily detected. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to ensure medications were stored and labeled appropriately when: 1. a narcotic emergency kit (E-kit) was only secured with two zip ties and was not locked in a compartment in the nursing station A medication room, 2. the medication cart on nursing station B was unlocked and unattended during medication administration, 3. there was no thermometer or temperature log in the medication storage room C where formula bottles, cans of supplements, house supply of medications, and nasal sprays were stored, and 4a and 4b. A blister pack of Tamsulosin (medication used to treat enlarged prostate) extended release (ER, medication that is absorbed over a period of time) and a vial (a small bottle) of Novolog insulin (medication for high blood sugar) had a changes in direction but had no change in direction stickers on their containers. These failures could result in the accidental administration of discontinued, expired or contaminated medication to residents. Findings: 1. During an observation of the nursing station A's medication room with licensed vocational nurse C (LVN C) on 3/6/18 at 9:12 a.m., the narcotic E-kit was secured with only two zip ties and was not locked in a compartment in the nursing station A's medication room. During an interview with LVN C on 3/6/18 at FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D33H11 Facility ID: CA070000023 If continuation sheet 36 of 39 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 03/09/2018 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 9:15 a.m., she stated the narcotic E-Kit was not locked in the compartment in the medication room and the narcotic E-kit had only 2 zip ties. She stated the narcotic E-kit should be locked at all times for safety. 2. During a medication pass observation on 3/5/18 at 5:05 p.m., LVN M entered a resident's room to check blood pressure and heart rate. LVN M did not lock the medication cart before entering the resident's room. During an interview on 3/5/18 at 5:07 p.m., LVN M stated she forgot to lock the medication cart when she went inside the resident's room to check the heart rate and blood pressure. She stated she should have locked the medication cart and not left unattended. 3. During an observation on 3/6/18 at 9:54 a.m., there was no thermometer in the medication storage room C which had nasal sprays, house supplies, formula feedings, supplements, over the counter vitamins/medicines, and treatment supplies. During an interview with the central supply staff staff (CS) on 3/6/18 at 9:55 a.m., she stated there was no thermometer or temperature log in the medication storage room C. She also stated medication storage room C should have a thermometer and room temperatures should be logged daily. A review of the facility's revised 4/2007 policy and procedure, "Storage of Medications", indicated medications and supplies in central supply must be stored per manufacturers' recommendation, temperature in the medication storage room must be logged daily. Compartments including cabinets, rooms, drawers, carts, and boxes containing drugs and biologicals shall be locked when not in use and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D33H11 Facility ID: CA070000023 If continuation sheet 37 of 39 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 03/09/2018 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 shall not be left unattended if open or potentially available to others. 4a. During medication pass observation with LVN K for Resident 39 on 3/5/18 at 11:30 a.m., LVN K prepared a vial of Novolog insulin. The vial indicated Novolog 100 unit/milliliter 5 units (unit/ml, unit of measurement) subcutaneous (injection under the skin in between the fatty layer) on the label. During an interview with LVN K on 3/5/18 at 11:35 a.m., she stated 10 units of Novolog should be given to Resident 39, but the vial of Novolog indicated 5 units. LVN K stated there was no change in directions sticker on the Novolog vial. A review of Resident 39's physician's order dated 6/27/17 indicated Novolog ten units subcutaneous with meals. 4b. During medication pass observation for Resident 93 on 3/5/18 at 5:30 p.m., registered nurse N (RN N) prepared and administered one capsule of Tamsulosin ER 0.4 milligrams (mg, a unit of measurement). The bubble pack indicated Tamsulosin 0.4 mg capsule ER via gastric tube (GT, a tube inserted through a small incision in the abdomen into the stomach and is used for long-term enteral nutrition) every morning for Resident 93. During an interview with RN N on 3/5/18 at 5:58 p.m., he stated Tamsulosin ER should be given in the evening at 5:00 p.m. RN N confirmed the bubble pack for Tamsulosin indicated every morning and had no change in directions sticker. RN N stated a change in directions sticker should have been put on the bubble pack. During a concurrent interview with the nurse FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D33H11 Facility ID: CA070000023 If continuation sheet 38 of 39 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 03/09/2018 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 consultant (NC) on 3/5/18 at 5:58 p.m., he also confirmed the bubble pack for Tamsulosin still indicated the medication was to be given in the morning and had no change in directions sticker. Review of Resident 93's physician's order dated 12/11/17 indicated Resident 93 was to receive Tamsulosin capsule ER 24 hours 0.4 mg via GT once a day at 5:00 p.m. Review of the facility's revised 6/1/11 policy and procedure, "Reordering, changing, and discontinuing orders," indicated attach a "Change in Directions" sticker to the existing quantity of medication until the Pharmacy permanently affixes the new label to the medication package or container. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D33H11 Facility ID: CA070000023 If continuation sheet 39 of 39