Other·April 18, 2019

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during a recertification survey conducted on 4/5/19. The facility was licensed for 199 beds. The census at the time of the survey was 150. The sample size was 30. For Facility Reported Incident CA00631728 regarding Quality of Care/Treatment, the Department did not substantiate a violation of federal or state regulations. A Class "B" Citation was also issued for F759. Representing the California Department of Public Health: 32892, Health Facilities Evaluator Supervisor; 33651, Health Facilities Evaluator Supervisor; 38174, Health Facilities Evaluator Nurse; 35302, Health Facilities Evaluator Nurse; 38087 , Health Facilities Evaluator Nurse; and 39588, Health Facilities Evaluator Nurse.

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

F550 05/05/2019 §483.10(a) Resident Rights. The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section. §483.10(a)(1) A facility must treat each resident with respect and dignity and care for each 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: DABZ11 Facility ID: CA070000023 If continuation sheet 1 of 69 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 04/05/2019 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 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. §483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source. §483.10(b) Exercise of Rights. The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States. §483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility. §483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure five of five residents (26, 28, 82, 2 and 525) were provided care in a manner that maintained the resident's dignity and respect when staff members stood while feeding Residents 26, 28, 82, 2 and 525. This deficient practice violated the resident's right to maintain and enhance FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DABZ11 Facility ID: CA070000023 If continuation sheet 2 of 69 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 04/05/2019 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 their self-esteem. Findings : During an observation on 4/3/19 at 8:15 a.m., Resident 26 was in a low bed and the certified nursing assistant Q (CNA Q) stood while feeding Resident 26. A folded chair was placed behind Resident 26's bedside drawer. During a concurrent interview with CNA Q, he stated he would sit on a chair to feed Resident 26 if there was one available. During an observation on 4/4/19 at 8:43 a.m., Resident 26 was in a low bed and CNA R stood while feeding Resident 26. A folded chair was placed behind Resident 26's bedside drawer. During a concurrent interview with CNA Q, she stated "I have to stand because there was no chair in the room". CNA Q stated "our training was to sit while feeding residents". During an observation on 4/4/19 at 8:02 a.m., Resident 28 was up in his wheelchair in his room. CNA P stood while feeding Resident 28. During a concurrent interview with CNA P, she stated "we were not allowed to have chairs in the room". CNA P stated she was aware she should sit while feeding Resident 28. During an observation on 4/4/19 at 8:33 a.m., Resident 82 was in bed and the speech therapist (ST) stood while feeding Resident 82. During an interview with the ST on 4/4/19 at 8:38 a.m., she stated there was no chair in the room. The ST also stated she would not delay the feeding for the "sake of looking for a chair". FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DABZ11 Facility ID: CA070000023 If continuation sheet 3 of 69 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 04/05/2019 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 the director of staff development (DSD) on 4/4/19 at 10:48 p.m., she stated staff was trained to sit while feeding residents to have eye contact and to maintain good body mechanics. During an interview with the assistant director of nursing (ADON) on 4/5/19 at 8:54 a.m., she stated staff should sit while feeding residents. Review of Resident 26's minimum data set (MDS, an assessment tool) dated 1/4/19 indicated he had moderate memory impairment. Review of Resident 28's MDS dated 1/10/19 indicated she had severe memory impairment. Review of Resident 82's MDS dated 1/27/19 indicated her cognitive skills for daily decision making was severely impaired. During an observation and concurrent interview with CNA X on 4/3/19 at 8:13 a.m., Resident 2 was in her bed and CNA X stood while feeding Resident 2. CNA X confirmed she was standing when she fed Resident 2. During an observation and concurrent interview with CNA Y on 4/3/19 at 1:31 p.m., CNA Y stated Resident 525 was very weak and needed help with feeding. Resident 525 sat in his wheelchair in his room. CNA Y stood beside him while feeding Resident 525. CNA Y stated there was no chair available. Review of the facility's 12/2016 policy, "Resident Rights", indicated employees should treat all residents with kindness, respect, and dignity. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DABZ11 Facility ID: CA070000023 If continuation sheet 4 of 69 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 04/05/2019 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

F558 Reasonable Accommodations Needs/Preferences CFR(s): 483.10(e)(3)

F558 SS=D PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 05/05/2019 §483.10(e)(3) The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents. This REQUIREMENT is not met as evidenced by: During a review of Resident 524's clinical record, it indicated Resident 524 was admitted on 4/1/19 with diagnoses including muscle weakness and difficulty in walking, morbid obesity (a disorder involving excessive body fat that increases the risk of health problems), diabetes mellitus (chronic condition that affects the way the body processes blood sugar) and right knee pain. During an interview with Resident 524 on 4/2/19 at 4:10 p.m., she stated she requested for a bariatric bed prior to admission to the facility from the hospital. Resident 524 also requested for a bariatric bed and side rails from the admitting nurse on 4/1/19. During an observation on 4/3/19 at 12:59 p.m., Resident 524 was in a regular bed watching television. No side rails were observed. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DABZ11 Facility ID: CA070000023 If continuation sheet 5 of 69 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 04/05/2019 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 Resident 524 on 4/3/19 at 2:03 p.m., she stated she was seen by the nurse practitioner (NP) on 4/2/19 and the NP told her she needed a bariatric bed with side rails for safety and safe transfers. During an interview on 4/3/19 at 1:57 p.m., CNA U stated Resident 524 needed threeperson assist to transfer out of bed. Resident 524 would help with the transfer by grabbing on to the night stand for support. During an interview with CNA V on 4/3/19 at 4:31 p.m., she stated Resident 524's bed was too narrow for the resident and she had difficulties turning from side to side because there was not enough space. CNA V further stated Resident 524 had to grab on to the night stand or the mattress to turn to the side during care. During an interview with LVN W on 4/3/19 at 4:41 p.m., she stated Resident 524 was alert and oriented, morbidly obese and was able to turn herself to the side with assistance, but she would not have side rails to hold on to. LVN W confirmed that the nurse practitioner saw Resident 524 on 4/2/19 and ordered a bariatric bed with side rails. During an interview with the maintenance director (MTNDIR) on 4/3/19 at 4:54 p.m., he stated the facility had an adjustable bariatric bed that was in the storage ready for residents if needed. During an observation and concurrent interview with Resident 524 on 4/4/19 at 5:51 p.m., Resident 524 had a bariatric bed but without side rails. She stated "I don't feel safe" without side rails since it helps me with bed mobility and "there is nothing to hold on to" when FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DABZ11 Facility ID: CA070000023 If continuation sheet 6 of 69 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 04/05/2019 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 moving or transferring. Resident 524 further expressed concerns about her safety and not being able to readjust herself in bed without side rails. During an interview with the director of rehabilitation (DOR) on 4/5/19 at 10:08 a.m., she stated Resident 524 would benefit from side rails for bed mobility. A review of the facility policy, "Quality of Life", indicated "Resident are provided with a safe, clean, comfortable and homelike environment..." and "Staff shall provide personcentered care that emphasizes the residents' comfort, independence and personal needs and preference.". Based on observation, interview, and record review, the facility failed to ensure the needs and preferences were met for two sampled residents (136 and 524) when for Resident 136, the facility failed to implement their "Food Brought by Family/Visitor" policy. For Resident 524, the facility failed to accommodate Resident 524's requests for a bariatric bed (an extra heavy duty and extra wide bed that safely accommodates larger individuals) and bed rails (an attachable and removable device used along the side of a bed intended to assist residents in repositioning in the bed and transfer into and out of bed). These failures had FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DABZ11 Facility ID: CA070000023 If continuation sheet 7 of 69 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 04/05/2019 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 potential to negatively affect resident's physical and psychosocial well-being. Findings: During a facility tour on 4/2/19 at 9:53 a.m., Resident 136 verbalized concerns about her left over foods. Resident 136 stated "last Sunday" she asked the certified nursing assistant P (CNA P) for her broccoli and bagel that was brought on Saturday. CNA P told her it was thrown away. Resident 136 also stated a "month ago", they threw her left over food worth about twenty dollars and she informed the head of the staff because she was really upset. Resident 136 stated staff should tell her whether 24 hours or 72 hours left over foods were good to stay in the refrigerator, but they did not. During an interview with CNA P on 4/2/19 at 2:29 p.m., she confirmed she did not find Resident 136's broccoli and bagel in the refrigerator because the administrator (ADM) cleaned the refrigerator "last Sunday". CNA P stated she told Resident 136 her food was thrown away. CNA P stated she would put a name, date, and time on the food and the food was good in the refrigerator "overnight" before it would be thrown away. During an observation and concurrent interview with licensed vocational nurse K (LVN K) on 4/3/19 at 12:53 p.m., a sign close to the refrigerator indicated "all foods must be labeled with a name and date. Foods are good for 72 hr. All food without proper labeling or food more than 72 hr will be discarded". LVN K stated staff was responsible to label food. During an interview with the ADM on 4/3/19 at 2:07 p.m., he confirmed he threw out food from the refrigerator, but he did not know it was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DABZ11 Facility ID: CA070000023 If continuation sheet 8 of 69 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 04/05/2019 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 136's food because it was not labeled and dated. The ADM stated staff was responsible to label food in the refrigerator and it would be good for 72 hours. Review of Resident 136 minimum data set (MDS, an assessment tool) dated 2/27/19, it indicated Resident 136 had no cognitive impairment. Review of the facility's 10/2017 policy, "Food Brought by Family/Visitors", indicated food brought by family/visitors that was left with resident to consume later will be labeled and stored in a manner that was clearly distinguishable from facility prepared foods. The nursing staff will discard perishable foods after 72 hours after opening.

F684 SS=E Quality of Care CFR(s): 483.25

F684 05/05/2019 § 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. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to ensure: 1. nursing staff monitored and documented for signs and symptoms (S/S) of a pacemaker (battery-powered device implanted inside the heart to restore normal heart beat) malfunction or S/S of infection around a pacemaker insertion site for eight of eight residents who had pacemakers (Residents 33, 34, 49, 60, 77, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DABZ11 Facility ID: CA070000023 If continuation sheet 9 of 69 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 04/05/2019 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 93, 116, and 128); nursing staff did not know which resident had a pacemaker and did not know what to monitor for s/s of a pacemaker malfunction; there was no pacemaker information (such as pacemaker model, battery life, programmed lowest heart rate, cardiologist contact information, type of pacemaker, and etc.) in the clinical record for all eight residents; seven of eight residents had no records indicating when was the last time their pacemakers were checked by a cardiologist or a specialist; 2. Nursing staff followed the facility's policy when administering breathing medications to Residents 92 and 105; 3. Nursing staff did not notify the physician when the ordered medication supply was not available for Resident 44; 4. Nursing staff followed the physician's order to administer medication in a timely manner for Resident 105; Nursing staff did not chart medication administration time accurately for Resident 105; 5. Nursing staff allowed Resident 105 to selfadminister a breathing medication without interdisciplinary team (IDT, heads from different department to discuss the care for residents) assessment; 6. For Resident 522, nursing staff did not follow the physician's order regarding oxygen and helmet treatment; improper placement of booties use. These failures could jeopardize residents' health safety, medical conditions, and quality of cares. Findings: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DABZ11 Facility ID: CA070000023 If continuation sheet 10 of 69 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 04/05/2019 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 the facility provided information dated 4/3/19 indicated there were eight residents who had pacemakers. 1a. During an observation with assistant director of nursing (ADON) on 4/4/19 at 8:14 a.m., ADON checked Resident 34 and stated Resident 34 had a protruding triangle shape of pacemaker on the left upper chest. During an interview with the ADON on 4/5/19 at 9:26 a.m., the ADON reviewed Resident 34's clinical record and stated: Resident was admitted on 5/21/15 and had a pacemaker and no information which model it was; There was no evidence when the pacemaker was last checked; There was no evidence that nursing staff monitored s/s of the pacemaker malfunction or s/s of the pacemaker insertion site. During an interview with licensed vocational nurse S (LVN S) on 4/4/19 at 1:45 p.m., LVN S stated she had no resident who had a pacemaker under her care. LVN S was not aware Resident 34 had a pacemaker. LVN S stated the facility did have training regarding a pacemaker for resident's care. LVN S was unable to tell what to monitor for s/s of a pacemaker malfunction. 1b. During an observation with the ADON on 4/4/19 at 8:20 a.m., the ADON assessed Resident 60 and stated the resident had an irregular round shaped of pacemaker on the left upper chest. The resident stated she had the pacemaker for more than six years. During an interview with the ADON on 4/5/19 at 9:37 a.m., she concurrently reviewed Resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DABZ11 Facility ID: CA070000023 If continuation sheet 11 of 69 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 04/05/2019 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 60's clinical record and stated: Resident was admitted on 7/23/18 and had a pacemaker; There was no evidence in the chart Resident 60 had a careplan for a pacemaker; There was no evidence of the pacemaker model information or when the pacemaker was checked the last time; There was no documentation monitoring was in place for a pacemaker malfunctioning, s/s of insertion site. During an interview with LVN I on 4/4/19 at 11:15 a.m., LVN I stated she was not aware Resident 60 had a pacemaker (Resident 60 was the care of LVN I); LVN I stated the facility did not have a training regarding a pacemaker for resident's care. LVN I was unable to tell what to monitor for s/s of a pacemaker malfunction. 1c. During an observation with the ADON on 4/4/19 at 8:23 a.m., the ADON assessed Resident 77 and stated the resident had a round shaped pacemaker on the left upper chest. The resident stated she had the pacemaker for two years. During an interview with the ADON on 4/5/19 at 9:47 a.m., the ADON concurrently reviewed Resident 77's clinical record and stated: The resident was admitted on 2/12/18 and had a pacemaker; There was no pacemaker information in the clinical record; the facility called the cardiologist office on 4/3/19 to obtain the resident's last pacemaker check report. The pacemaker check report indicated Resident 77's pacemaker was checked on 2/20/19. The care plan initiated on 2/13/18 to monitor lowest heart rate (HR) of 50 beats per minute (bpm); however, the resident's pacemaker check report dated 2/20/19 indicated Resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DABZ11 Facility ID: CA070000023 If continuation sheet 12 of 69 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 04/05/2019 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 77's pacemaker lowest HR was 60 bpm; There was no evidence nursing staff monitored s/s of a pacemaker malfunction or s/s of a pacemaker insertion site. 1d. During an observation with the ADON on 4/4/19 at 8:28 a.m., she assessed Resident 49 and stated the resident had a round shaped pacemaker on the left upper chest. During an interview with the ADON on 4/5/19 at 9:55 a.m., the ADON currently reviewed Resident 49's clinical record and stated: Resident 49 was admitted on 10/15/18 and had a pacemaker; There was no evidence of a pacemaker information in the clinical record; There was no care plan for a pacemaker care and no evidence nursing staff monitored s/s of a pacemaker malfunction or s/s of a pacemaker insertion site; There was no evidence when the last time the pacemaker was checked. During an interview with registered nurse G (RN G) on 4/4/19 at 9:14 a.m., she stated she worked both morning and evening shifts at all stations as a float nurse. RN G stated she was not aware which resident had a pacemaker. RN G stated the facility did not have training regarding a pacemaker for resident's care. RN G was unable to tell what to monitor for s/s of a pacemaker malfunction. 1e. During an observation with the ADON on 4/4/19 at 8:43 a.m., the ADON assessed Resident 33 and stated the resident had a big round shaped pacemaker on the left upper chest. On 4/4/19 at 1:10 p.m., the ADON re-assessed Resident 33 and stated the resident had a long tube-like pacemaker on the right groin area (the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DABZ11 Facility ID: CA070000023 If continuation sheet 13 of 69 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 04/05/2019 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 area joins the leg and hip), not on the chest. Resident 33 did not speak English and showed the ADON the pacemaker booklet information. Resident 33 had a special model of a pacemaker. Review of Resident 33's special pacemaker manufacturer online resource indicated Resident 33's special pacemaker was inserted into the heart directly via groin area through a catheter. The pacemaker was actually attached to the heart directly. During an interview with the ADON on 4/5/19 at 10:04 a.m., the ADON reviewed Resident 33's clinical record and stated: Resident 33 was admitted on 9/20/17 and had a pacemaker; There was no evidence nursing staff monitored s/s of a pacemaker malfunction or s/s of a pacemaker insertion site; There was no evidence when the pacemaker was checked the last time. During an interview with LVN J on 4/4/19 at 12:57 p.m., she stated she worked at all stations as a float nurse. LVN J stated she was not aware which resident had a pacemaker. LVN J stated the facility did not have training regarding a pacemaker for resident's care. LVN J was unable to tell what to monitor for s/s of a pacemaker malfunction. 1f. Resident 128 was not available to be assessed by the ADON due to being admitted to an acute care hospital. On 4/5/19 at 10:09 a.m., the ADON reviewed Resident 128's clinical record and stated: Resident 128 was admitted on 3/21/15 and had a pacemaker; There was no evidence nursing staff monitored s/s of a pacemaker malfunction or s/s of a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DABZ11 Facility ID: CA070000023 If continuation sheet 14 of 69 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 04/05/2019 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 pacemaker insertion site; There was no evidence when the last time the pacemaker was checked. 1g. During an observation with the ADON on 4/4/19 at 8:45 a.m., the ADON assessed Resident 93 and stated the resident had a square shaped pacemaker on the left upper chest. On 4/5/19 at 10:18 a.m., the ADON reviewed Resident 93's clinical records and stated: Resident 93 was admitted on 6/18/15 and had a pacemaker; There was no evidence nursing staff monitored s/s of a pacemaker malfunction or s/s of a pacemaker insertion site; There was no evidence when the last time the pacemaker was checked. 1h. During an observation with the ADON on 4/4/19 at 8:09 a.m., the ADON assessed Resident 116 and stated the resident had a rectangle shaped pacemaker on the left upper chest. On 4/5/19 at 10:20 a.m., the ADON reviewed Resident 116's clinical records and stated: Resident 116 was admitted on 9/20/15 and had a pacemaker; There was no evidence nursing staff monitored s/s of a pacemaker malfunction or s/s of a pacemaker insertion site; There was no evidence when the last time the pacemaker was checked. During an interview with LVN L on 4/4/19 at 8:10 a.m., she stated she had no residents who had a pacemaker under her care. Residents 93 and 116 were under LVN L's care. LVN L stated the facility did not have training regarding a pacemaker for resident's care. LVN L was unable to tell what to monitor for s/s of a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DABZ11 Facility ID: CA070000023 If continuation sheet 15 of 69 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 04/05/2019 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 pacemaker malfunction. During an interview with the ADON on 4/5/19 at 10:35 a.m., the ADON stated, nursing staff should monitor and document for s/s of pacemaker malfunction and s/s infection at pacemaker insertion site for residents. There should be documentation of residents' pacemaker information and staff should initiate an appropriate care plan for a pacemaker care. The ADON further stated, nursing staff should follow the policy and procedure regarding pacemaker care for residents. Review of the facility's undated policy, "Pacemaker, Care of a resident With a", indicated the facility staff should monitor the signs and symptoms of bradyarrhythmias (abnormal slow heart rhythm) for pacemaker failure, such as fainting, short of breath, dizziness, fatigue, and or confusion. Staff should monitor the complication of the pacemaker, be aware the devices may interfere with pacemaker functioning, such as cell phone, MP3 players, microwave ovens, metal detectors, and electrical generators. The policy also indicated " ...When available, document the following in the medical record ...The name, address, and telephone number of the cardiologist ...Type of pacemaker ...Type of leads ...Manufacturer and model ...Serial number ...Date of implant ...Paced rate ..." 3a. During an observation on 4/2/19 at 10:19 a.m., RN G administered breathing medications to Resident 92. Duoneb (also known as Ipratropium bromide and albuterol sulfate, inhalation solution medication for breathing) and Wixela (Fluticasone propionate and salmeterol, inhaler medication for breathing). RN G did not assess Resident 92 before and after the breathing treatment for lung sounds, respiratory rate, and pulse. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DABZ11 Facility ID: CA070000023 If continuation sheet 16 of 69 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 04/05/2019 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 RN G on 4/2/19 at 10:58 a.m., she confirmed she did not assess Resident 92's lung sounds, pulse and respiratory rate before and after the breathing medication treatment. 3b. During an observation on 4/2/10 at 1 p.m., LVN L administered breathing medications to Resident 105. Medications included Albuterol (inhalation medication for asthma, breathing problem) via nebulizer and Symbicort (also known as budesonide-formoterol, medication for breathing problem). LVN L did not assess Resident 105 before and after the breathing treatment for lung sounds, respiratory rate, and pulse. During an interview with LVN L on 4/2/19 at 1:20 p.m., she confirmed she did not assess Resident 105's lung sounds, pulse and respiratory rate before and after the breathing medication treatment. Review of the facility's revised policy, "Administering Medications through a Metered Dose Inhaler" dated October 2010, indicated nursing staff should assess the resident for lung sounds, respiratory rate, and vital signs prior to administer the inhaler medications. Review of the facility's revised policy, "Administering Medications through a Small Volume (Handheld) Nebulizer" dated October 2010, indicated nursing staff should " ...Obtain baseline pulse, respiratory rate and lung sounds ..." prior to treatment. The policy indicated " ...Obtain post-treatment pulse, respiratory rate and lung sounds ..." 4. During an observation on 4/2/19 at 11:24 a.m., LVN K draw insulin (injection medication to lower the blood sugar) injection solution from FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DABZ11 Facility ID: CA070000023 If continuation sheet 17 of 69 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 04/05/2019 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 vial for Resident 44. Review Resident 44's physician order dated 2/20/19, indicated to administer insulin lispro (one type of insulin injection medication) via Humalog KwikPen (prefilled insulin into a pen, especially used for designated resident). During an interview on 4/2/19 at 2:40 p.m., LVN K stated the pharmacy did not have Humalog Kwipen Insulin supply for Resident 44. Pharmacy provided insulin vial instead. LVN K stated she should have notified the physician regarding the pharmacy supplied a different form of insulin for Resident 44. 5. During an observation on 4/2/10 at 1 p.m., LVN L administered total 16 medications to Resident 105. These 16 medications were schedule to be administered at 8 a.m. and 9 a.m. However, LVN L charted medication administration time as on time at 8 a.m. and 9 a.m.; LVN L did not chart the actual administered time of 1 p.m. for these medications. During an interview with LVN L on 4/2/19 at 1:20 p.m., LVN L stated she administered these 16 mediations late and she should have administered these 16 medications at 8 a.m. and 9 a.m. as scheduled. She stated she should have chart the actual medication administering time. Review of the facility's revised policy, "Documentation of Medication Administration" dated April 2007, indicated nursing staff should document "...Date and time of administration..." 6. During an observation on 4/2/19 at 1 p.m., LVN L administered albuterol to Resident 105. However, LVN L did not stay with the resident during the Albuterol treatment. LVN L stepped FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DABZ11 Facility ID: CA070000023 If continuation sheet 18 of 69 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 04/05/2019 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 out of the resident's room and talked to another resident in the hallway. Resident 105's privacy curtain was pulled and LVN L was not able to see Resident 105 during the Albuterol medication treatment. Resident 105 stopped the Albuterol treatment by himself before LVN L entered the room. LVN L stated she "normally" gave the albuterol inhalation medication to the resident and let the resident administer it to himself. Resident 105 stated he administered Albuterol by himself "all the time." Review Resident 105's minimum date set (MDS, clinical assessment) dated 2/13/19, indicated Resident 105 had intact cognition. There was no ITD assessment indicated Resident 105 was capable to self-administer medication. Review of the facility's revised policy, "SelfAdministration of Medications" dated December 2016, indicated "Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so." 7. A review of Resident 522's clinical record, indicated she was admitted to the facility on 3/21/19 with diagnoses including left hemicraniectomy (surgical operation in which a bone flap is removed from the skull to access the brain), hemiplegia (partial paralysis on one side of the body that can affect the arms, legs, and facial muscles) and hemiparesis (muscle weakness on one side of the body that can affect the arms, legs, and facial muscles) following cerebral infraction (or stroke, damage to the brain from interruption of its blood supply) affecting the right side. 7a. During a review of the clinical record for Resident 522, the physician order indicated an FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DABZ11 Facility ID: CA070000023 If continuation sheet 19 of 69 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 04/05/2019 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 order for Oxygen at 2 liters/minute via nasal cannula (a device used to deliver supplemental oxygen through a person's nose) as needed: Give 2 liters only if oxygen saturation drops below 92%. During an observation on 4/3/19 at 8:28 a.m., Resident 522 was lying in her bed with her oxygen on via nasal cannula at 1.5 liters/minute. During an observation and concurrent interview with minimum data set coordinator (MDSC) at 4/3/19 at 8:31 a.m., she confirmed the oxygen was below 2 liters/minute and Resident 522's oxygen saturation was at 95%. 7b. During a review of the clinical record for Resident 522, the physician order indicated protective helmet ON when out of bed to protect left skull. During an observation on 4/3/19, Resident 522 was in her wheelchair in the activity room after breakfast and wore no helmet. During an interview with the director of rehabilitation (DOR) on 4/3/19 at 2:51 p.m., the DOR confirmed that Resident 522 was transferred from her bed to her wheelchair this morning to attend activities by the rehabilitation staff. The DOR further stated Resident 522 did not wear a helmet and she did not have a helmet. During an interviewwith the treatment nurse (TN) on 4/3/19 at 3:15 p.m., she stated Resident 522 has a helmet and it was kept on her night stand. During an observation and concurrent interview with the TN on 4/3/19 at 3:35 p.m., the TN located Resident 522's helmet on the resident's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DABZ11 Facility ID: CA070000023 If continuation sheet 20 of 69 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 04/05/2019 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 night stand. 7c. During a review of the clinical record for Resident 522, the physician order indicated orders for pressure redistribution device for both right and left heels dated 3/21/19. The order was to apply left foot PRAFO (pressure relief of the ankle and foot orthosis, a device worn on calf and foot similar to a boot, used to prevent and protect the heel from pressure injuries and to position foot) boot while in bed; and to apply Z-Flex Fluidized Heel boot (Z Flex, a device worn on calf and foot similar to a boot used to offload heel pressure with an air chamber and support natural foot position) to right foot while in bed. During initial tour observation on 4/2/19 at 8:00 a.m., Resident 522 was lying in her bed with her Z Flex boot on her right foot and on top of a pillow. During an observation 4/2/19 at 2:03 p.m., Resident 522 was in her bed and with pressure relieving boots on both feet. During an observation on 4/3/19 at 8:28 a.m., Resident 522 was in her bed with a PRAFO boot on her right foot and a Z flex boot on her left foot. During an interview with the ADON on 4/3/19 at 3:15 p.m., she stated Resident 522's order was to apply a PRAFO boot on left foot/leg and apply Z Flex Fluidized heel boot to right foot while in bed. The ADON further stated the order was transcribed by the TN. During an interview with the TN on 4/3/19 at 3:15 p.m., she stated on the morning of 4/2/19, Resident 522 was only wearing the boot on her right foot and she seen the other boot on the table in Resident 522's room. She further FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DABZ11 Facility ID: CA070000023 If continuation sheet 21 of 69 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 04/05/2019 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 stated she observed Resident 522's boots were placed the opposite way this morning. During an observation and concurrent interview with registered nurse F (RN F) on 4/5/19 at 9:32 a.m., Resident 522 was in bed with a PRAFO boot on her right foot and a Z Flex boot on her left foot. RN F confirmed placement of the boots. She also stated she did not know the difference between the two boots. During an interview with the director of rehabilitation (DOR) on 4/5/19 at 10:36 a.m., the DOR confirmed her team applied Resident 522's boots this morning. The DOR stated the correct application of the boots were to apply a Z flex boot on the resident's left foot to prevent pressure injury and a PRAFO boot on the resident's right foot to prevent foot drop and pressure injury as Resident 522 was not able to move her right side. The DOR further stated after some research she believed the orders were incorrectly transcribed. During an interview with the ADON on 4/5/19 at 2:23 p.m., the ADON confirmed the above statement by the DOR was the correct order. She further stated she was not able to talk to the TN regarding the original physician orders for Resident 522's boots and was not able to find the original documentation. A review of facility's policy, "Medication and Treatment Orders" revised on July 2016, indicated "Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications ..." A review of facility's policy, "Administering Medications" revised on December 2012, indicated "Medications shall be administered in a safe and timely manner, and as prescribed." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DABZ11 Facility ID: CA070000023 If continuation sheet 22 of 69 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 04/05/2019 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

F688 Increase/Prevent Decrease in ROM/Mobility CFR(s): 483.25(c)(1)-(3)

F688 SS=D PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 05/05/2019 §483.25(c) Mobility. §483.25(c)(1) The facility must ensure that a resident who enters the facility without limited range of motion does not experience reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable; and §483.25(c)(2) A resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. §483.25(c)(3) A resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable. This REQUIREMENT is not met as evidenced by: 2. Review of Resident 80's clinical record indicated she was admitted to the facility with a diagnoses incliding hemiplegia and hemiparesis (weakness of one entire side of the body) following cerebral infarction affecting right dominant side. Review of Resident 80's phyiscian order dated 3/1/19 indicated RNA for BUE ROM for 3xw x 3 months and RNA for BLE ,AAROM LLE , PROM R LE 3x/w x 12 weeks . Review of the RNA flowsheet indicated restorative nursing program was started on 3/29/19. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DABZ11 Facility ID: CA070000023 If continuation sheet 23 of 69 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 04/05/2019 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 RNA weekly summary indicated missing documentation from 3/1/19 - 3/28/19. Review of Resident 80's census record indicated she was in a general acute care hospital (GACH) from 2/28/19-3/6/19. During an interview with the restorative nursing assistant M ( RNA M) on 4/5/19 at 9:34 a.m., she confirmed Resident 80 did not have RNA until 3/29/19 because there was no referral from the rehabilitation department. RNA M also confirmed she did not have the weekly summary from 3/1/19 to 3/28/19. Durinng an interview with the RD on 4/5/19 at 9:55 a.m., she stated there was a referral made on 2/28/19 for the restorative nursing program but Resident 80 was sent to a general acute care hospital on 2/28/19 and did not return until 3/6/19. The RD stated there was a " miscommunication" regarding the "referral form" ordered on 2/28/19 which the RNA did not know about. Review of the facility's undated policy, "Restorative Nursing Services", indicated "Residents will receive restorative nursing care as needed to help promote optimal safety and independence." Based on interview and record review, the facility failed to provide restorative nursing assistant (RNA) therapy (nursing interventions that promote the residents' ability to live as independently and safely as possible) for two residents (168 and 80). This failure had the potential to result in the resident's decline in mobility. Findings: 1. Review of Resident 168's clinical record indicated a diagnosis of monoplegia (paralysis FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DABZ11 Facility ID: CA070000023 If continuation sheet 24 of 69 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 04/05/2019 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 restricted to one limb or region of the body) of the upper limb following cerebral infarction (stroke) affecting the right dominant side. Review of Resident 168's physician orders dated 3/4/19 indicated Resident 168 had an RNA therapy for passive range of motion (PROM, exercises where another person is moving the individual's joints) right upper extremity and to apply an elbow splint (a device used for support or immobilization of a limb) five times a week for 12 weeks. It also indicated Resident 168 was to wear a splint for 2 to 3 hours or as tolerated. Review of Resident 168's physician orders dated 3/4/19 indicated Resident 168 had an RNA therapy for PROM of both lower extremities five times a week for three months. Review of Resident 168's care plan for RNA indicated Resident 168 was at risk for decline in range of motion, increased pain and discomfort, and contracture (shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints). It indicated Resident 168 required an RNA program. Review of Resident 168's Point of Care RNA flowsheet for March 2019 indicated there was no staff member initials if an RNA therapy was provided between 3/4/19 to 3/15/19. During a concurrent interview and record review with the rehabilitation director (RD) on 4/5/19 at 12:24 p.m., the RD stated Resident 168 finished rehabilitation therapy and the rehabilitation department made the referral for RNA on 3/4/19. The RD stated there was an oversight from the RNA staff and confirmed the RNA therapy was not initiated until 3/14/19. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DABZ11 Facility ID: CA070000023 If continuation sheet 25 of 69 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 04/05/2019 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

F740 Behavioral Health Services CFR(s): 483.40

F740 SS=D PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 05/05/2019 §483.40 Behavioral health services. Each resident must receive and the facility must provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Behavioral health encompasses a resident's whole emotional and mental well-being, which includes, but is not limited to, the prevention and treatment of mental and substance use disorders. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to address behaviors that includes episodes of crying and saying " mama, mama " for one of two sampled residents (93). This failure could negatively affect the resident's physical, mental, and psychosocial well-being. Findings: During an observation on 4/2/19 at 9:00 a.m., Resident 93 was in the hallway in front of a nursing station. When Resident 93 was approached, Resident 93 was teary eyed and stated "mama, mama". Resident 93 did not verbalize other words and continued to say "mama, mama". During a dining observation on 4/2/19 at 12:28 p.m., Resident 93 had episodes of crying and stated "mama, mama" multiple times. During an observation on 4/3/19 at 8:45 p.m., Resident 93 was in the hallway and had episodes of crying and mumbling some words. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DABZ11 Facility ID: CA070000023 If continuation sheet 26 of 69 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 04/05/2019 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 a concurrent interview with certified nursing assistant N (CNA N) , she stated Resident 93's crying spells and saying "mama, mama" was not new, "she was always like that". Review of Resident 93's clinical record indicated she was admitted to the facility with a diagnoses including major depressive disorder and dementia with behavioral disturbance. Review of Resident 93's minimum data set (MDS, an assessment tool) dated 2/12/19, indicated her cognitive level was moderately impaired. Review of Resident 93's physician order dated 1/12/19, indicated to monitor episodes of behavioral and psychological manifestation of demetia as evidence by combativeness, harm to self and others. Review of Resident 93's behavioral care plan did not contain Resident 93 crying episodes. During an interview with the nursing supervisor A (NS A) on 4/3/19 at 9:19 a.m., she confirmed Resident 93's did not have monitoring for crying episodes and this should have been addressed. Review of the facility's undated policy, "Behavior Assessment, Intervention and Monitoring", indicated the interdisciplinary team would thouroughly evaluate new or changing behavioral symsptoms in order to identify underlying causes and address any modifiable factors that may have contributed to the resident's change in condition incluiding emotional , psychiatric and or psychological stressors. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DABZ11 Facility ID: CA070000023 If continuation sheet 27 of 69 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 04/05/2019 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

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

F755 SS=D PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 05/05/2019 §483.45 Pharmacy Services The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse. §483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. §483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who§483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility. §483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and §483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure the controlled substance medications (medication with a high potential for abuse and addiction) were accurately accounted on the medication administration FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DABZ11 Facility ID: CA070000023 If continuation sheet 28 of 69 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 04/05/2019 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 record (MAR) and the controlled Substance Accountability Sheet (CSAS) for three randomly selected residents (Residents 54, 225, and 229). These failures had the potential to result in residents not getting medications per physician's order and potential to cause controlled medication misuse and abuse. Findings: 1. Review of Resident 229's physician order dated 3/22/19, indicated to administer one tablet of hydrocodone-acetaminophen (also known as Norco, controlled medication for pain) 5-325 milligrams (mg, measure unit) by mouth every six hours as needed for pain. Review of Resident 229's CSAC and MAR from 3/28/19 to 4/1/19 indicated registered nurse E (RN E) removed one tablet of Norco from the medication cart on 3/28/19 at 10:11 p.m. However, there was no evidence on the MAR indicating RN E administered this tablet of Norco to the resident. During an interview with registered RN E on 4/4/19 at 3:40 p.m., she stated she signed on CSAC on 3/28/19 at 10:11 p.m., indicating she took one tablet of Norco from the medication cart. However, she did not write on the MAR indicating she administered the tablet of Norco to Resident 229. RN E stated she did not remember what happened to this controlled medication. RN E stated the controlled medication should have been accounted for on both the CSAC and the MAR. 2. Review Resident 225's physician's order dated 3/24/19, indicated to administer morphine (controlled medication for pain) 15 mg orally every six hours for severe pain. Review of Resident 225's CSAC and MAR from FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DABZ11 Facility ID: CA070000023 If continuation sheet 29 of 69 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 04/05/2019 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 3/25/19 to 3/29/19 indicated RN F removed one tablet of Morphine from the medication cart on 3/26/19 at 12 a.m. and 4:30 a.m. RN E removed one tablet of Morphine from the medication cart on 3/28/19 at 5:45 p.m. However, there was no evidence on the MAR indicating RN F administered the two tablets of Morphine to Resident 225 on 3/26/19. There was no evidence indicating RN E administer one tablet of Morphine to Resident 225 on 3/28/19 at 5:45 p.m. During a telephone interview with RN F on 4/4/19 at 4:38 p.m., she stated she signed on the CSAC on 3/26/19 at 12 a.m. and 4:30 a.m. indicating she took one tablet of morphine from the medication cart at 12 a.m. and 4:30 a.m. However, she did not sign on MAR indicating she administered the two tablets of morphine to Resident 225 on 3/26/19. RN F stated she did not remember what happened to the two morphine tablets. RN F stated controlled medications should have been accounted for on both the CSAC and the MAR. During an interview with RN E on 4/4/19 at 3:42 p.m., she stated she signed the CSAC on 3/28/19 at 5:45 p.m. indicating she took one tablet of Morphine from the medication cart. However, she did not write on the MAR indicating she administered Morphine to Resident 225. RN E stated she did not remember what happened to this tablet of Morphine. RN E stated controlled medications should have been accounted for on both the CSAC and the MAR. 3. Review Resident 54's physician's order dated 11/22/18, indicated to administer Norco 5 -325 mgs orally every six hours for severe pain. Review of Resident 54's CSAC and MAR from 3/31/19 to 4/2/19 indicated nursing staff FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DABZ11 Facility ID: CA070000023 If continuation sheet 30 of 69 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 04/05/2019 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 removed one tablet of Norco from the medication cart on 4/1/19 at 4:55 a.m.. However, there was no evidence on the MAR indicating nursing staff administered Norco to Resident 54. During an interview with the assistant director of nursing (ADON) on 4/4/19 at 5 p.m., she stated controlled medications should have been accounted for on both the CSAC and the MAR. Review of the facility's revised policy, "Medication Administration-Preparation and General Guidelines Controlled Substances", dated 1/31/19, indicated "...Accurate accountability of the inventory of all controlled drugs is maintained at all times. When a controlled substance is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record and the medication administration record (MAR) ...Date and time of administration (MAR, Accountability Record) ...Amount administered (Accountability Record)..."

F757 SS=D Drug Regimen is Free from Unnecessary Drugs CFR(s): 483.45(d)(1)-(6)

F757 05/05/2019 §483.45(d) Unnecessary Drugs-General. Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used§483.45(d)(1) In excessive dose (including duplicate drug therapy); or §483.45(d)(2) For excessive duration; or §483.45(d)(3) Without adequate monitoring; or FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DABZ11 Facility ID: CA070000023 If continuation sheet 31 of 69 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 04/05/2019 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 §483.45(d)(4) Without adequate indications for its use; or §483.45(d)(5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or §483.45(d)(6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review the facility failed to ensure one of 30 sampled residents (Resident 73) was free from unnecessary drugs when Resident 73 was not appropriately assessed and monitored for 1) behavior manifestations and 2) side effects for his medications for major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). These failures had the potential for these side effects to go undetected and not intervened timely and unnecessary medications. Findings: During a review of the clinical record for Resident 73 it indicated he was admitted to the facility on 2/7/13 with diagnoses including major depressive disorder and anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). His minimum data set (MDS, an assessment tool) dated 2/1/19, indicated he was able to make himself understood and he was able to understand others with clear comprehension. The physician order indicated Resident 73 was prescribed Buspropion 150 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DABZ11 Facility ID: CA070000023 If continuation sheet 32 of 69 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 04/05/2019 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 mg (mg, a unit of measurement) and venlafaxine 25 mg for his depression with behavior manifestation of feeling hopeless related to his medical condition. Resident 73 was being monitored for episodes of depression as evidenced by verbalization of hopelessness related to medical condition for both buspropion and venlafaxine. During a telephone interview with the pharmacy consultant (PC) on 4/5/19 at 1:10 p.m., the PC advised for two separate behavior monitorings for Resident 73's two medications for depression. During a review of the clinical record for Resident 73 it indicated he was being monitored for side effects for anti-depressant medications. Medication side effects of bupropion and venlafaxine include nausea and vomiting, anxiety, insomnia (sleep disorder that is characterized by difficulty falling and/or staying asleep), dizziness, weight loss/gain, tremors (unintentional, rhythmic muscle movement involving to-and-fro movements (oscillations) of one or more parts of the body), sweating, drowsiness, fatigue (overall feeling of tiredness or lack of energy), dry mouth, diarrhea, constipation, headaches, increased risk for falls and fractures. During an observation and concurrent interview with Resident 73 on 4/2/19 at 11:32 a.m., Resident 73 was observed with tremors on both hands. Resident 73 confirmed the observation and stated the tremors started last year. During an observation on 4/3/19 at 10:00 a.m. Resident 73 sat in his wheelchair and had tremors on both hands. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DABZ11 Facility ID: CA070000023 If continuation sheet 33 of 69 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 04/05/2019 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 observation of Resident 73 on 4/4/19 at 10:16 a.m. in his room, Resident 73 sat on his bed holding his phone and had tremors on both hands. During an interview with licensed vocational nurse S (LVN S) on 4/4/19 at 10:16 a.m., she stated Resident 73 was alert and oriented to person, place, time and situation. She saw Resident 73 with hand tremors when he reached for his water cup and took his medications. She further stated she observed this for approximately one year. During an interview with the director of nursing (DON) and Resident 73 on 4/4/19 at 11:34 a.m., Resident 73 stated his hand tremors started on his left hand and had gotten worse throughout the year. Resident 73 further stated he associated the hand tremors as a side effect of his anti-depressant medications. Resident 73 had hand tremors during the interview. During an interview and conurrent record review with the DON on 4/4/19 at 11:39 a.m., the DON confirmed the observation above and confirmed Resident 73 had tremors on both hands. He further stated the tremors should have been documented and monitored. The DON did not find evidence Resident 73's tremors were monitored as side effect of the anti-depressants. During a review of the clinical record for Resident 73 for side effects monitoring for antidepressants no evidence was found for January, February and March 2019 for side effects. A review of the facility's policy, "Charting and Documentation" revised on July 2017, indicated "All services provided to the resident, progress towards the care plan goals, or any FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DABZ11 Facility ID: CA070000023 If continuation sheet 34 of 69 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 04/05/2019 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 changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care."

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

F759 05/05/2019 §483.45(f) Medication Errors. The facility must ensure that its§483.45(f)(1) Medication error rates are not 5 percent or greater; This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility had a 26.66% medication error rate with eight medication errors during 30 opportunities were observed during the medication passes for three of four observed residents (Residents 92, 105, and 423). These failures had the potential to jeopardize residents' medical condition and health. Findings: 1. During an observation on 4/2/19 at 9:40 a.m., licensed vocational nurse H (LVN H) crushed Resident 423's six oral tablet medications including Metoprolol Succinate (also known as Toprol XL, extended release medication for blood pressure, BP). LVN H administered these crushed medications with apple sauce to Resident 423. After LVN H finished administering the medications to Resident 423, some orange-yellow color of the crushed medications residues remained on the bottom of the medication cup and in the apple sauce. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DABZ11 Facility ID: CA070000023 If continuation sheet 35 of 69 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 04/05/2019 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 423's physician's order dated 3/13/19 indicated may crush medications unless contraindicated. Physician's order dated 3/12/19 indicated to administer one tablet of Toprol XL (Metoprolol Succinate) extended release in 24 hours, 25 milligrams (mg: measure unit) orally once a day for hypertension (high blood pressure). During an interview with LVN H on 4/2/19 at 10:05 a.m., LVN H confirmed that he did not administer all mixed crushed medications to Resident 423. LVN H stated he did not give the full doses of mixed medications because a residue still remained on the bottom of the medication cup and in the apple sauce. During another interview with LVN H on 4/2/19 at 1:25 p.m., he reviewed Resident 423's medication packet and the physician's order and stated Metoprolol Succinate was extended release and should not have been crushed. LVN H stated he should not have crushed Metoprolol Succinate for Resident 423. LVN H stated the resident was not able to swallow a whole pill and he should have notified the physician to change the order to a crushable BP medication. Review of the facility's undated "Oral Dosage Forms That Should Not Be Crushed", indicated Metoprolol Succinate (Toprol XL) should not be crushed. Review of the facility's revised policy, "Crushing Medications" dated April 2018, indicated "...The nursing staff and/or consultant pharmacist shall notify any attending physician who gives an order to crush a drug that the manufacturer states should not be crushed..." Review of "Lexi-comp" online (www.lexi.com), FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DABZ11 Facility ID: CA070000023 If continuation sheet 36 of 69 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 04/05/2019 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 nationally recognized drug information resource, indicated all Metoprolol oral tablets should not be chewed or crushed. 2. During an observation on 4/2/19 at 10:19 a.m., registered nurse G (RN G) administered total six medications to Resident 92. These medications included fiber powder (for constipation), Duoneb (also known as Ipratropium bromide and albuterol sulfate, inhalation solution medication for breathing) and Wixela (Fluticasone propionate and salmeterol, inhaler medication for breathing). RN G mixed one teaspoon of fiber powder with 100 milliliters (ml: measure unit) of water; orange color of powder mixture did not fully dissolve and still remained on the bottom of the cup. RN G did not give the full dose of fiber powder to the resident; RN G administered the Duoneb via a nebulizer (medical device for inhalation solution medication, nebulizer included a cup to hold the solution), some inhalation solution remained inside the nebulizer cup, RN G discarded the remaining Duoneb solution into the trash can; RN G did not give the full dose of Duoneb to the resident; RN G administered the Wixela inhaler five seconds after she finished administering Duoneb to Resident 92. RN G allowed five seconds between the Duoneb and the Wixela inhalation administering for the resident. Review of Resident 92's physician orders dated 2/21/19 indicated to administer Ipratropiumalbuterol (Duoneb solution for nebulization) 0.5mg-3mg (2.5 mg base)/3 ml via inhalation twice a day for short of breath/ wheezing; An order dated 3/30/19 indicated to administer one puff of Wixela (Fluticasone-salmeterol) 250 -50 micrograms (mcg: measure unit) per dose, inhalation for chronic obstructive pulmonary disease (COPD: lung disease, breathing FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DABZ11 Facility ID: CA070000023 If continuation sheet 37 of 69 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 04/05/2019 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 problem); An order dated 3/31/19 indicated to administer one teaspoon of fiber powder orally twice a day. During an interview with RN G on 4/2/19 at 10:58 a.m., RN G confirmed she did not dissolve the fiber powder fully and did not give the full dose of the fiber powder to Resident 92; RN G confirmed that there was still some Duoneb inhalation solution remaining in the nebulizer cup and she discarded the remaining Duoneb solution into the trash can. RN stated she should have given the full dose of Duoneb to the resident. RN G stated she should have waited at least three minutes between two inhalation medications for the resident. Review of the facility's revised policy, "Administering Medications through a Small Volume (Handheld) Nebulizer" dated October 2010, indicated nursing staff should " ...Tap the nebulizer cup occasionally to ensure release of droplets from the sides of the cup ...Administer therapy until medication is gone ..." Review of the facility's revised policy, "Administering Medications through a Metered Dose Inhaler" dated October 2010, indicated nursing staff should allow " ...at least two (2) minutes between inhalations of different medications ..." 3. During an observation on 4/2/10 at 1 p.m., LVN L administered total 16 medications to Resident 105. Medications included Albuterol (inhalation medication for asthma,breathing problem) via nebulizer, artificial tears eye drops (eye medication for dry eyes), and Symbicort (also known as budesonide-formoterol, 80mcg-4.5mcg, medication for breathing FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DABZ11 Facility ID: CA070000023 If continuation sheet 38 of 69 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 04/05/2019 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 problem). LVN L did not stay with the resident during the Albuterol treatment. LVN L stepped out of the resident's room and talked to another resident in the hallway. Resident 105's privacy curtained was pulled and LVN L was not able to see Resident 105 during the Albuterol medication treatment; Resident 105 stopped the Albuterol treatment by himself before LVN L entered the room; LVN L administered all 16 medications late at 1 p.m. These 16 medications were scheduled to be administered at 8 a.m. and 9 a.m. However, LVN L charted medication administration time as on time at 8 a.m. and 9 a.m. LVN L did not chart the actual administered time of 1 p.m. for these medications.; LVN L should have administered one dose of the Albuterol at 8 a.m., and 12 p.m., and she administered one dose of the Albuterol to the resident at 1 p.m., one dose of the Albuterol was omitted and missed; LVN L charted the Albuterol administration time as on time at 8 a.m. and 12 p.m. LVN L did not chart the actual Albuterol administering time of 1 p.m.; LVN L administered the Symbicort (steroid medication) prior to the Albuterol inhalation (Albuterol is a bronchodilator medication and should administer prior to steroid inhaler in order to open up the airway. In this way, the steroid inhaler medication can penetrate the lungs more effectively.); LVN L did not shake the Symbicort inhaler prior to administering to the resident; LVN L did not instruct Resident 105 to rinse his mouth after administering the Symbicort Inhaler; LVN L instilled two drops of artificial tears into Resident 105's right eye, one drop to Resident 105's left eye, partial of the eye drop ran down from the left eye; Resident 105 sat straight and unable to tilt his head back when LVN L FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DABZ11 Facility ID: CA070000023 If continuation sheet 39 of 69 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 04/05/2019 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 administered the eye drops; Review Resident 105's physician's orders indicated: An order dated 8/17/18 indicated to administer the Albuterol sulfate solution for nebulization, 2.5mg/3ml inhalation every four hours for asthma (breathing disease); An order dated 10/19/18 indicated to administer the Symbicort (budesonide-formoterol) aerosol inhaler 80-4.5 mcg/actuation, 1 puff inhalation twice a day for asthma, rinse mouth with water after administration Symbicort; An order dated 1/26/19 indicated to administer one drop of artificial tears to each eye once a day for the dry eye. During an interview with LVN L on 4/2/19 at 1:20 p.m., LVN L stated she administered these 16 mediations late and she should have administered these 16 medications at 9 a.m. as scheduled. She should have charted the actual medication administering time; She should have stayed with the resident during the Albuterol treatment; She should not have left the resident alone for the Albuterol treatment; She should have instructed the resident to rinse his mouth after the Symbicort administration; She should have administered the correct eye drop to each eye for the resident; LVN L stated it was hard to administer eye drops when Resident 105 sat straight and was unable to tilt his head back; She did not know if she should have administered the Albuterol prior to the Symbicort; Administer one dose of albuterol to the resident at 1 p.m. Review of the facility's revised policy, "Administering Medications through a Small FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DABZ11 Facility ID: CA070000023 If continuation sheet 40 of 69 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 04/05/2019 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 Volume (Handheld) Nebulizer" dated October 2010, indicated nursing staff should " ...Remain with the resident for the treatment ..." Review of the facility's revised policy, "Administering Medications" dated December 2012, indicated " ...Medications shall be administered in a safe and timely manner as prescribed."

F760 SS=D Residents are Free of Significant Med Errors CFR(s): 483.45(f)(2) FORM CMS-2567(02-99) Previous Versions Obsolete

F760 Event ID: DABZ11 05/05/2019 Facility ID: CA070000023 If continuation sheet 41 of 69 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 04/05/2019 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 ensure that its§483.45(f)(2) Residents are free of any significant medication errors. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to follow the physicians' orders for two of 30 sampled residents (Residents 132 and 423) regarding medication administration: 1. For Resident 132, the nursing staff failed to measure the respiratory rate (RR) before administering oxycodone-acetaminophen (also known as Percocet, controlled pain medication with a high potential for abuse and addiction. Percocet has life-threatening respiratory depression). This failure had potential to cause life-threatening respiration problem to Resident 132 and jeopardize the resident's health safety and medical conditions. 2. For Resident 423, the nursing staff crushed and administered the extended release (the medication is formulated to release slower and steadier into bloodstream over time. The extended release medication should not be crushed) blood pressure (BP) medication for Resident 423. This failure had potential to drop resident's BP fast and jeopardize Resident 423's health safety and medical conditions. Findings: 1. Review of Resident 132's physician's order dated 3/15/19 indicated to administer one tablet of Percocet 5-325 milligrams (mg: measure unit) orally every three hours for severe pain and hold the medication if the resident's RR was lower than 12 beat per minute (bpm). Review of Resident 132's medication administration record (MAR) dated from FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DABZ11 Facility ID: CA070000023 If continuation sheet 42 of 69 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 04/05/2019 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 3/16/19 to 4/2/19 indicated nursing staff administered a total of 79 tablets of Percocet to Resident 132. However, nursing staff administered 70 of 79 tablets of Percocet without checking Resident 132's RR as the physician ordered. During an interview and concurrent record review with the nurse supervisor A (NS A) on 4/4/19 at 11:02 a.m., she reviewed Resident 132's physician's order and the MAR. NS A confirmed multiple nurses did not check Resident 132's RR prior to administering Percocet. NS A stated nursing staff should have followed the physician's order to check the resident's RR prior to administering Percocet to Resident 132. Review of "Lexi-comp" online (www.lexi.com), a nationally recognized drug information resource, indicated Percocet has a black box warning (manufacturer lists the most serious medication warning required by the food and drug administration-FDA) of life-threatening respiratory depression when taking Percocet. Lexi-comp online resource indicated Percocet " ...may cause very bad and sometimes deadly breathing problems." Review of the facility's revised policy, "Administering Medications" dated December 2012, indicated " ...Medications shall be administered in a safe and timely manner, and as prescribed." 2. During an observation on 4/2/19 at 9:40 a.m., licensed vocational nurse H (LVN H) crushed Resident 423's six oral tablet medications including Metoprolol Succinate (also known as Toprol XL) extended release medication for BP. LVN H administered these crushed medications with apple sauce to Resident 423. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DABZ11 Facility ID: CA070000023 If continuation sheet 43 of 69 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 04/05/2019 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 423's physician's order dated 3/13/19 indicated may crush medications unless contraindicated. Physician's order dated 3/12/19 indicated to administer one tablet of Toprol XL (Metoprolol Succinate) extended release in 24 hours, 25 milligrams (mg: measure unit) orally once a day for hypertension (high blood pressure). During an interview with LVN H on 4/2/19 at 1:25 p.m., he stated Resident 423's medication of Metoprolol Succinate was extended release and should have not been crushed. LVN H stated he should not have crushed Metoprolol Succinate for Resident 423. LVN H stated the resident was not able to swallow the whole pill and he should have notified the physician to change it to a crushable BP medication. During an interview with the director of nursing (DON) on 4/5/19 at 2:35 p.m., he stated Resident 423 had a physician order to crush the medications. The DON stated it was okay for nursing staff to crush all Resident 423's oral medications including Metoprolol Succinate because the resident would not be able swallow the pills. The DON stated the facility's pharmacy consultant (PC) was okay that all the resident's oral medications were crushed together. Review of the facility's PC email to the DON dated 4/5/19 indicated PC was okay to allow nursing staff to crush Resident 423's above observed oral medications together. The crushable medication included Metoprolol Succinate. Review of the facility's revised policy, "Crushing Medications" dated April 2018, indicated "...The nursing staff and/or consultant pharmacist shall notify any attending physician who gives an FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DABZ11 Facility ID: CA070000023 If continuation sheet 44 of 69 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 04/05/2019 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 order to crush a drug that the manufacturer states should not be crushed..." Review of the facility's undated "Oral Dosage Forms That Should Not Be Crushed", indicated Metoprolol Succinate (Toprol XL) should not be crushed. Review of "Lexi-comp" online (www.lexi.com), a nationally recognized drug information resource, indicated all Metoprolol oral tablets should not be chewed or crushed.

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

F761 05/05/2019 §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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DABZ11 Facility ID: CA070000023 If continuation sheet 45 of 69 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 04/05/2019 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 §483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to properly store medications in a safe and sanitary condition when: 1. Medication Cart 6 (MC 6) had multi-color substances and sticky substances, pill crusher (device to crush the pills into powder form) had multi-color substances, medication pill spilled inside the MC, suppository medications (medication administer via rectal area) stored next to insulin injection (injection medication to lower the blood sugar level) and eye drop medications, medication packets had no direction change stickers when the instruction on the medication packets differed from the physician orders for three residents (Residents 88, 93 and 132). 2. MC 5 had multi-color substances and sticky substances, pill divider (device to cut the pill into half or small pieces) and pill crusher had multi-color substances, ripped paper noted inside the MC, medication pill spilled inside the med cart. 3. MC 4 had multi-color substances and sticky substance, pill crusher hand multi-color substances. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DABZ11 Facility ID: CA070000023 If continuation sheet 46 of 69 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 04/05/2019 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 4. MC 1 had multi-color substances and sticky substances, hair and ripped paper noted inside the med cart, eye drops stored next to oral medications, pill crusher had multi-color substances. 5. The medication refrigerator inside Medication Room 1 (Med Room 1) did not maintain the normal temperature range. These failures had the potential for the residents to receive contaminated and/or deteriorated medications. Findings: 1. During a MC inspection with nurse supervisor A (NS A) on 4/2/19 at 2:57 p.m., the following was observed at MC 6: a. White, black, orange and pink substances noted inside MC; pink and orange sticky substances noted on oral liquid bottles and inside the MC. b. An opened box of dulcolax (also known as Bisacodyl, suppository medication for constipation) and an opened box of acetaminophen suppository (suppository medication for pain and/or fever) stored next to an insulin injection vial and eye drop medications. c. The pill crusher on MC noted with white and gray powder substances. d. One white tablet pill spilled inside the controlled medication (medication with a high potential for abuse and addiction) storage area inside MC. e. Resident 88's Norco (controlled medication for pain) direction of use on medication packet was different from the physician's order; Resident 93's lorazepam (medication for anxiety) direction of use on the medication packet was different from the physician's order; Resident 132's Percocet (controlled medication FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DABZ11 Facility ID: CA070000023 If continuation sheet 47 of 69 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 04/05/2019 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 for pain) direction of use on the medication packet was different from the physician's order. There were no stickers of direction change posted on these three residents' medication packets to alert nursing staff to refer to the latest physicians' order for the correct direction of use. During an interview with NS A on 4/2/19 at 3:10 p.m., she stated: Nursing staff should have cleaned the MC. Suppository medications should not be stored next to injection and eye drop medications, Nursing staff should have cleaned the pill crusher every shift. Nursing staff should have put a sticker of direction change on Resident 88, 93 and 132's medication packets when the direction of use was differed from the physicians' orders. 2. During a MC 5 inspection with the assistant director of nursing (ADON) on 4/2/19 at 4:33 p.m.: A pill divider and pill crusher had white and gray powder substances. An orange and yellow sticky substance was noted inside MC. White, gray, black and pink substance noted inside MC; A ripped paper noted inside med cart; One red capsule pill spilled inside MC. During an interview with the ADON on 4/2/19 at 4:45 p.m., she stated nursing staff should have maintained the MC clean and should have cleaned the pill divider and the pill crusher after each use. 3. During a MC 4 inspection with the ADON on 4/2/19 at 5:14 p.m.: A pink sticky substance was noted inside MC and on the liquid bottles. A white and gray substance was noted inside MC. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DABZ11 Facility ID: CA070000023 If continuation sheet 48 of 69 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 04/05/2019 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 pill crusher had a white and gray powder substance. During an interview with the ADON on 4/2/19 at 5:20 p.m., she stated nursing staff should have maintained the MC clean and should cleaned the pill crusher after each use. 4. During a MC 1 inspection with the ADON on 4/2/19 at 5:23 p.m.: A pink sticky substance was spilled on oral medication packets and inside MC; a brown sticky substance was noted inside MC; A white and gray powder substance was noted inside MC. One piece of hair noted inside MC; Ripped paper noted inside MC; Resident 73's opened box of eye drop medication (Restasis EMU0.05%, eye drop medications for eye disease) was stored on the white and gray powder substances and stored next to three opened bottles of oral medications. A pill crusher had a white and gray powder substance. During an interview with the ADON on 4/2/19 at 5:33 p.m., she stated nursing staff should have maintained the MC clean, they should not have stored eye drops with oral medications and nursing staff should cleaned the pill crusher after each use. 5. During MC 1 inspection with the ADON at the different dates and times: On 4/2/19 at 5:35 p.m., the medication refrigerator (one medication refrigerator inside MC 1) stored influenza vaccines, purified protein derivative (PPD: skin test agent for tuberculosis; tuberculosis is a high contagious infection cause by the bacterium), insulin injections medications, eye drop medications, and emergency kits for insulin injection FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DABZ11 Facility ID: CA070000023 If continuation sheet 49 of 69 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 04/05/2019 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 medications. The medication refrigerator temperature was 48 Fahrenheit degree (F: temperature measure unit); On 4/3/19 at 8:05 a.m., the refrigerator temperature was 48F degree with the ADON present. On 4/4/19 at 8:01 a.m., the refrigerator temperature was 22 F degree with the ADON present. During an interview with the ADON on 4/2/19 at 5:35 p.m., the ADON stated the medication refrigerator temperature should have been maintained between 36 F to 46 F degree. Review of the facility's revised policy, "Storage of Medications" dated April 2007, indicated "The facility shall store all drugs and biologicals in a safe, secure, and orderly manner ...The nursing staff shall be responsible for maintaining medication storage AND preparation areas in a clean, safe, and sanitary manner... Drugs for external use ...shall be separately from other medications ..." Review of the facility revised policy, "Medication Storage in the Facility Storage of Medications" dated 1/31/19, indicated " ...Orally administered medications are kept separate from externally used medications and treatment such as suppositories ...Eye medications are stored separately per facility policy ..." The policy also indicated the medications store in a refrigerator should maintain refrigerator temperature between 36 F to 46 F degree.

F801 SS=E Qualified Dietary Staff CFR(s): 483.60(a)(1)(2) FORM CMS-2567(02-99) Previous Versions Obsolete

F801 Event ID: DABZ11 05/05/2019 Facility ID: CA070000023 If continuation sheet 50 of 69 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 04/05/2019 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 §483.60(a) Staffing The facility must employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.70(e) This includes: §483.60(a)(1) A qualified dietitian or other clinically qualified nutrition professional either full-time, part-time, or on a consultant basis. A qualified dietitian or other clinically qualified nutrition professional is one who(i) Holds a bachelor's or higher degree granted by a regionally accredited college or university in the United States (or an equivalent foreign degree) with completion of the academic requirements of a program in nutrition or dietetics accredited by an appropriate national accreditation organization recognized for this purpose. (ii) Has completed at least 900 hours of supervised dietetics practice under the supervision of a registered dietitian or nutrition professional. (iii) Is licensed or certified as a dietitian or nutrition professional by the State in which the services are performed. In a State that does not provide for licensure or certification, the individual will be deemed to have met this requirement if he or she is recognized as a "registered dietitian" by the Commission on Dietetic Registration or its successor organization, or meets the requirements of paragraphs (a)(1)(i) and (ii) of this section. (iv) For dietitians hired or contracted with prior to November 28, 2016, meets these requirements no later than 5 years after November 28, 2016 or as required by state law. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DABZ11 Facility ID: CA070000023 If continuation sheet 51 of 69 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 04/05/2019 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 §483.60(a)(2) If a qualified dietitian or other clinically qualified nutrition professional is not employed full-time, the facility must designate a person to serve as the director of food and nutrition services who(i) For designations prior to November 28, 2016, meets the following requirements no later than 5 years after November 28, 2016, or no later than 1 year after November 28, 2016 for designations after November 28, 2016, is: (A) A certified dietary manager; or (B) A certified food service manager; or (C) Has similar national certification for food service management and safety from a national certifying body; or D) Has an associate's or higher degree in food service management or in hospitality, if the course study includes food service or restaurant management, from an accredited institution of higher learning; and (ii) In States that have established standards for food service managers or dietary managers, meets State requirements for food service managers or dietary managers, and (iii) Receives frequently scheduled consultations from a qualified dietitian or other clinically qualified nutrition professional. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to employ staff with the appropriate competencies and skills to carry out the functions of the food and nutrition service when: 1. Dietary staff did not know how to check the dish machine's temperature correctly; 2. Dietary staff did not know how to calibrate the temperature thermometers correctly; both the registered dietitian (RD) and the dietary supervisor (DS) did not know how to calibrate the temperature thermometers correctly; 3. Dietary staff did not know how to check the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DABZ11 Facility ID: CA070000023 If continuation sheet 52 of 69 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 04/05/2019 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 quaternary sanitizer (sanitizer used to clean kitchen counters, tables and surfaces, and used to manually sanitize dishes); 4. Dietary staff did not know how to manually sanitize dishes; 5. RD and DS did not provide training for dietary staff regarding the thermometer calibration and how to check the quaternary sanitizer; 6. A post with wrong instructions regarding manually sanitizing dishes on the wall near the three compartment sinks (3 sinks used to manually sanitize dishes with quaternary sanitizer). The lack of knowledge of the RD and the DS created the potential for dietary staff to be inadequately trained and supervised to carry out their job functions properly; the lack knowledge of dietary staff had potential of unable to carry out their job functions properly and ensure sanitary conditions in the kitchen. Findings: 1. During an observation on 4/4/19 at 9:17 a.m., the dietary aide CC (DA CC) washed dishes in the dish machine. When DA CC demonstrated how to check the dish machine temperature, he checked the thermometer (thermometer was located at a lower level of the dish machine, staff need to squat in order to maintain an eye level to check the temperature reading accurately) with a standing position and said the wash temperature was 150 Fahrenheit (F: temperature measure unit) and the rinse temperature was 140 F. The actual wash temperature was 136 F and the rinse temperature was 150 F. DA CC was unable to check the dish machine temperature correctly. 2a. During an observation on 4/3/19 at 11:20 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DABZ11 Facility ID: CA070000023 If continuation sheet 53 of 69 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 04/05/2019 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.m., cook DD calibrated three thermometers. She mixed with half ice cubes with half water in a glass, then put the thermometers inside the ice water glass, the stem tips of the thermometers touched on the bottom of the glass. Cook DD checked the ice water temperature as 26 F and started to calibrate the thermometers after the thermometer stemps submerged in the ice water for five seconds. 2b. During an observation on 4/3/19 at 11:25 a.m., the assistant of dietary supervisor (ADS) put the thermometer in the middle of crushed ice water, the dimple mark of the thermometer stem did not completely submerge in the ice water. The ADS checked the ice water temperature in 20 seconds after the thermometer submerged in the ice water. 2c. During an interview with the RD and the DS on 4/3/19 at 11:30 a.m., both the RD and the DS were unable to tell how to calibrate the thermometer correctly. The RD stated she would check the policy and procedure for the correct way to calibrate a thermometer. During an interview with the DS on 4/3/19 at 12 p.m., she reviewed the thermometer calibration policy and stated the dietary staff did not calibrate the thermometers correctly and staff should have followed the policy for the correct thermometer calibration. Review of the facility's undated policy, "Thermometer Use and Calibration", indicated " ...Food thermometers are to be used properly and calibrated to ensure accurate temperature reading." The policy indicated how to check the accuracy and calibrating by " ...Fill a large glass with crushed ice and add clean tap water until slush is formed. Stir the mixture well ...Put the thermometer's stem into the ice water so that FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DABZ11 Facility ID: CA070000023 If continuation sheet 54 of 69 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 04/05/2019 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 sensing area is completely submerged (a dimple marks the end of the sensing area). Do not let the stem touch the bottom or sides of the glass. The thermometer stem or probe must maintain in the ice water one minute and during calibration process ..." 3a. During an observation on 4/4/19 at 4:57 p.m., DA EE demonstrated how to check the quaternary sanitizer concentration. She put the whole bottle of test strips (all tips of test strips touched the wet glove) in her left wet glove in order to pick up one test strip; she dipped the test strip into the sanitizer solution for one second and compared the strip with the color chart right away to get the sanitizer concentration level. 3b. During an observation on 4/4/19 at 5 p.m., DA FF demonstrate to check the quaternary sanitizer concentration. DA FF dispensed detergent solution to test. She did not know which line was the dispensed detergent and which line dispensed the sanitizer from the dispense machine on the wall. DS guided DA FF to dispense the sanitizer to test. DA FF dipped the test strip into the sanitizer solution for two seconds and compared the test strip right away with the color chart. DA FF stated she could not read the concentration result because she did not wear her glasses. DA FF stated she did not wear glasses when she worked in the kitchen. 3c. Review of the quaternary manufacturer test strip instruction indicated to use " ...dry finger to remove strip from vial. Remove one strip and dip strip for one second into solution to be tested. Allow 5-10 seconds to develop, then compare to color chart ..." 4a. During an interview with DA EE on 4/4/19 at 4:57 p.m., she was unable to tell how to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DABZ11 Facility ID: CA070000023 If continuation sheet 55 of 69 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 04/05/2019 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 manually sanitize dishes. DA EE was unable to tell how long the dishes needed to be submerged in the quaternary sanitizer for sanitizing. 4b. During an interview with DA FF on 4/4/19 at 5 p.m., she was unable to tell how to manually sanitize dishes. DA FF was unable to tell how long the dishes needed to be submerged in the quaternary sanitizer for sanitizing. Review of the manufacturer quaternary food contact surface sanitizer instruction indicated to immerse the pre-cleaned dishes in sanitizer solution and keep the surfaces wet for one minute. The policy also indicated "...To sanitize pre-cleaned public eating establishment surfaces...apply a 200 ppm active quat solution with a cloth, sponge, low pressure coarse sprays or hand pump style sprayer making sure that the surface remains completely wet for at least 60 seconds and let air-dry." 5. During an interview with the RD and the DS on 4/3/19 at 11:30 a.m., both of them stated they did not provide training for the dietary staff regarding how to calibrate a thermometer. Both the RD and the DS stated they started to work in the facility a few months ago. Review facility's dietary in-service records from 3/14/18 to 4/1/19 indicated the facility did not provide training for dietary staff for thermometer calibration and how to check quaternary sanitizer concentration. 6. During an observation and an interview on 4/4/19 at 4:45 p.m., facility posted a wrong manufacturer sanitizer instruction regarding manually sanitizing dishes on the wall near the three compartment sinks. The DS stated the facility should have posted the current manufacturer sanitizer instruction for the staff FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DABZ11 Facility ID: CA070000023 If continuation sheet 56 of 69 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 04/05/2019 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 to follow the correct way to manually sanitize dishes.

F812 SS=F Food Procurement,Store/Prepare/ServeSanitary CFR(s): 483.60(i)(1)(2)

F812 05/05/2019 §483.60(i) Food safety requirements. The facility must §483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities. (i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations. (ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. (iii) This provision does not preclude residents from consuming foods not procured by the facility. §483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to maintain a sanitary condition when: 1. Dietary staff did not cover their hair completely with a hairnet; 2. Toasters had multi-color substances; 3. The can opener had multi-color substances; 4. The interior of the ice machine door had yellow substance and ice bin (the bin inside the ice machine where the ice is collected) frame had chipped gray plastic substances; FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DABZ11 Facility ID: CA070000023 If continuation sheet 57 of 69 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 04/05/2019 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 5. The mixture machine had multi-color substances; 6. Bananas stored next to clean cups on the clean food prepare table; 7. Dry storage room stored potatoes with sprouting and multi-color substances; 8. Cook staff wore the same pair of gloves to prepare different pureed foods; 9. Dietary staff wore the same pair of mitten to take the heated food trays out of oven and transferred the uncovered food trays to the steam table; 10. Dietary staff used a cloth from a stool to wipe the food prepare table without proper sanitize food prepare table; dietary staff used detergent to sanitize the food prepare table; These failures had the potential to cause forborne illness for residents. Findings: 1a. During an initial kitchen tour with the dietary supervisor (DS) on 4/2/19 at 7:45 a.m., the DS did not cover her hair on the sides and back completely with a hair net. The assistant of dietary supervisor (ADS), dietary aide GG (DA GG), DA EE, DA CC, DA HH, and cook DD were preparing breakfast trays for residents and their hair on the sides and back was not completely covered with a hair net. During an interview with the DS on 4/2/19 at 7:56 a.m., she stated dietary staff should have covered their hair completely with a hair net. 1b. During a kitchen inspection on 4/3/19 at 10:35 a.m., registered dietitian II (RD II), DS, ADS, DA JJ, cook DD, cook KK, DA LL, DA CC, DA GG, DA MM, DA NN, DA OO, DA PP, DA FF, and DA EE did not cover their hair on the sides and back completely with a hair net. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DABZ11 Facility ID: CA070000023 If continuation sheet 58 of 69 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 04/05/2019 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 the facility's undated policy, "Dress Code for Women and Men", indicated dietary staff should wear the disposable hair net to cover the hair. 2. During an initial kitchen tour with the DS on 4/2/19 at 7:59 a.m., two toasters had gray, brown and pink sticky substances at both interior and exterior areas. The DS stated there were total two toasters in the kitchen and the staff should clean the toasters. 3. During an initial kitchen tour with the DS on 4/2/19 at 7:59 a.m., the can opener had brown and orange substances at blade and surrounding areas. The DS stated there was "only" one can opener in the kitchen and the staff should have cleaned the can opener after each use. 4. During an initial kitchen tour with the DS on 4/2/19 at 8:16 a.m., the interior of ice machine door (the side of the ice machine door that is closed to the ice bin) had a yellow substance. Ice bin frame had chipped gray plastic substance. The DS stated staff should have cleaned the ice machine door. DS stated the chipped plastic substances could drop into the ice bin and the facility should fix the ice bin frame. Review of the facility's undated policy, "Ice Machine Cleaning Procedures", indicated to clean ice machine bin and internal area monthly and clean the ice machine door and lid. 5. During an initial kitchen tour with the DS and the ADS on 4/2/19 at 8:16 a.m., a big mixture machine had sticky orange and black substances; the mixture beater area had black, brown and orange substance; the paint on the mixture machine was off. The ADS stated the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DABZ11 Facility ID: CA070000023 If continuation sheet 59 of 69 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 04/05/2019 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 mixture was used to mix for everything including meat, cake and cookie dough. The DS stated there was "only" one mixture machine in the kitchen and staff should have cleaned the mixture machine. Review of the facility's undated policy, "Electrical Food Machines", indicated " ...Keep and maintain all food machines in good operating, sanitary condition. This includes mixers, grinders, slicers, and toasters." The policy indicated the facility staff should clean mixing machine after each use and clean toasters daily. 6. During an initial kitchen tour with the DS on 4/2/19 at 8:29 a.m., 50 to 60 bananas were stored next to the clean cups on the clean food prepare table. The DS stated bananas should not be stored next to the clean cups. 7. During an observation in the dry storage room with the DS on 4/2/19 at 9:10 a.m., 30 red potatoes had sprouting, white furry and brown substance; four brown potatoes had sprouting, white and brown furry substances. The DS stated these potatoes should have been discarded. 8. During a kitchen inspection on 4/3/19 at 10:40 a.m., cook KK wore the same pair of gloves to prepare pureed vegetable and beef, his gloved hands touched blender, blender lid, table surface, food container surface, boxes of supply on the table, measure cup and poured the pureed food into a container. Cook KK did not perform hand hygiene or changed to a new pair of gloves during different pureed food preparations. During an interview with cook KK on 4/3/19 at 11 a.m., he stated he should not have worn the same gloves to prepare all the pureed food and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DABZ11 Facility ID: CA070000023 If continuation sheet 60 of 69 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 04/05/2019 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 he should have performed hand hygiene and wear a new pair of gloves. 9. During a kitchen inspection on 4/3/19 at 11:45 a.m., cook DD and cook KK wore the same pair of mittens to take heated food trays out of the oven, removed the foil covers from food trays, and then transferred the uncovered food trays to the steam table. Both cooks did not perform hand hygiene or changed to new gloves. During an interview with the DS on 4/3/19 at 11:48 a.m., the DS stated the cooks should not wear the same mitten to take food trays out of the oven, or transferred uncover food trays to the steam table and crossed the uncovered food tray for each food transfer to the steam table. The DS stated the staff should have removed the mitten and perform hand hygiene after removing the food tray from the oven. 10a. During an observation on 4/3/19 at 12:05 p.m., DA FF's wore the same pair of gloves to pat on one male DA, picked up an orange cloth on the stool, and continued to wipe the food prepare table with the cloth. During an interview with DA FF on 4/3/18 at 12:10 p.m., she stated she should have changed gloves and perform hand hygiene after she touched the coworker. DA FF stated she should have sanitized the cloth before she wiped the food prepare table. 10b. During an observation on 4/3/19 at 12:30 p.m., DA FF put an orange cloth into a detergent solution and then continued to use the cloth to wipe the food prepare table. The DS stopped DA FF and stated that DA FF should have used the sanitizer solution to sanitize cloth and wipe the food prepare table. The DS stated DA FF was new and needed "a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DABZ11 Facility ID: CA070000023 If continuation sheet 61 of 69 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 04/05/2019 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 lot of" training. Review of the manufacturer quaternary food contact surface sanitizer instruction indicated "...To sanitize pre-cleaned public eating establishment surfaces...apply a 200 ppm active quat solution with a cloth, sponge, low pressure coarse sprays or hand pump style sprayer making sure that the surface remains completely wet for at least 60 seconds and let air-dry." Review of the facility's revised policy, "Handwashing/Hand Hygiene" dated August 2015, indicated " ...This facility considers hand hygiene the primary means to prevent the spread of infections ...All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents ..."

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

F880 05/05/2019 §483.80 Infection Control The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. §483.80(a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: §483.80(a)(1) A system for preventing, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DABZ11 Facility ID: CA070000023 If continuation sheet 62 of 69 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 04/05/2019 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 identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards; §483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to: (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; (iv)When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and (vi)The hand hygiene procedures to be followed by staff involved in direct resident contact. §483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DABZ11 Facility ID: CA070000023 If continuation sheet 63 of 69 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 04/05/2019 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 §483.80(e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. §483.80(f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure to follow proper infection control practices for five of 30 sampled residents (Residents 41, 44, 92, 105, and 423) when: 1. Nursing staff did not perform hand washing or hand hygiene prior to administering eye drops to Resident 423. 2. Nursing staff did not perform hand hygiene before and during medication administration to Resident 92. Nursing staff stored Resident 92's prepared and uncovered medications inside medication cart (med cart) prior to administering. 3. Nursing staff did not perform hand hygiene after checking Resident 44's finger stick blood sugar (FSBS, obtain a drop of blood from the resident's finger tip to check blood sugar level) via glucometer (device to check the resident's FSBS ) and lancet (device with sharp needle to poke the resident's finer tip in order to get a drop of blood sample for FSBS ). Nursing staff did not perform hand hygiene after administering an insulin injection (medication to lower blood sugar) to the resident's abdomen area. 4. Nursing staff did not follow infection practice during medication administration for Resident 105. 5. Clean supply boxes were stored next to soiled linen bins and beside commode near the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DABZ11 Facility ID: CA070000023 If continuation sheet 64 of 69 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 04/05/2019 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 laundry room; 6. Nursing staff did not perform hand hygiene in between gloving during a wound treatment for Resident 41. These deficient practics had the potential to result in cross-contamination and the spread of infections. Findings: 1. During an observation on 4/2/19 at 9:40 a.m., licensed vocational nurse H (LVN H) wore the same pair of gloves to administer six oral medications and one eye drop medication to Resident 423. LVN H did not wash hands or perform hand hygiene prior to administering the eye drops to Resident 423. During an interview with LVN H on 4/2/19 at 10:05 a.m., he stated he should have washed his hands prior to administering the eye drop medication to Resident 423. Review of the facility's revised policy, "Instillation of Eye Drops" dated January 2014, indicated nursing staff should wash hands prior to administering eye drops. 2. During an observation on 4/2/19 at 10:19 a.m., RN G did not wash her hands or perform hand hygiene before preparing medications for Resident 44. RN G stored Resident 92's prepared and uncovered medications inside the med cart and went to look for a supplement at a different nursing station. RN G did not wash her hands or perform hand hygiene before, during and after the medication administration for Resident 92. RN G's did not wash hands or perform hand hygiene after her gloved hands touched Resident 92's legs when RN G assisted to put the resident's legs on the wheelchair's foot rest. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DABZ11 Facility ID: CA070000023 If continuation sheet 65 of 69 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 04/05/2019 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 RN G on 4/2/19 at 10:58 a.m., RN G stated she should have performed hand hygiene before, during and after medication administration for Resident 92. As well as, she should not have stored the prepared and uncovered medications inside the med cart and she should have performed hand hygiene whenever she touched the resident and surfaces. 3. During an observation on 4/2/19 at 11:24 a.m., LVN K checked Resident 44's finger stick blood sugar with a lactometer (device to check the resident's finger stick blood sugar level) and lancet (device with sharp needle to poke the resident's finer tip in order to get a drop of blood sample for blood sugar level check), LVN K did not wash her hands or perform hand hygiene after she checked the resident's finger stick blood sugar and after she administered an insulin injection to Resident 44's abdomen area. LVN K removed her gloves and continued to grab a new lactometer and new gloves from the medication cart. During an interview with LVN K on 4/2/19 at 11:35 a.m., she stated she should have performed hand hygiene after she checked the resident's finger stick blood sugar level and after removed gloves. 4. During an observation on 4/2/19 at 1 p.m., LVN L prepared and administered medications for Resident 105. LVN L did not perform hand hygiene after she picked up a medication cup from the floor and continued to prepare medications for Resident 105. LVN L stored Resident 105's prepared and uncovered medications inside the med cart and went to a medication room to get supplies. During an interview with LVN L on 4/2/19 at FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DABZ11 Facility ID: CA070000023 If continuation sheet 66 of 69 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 04/05/2019 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 1:20 p.m., she stated she should have performed hand hygiene after she picked up the medication cup from the floor. She should have not stored the prepared and uncovered medications inside the medication cart. Review of the facility's revised policy, "Handwashing/Hand Hygiene" dated August 2015, indicated "...All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors." The policy indicated the facility staff should perform hand hygiene "...Before and after direct contact with residents...Before preparing or handling medications...After removing gloves..." 5. During an inspection at laundry room area with infection control nurse (INC) on 4/5/19 at 12:19 p.m., certified nurse assistant QQ (CNA QQ) placed a dirty floor mat next to clean supply boxes (clean boxes of drinking cups, gloves, zip bag, humidifier used for oxygen treatment) near the laundry room. CNA QQ stated she always placed the dirty floor mat in this area. In the hallway near the laundry room, the clean supply boxes of drinking cups, zip bag, humidifier, gloves and zip lock bag were stored next to soiled linen bins, a bed side commode, oxygen poles, and one resident's helmet. During an interview with the INC on 4/5/19 at 12:19 p.m., the INC stated it was okay to store the clean supplies boxes next to the soiled linen bins, a bed side commode as long as the clean supply boxes were sealed with a piece of plastic tape. During an interview with the facility administrator (ADM) on 4/5/19 at 12:55 p.m., he stated there was no specific policy regarding clean supply storage management. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DABZ11 Facility ID: CA070000023 If continuation sheet 67 of 69 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 04/05/2019 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 6. During a wound care treatment observation of Resident 41 with the treatment nurse (TN) on 4/3/19 at 1:23 p.m., the TN applied a moistened gauze dressing on Resident 41's wound. Then, the TN removed her gloves and opened packets of dry gauze dressings. Afterwards, the TN put on a new pair of gloves without performing hand hygiene and then she applied the dry gauze dressing on top of the moistened gauze dressing. During an interview with the TN on 4/3/19 at 1:49 p.m., the TN stated she did not do hand hygiene when she took off the gloves to prep the dry dressing and she should have.

F919 SS=D Resident Call System CFR(s): 483.90(g)(2)

F919 05/05/2019 §483.90(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. §483.90(g)(2) Toilet and bathing facilities. This REQUIREMENT is not met as evidenced by: Base on observation and interview the facility failed to maintain a functioning call light system for four residents (Residents 523, 85, 28, 39). This failure could prevent residents from communicating with staff for basic needs and in emergency situations. Findings: During an observation on 4/2/18 at 9:45 am, Resident 39's call light button was pressed but no call light signal was not turned on. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DABZ11 Facility ID: CA070000023 If continuation sheet 68 of 69 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 04/05/2019 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 the minimum data set coordinator (MDSC) on 4/2/19 at 9:45 a.m., she confirmed Resident 39's call light button was pressed but the call light system was not working. During an observation and concurrent interview with Resident 85's family member on 4/2/19 at 10:57 a.m., Resident 85's call light was pressed but the light signal outside the door was not on. Resident 85's family member stated, Resident 85 used her call light to call for help especially during transfers to the commode because Resident 85 was not allowed to go to the commode without assistance. During an observation and concurrent interview with Resident 523 on 4/2/19 at 11:00 a.m., she stated her call light had not been working since the previous night. Resident 523 had to use her roommates call button last night. Resident 523 further stated, she was not given a working call light button this morning. When Resident 523 pressed her call light button, the light signal outside the room's door did not turn on. During an interview with CNA D on 4/2/19 at 11:05 a.m., she confirmed the call light was not working for Resident 523. She further stated, she did not get a report Resident 523's call light was not working since the previous night. During an observation and interview with the maintenance director (MTNDIR) on 4/2/19 at 11:10 a.m., he tested the call lights of Residents 28 and 85 and confirmed they were not working and needed to be fixed or replaced. He further stated call lights needed to be in good working condition. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DABZ11 Facility ID: CA070000023 If continuation sheet 69 of 69