Other·December 11, 2017

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 an investigation of an entity reported incident conducted from 11/13/17 to 12/7/17. For Entity Reported Incident CA00558628 regarding Quality of Care/Treatment, federal deficiencies were identified (see F225 and

F323).

F 323 483.25(d)(1)(2)(n)(1)-(3) Free of Accident Hazards/Supervision/Devices had a scope and severity of "G". A Class B citation was issued. Inspection was limited to the entity reported incident investigated and does not represent the findings of a full inspection of the facility. Representing the California Department of Public Health: 37883, Health Facilities Evaluator Nurse.

F225 SS=D INVESTIGATE/REPORT ALLEGATIONS/INDIVIDUALS CFR(s): 483.12(a)(3)(4)(c)(1)-(4)

F225 12/21/2017 483.12(a) The facility must(3) Not employ or otherwise engage individuals who(i) Have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law; (ii) Have had a finding entered into the State nurse aide registry concerning abuse, neglect, 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: E7PC11 Facility ID: CA070000031 If continuation sheet 1 of 9 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: _______________ 555838 (X3) DATE SURVEY COMPLETED 12/07/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CAMDEN POSTACUTE CARE, INC. 1331 Camden Ave Campbell, CA 95008 (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 exploitation, mistreatment of residents or misappropriation of their property; or (iii) Have a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property. (4) Report to the State nurse aide registry or licensing authorities any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff. (c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: (1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in longterm care facilities) in accordance with State law through established procedures. (2) Have evidence that all alleged violations are thoroughly investigated. (3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. (4) Report the results of all investigations to the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: E7PC11 Facility ID: CA070000031 If continuation sheet 2 of 9 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: _______________ 555838 (X3) DATE SURVEY COMPLETED 12/07/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CAMDEN POSTACUTE CARE, INC. 1331 Camden Ave Campbell, CA 95008 (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 administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to report unwitnessed injuries to the state survey agency (SSA) in a timely manner for one of three residents (Resident 1). An injury on 10/26/17 resulting in a loss of consciousness requiring emergent medical intervention was reported late. An injury on 5/15/17 resulting in a separated right shoulder was not reported. An injury on 8/30/17 resulting in a bump on the head measuring 3.5 cm x 3 cm was not reported. These failures had the potential to delay identification and implementation of appropriate corrective action. Findings: A review of Resident 1's medical record indicated he was admitted on 2/26/2015 with diagnoses including muscle weakness, history of falling, abnormal posture, altered mental status, abnormalities of gait and mobility, and Parkinson's disease (a progressive disorder that affects movement impairing posture and balance). Resident 1's Minimum Data Set (MDS, an assessment tool) dated 9/3/17, indicated the resident required staff assistance for mobility and that his balance during transitions and walking was "not steady, only able to stabilize with staff assistance". In an interview on 11/17/17 at 1:31 p.m., the director of nurses (DON) stated the administrator called the SSA on 10/27/17 to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: E7PC11 Facility ID: CA070000031 If continuation sheet 3 of 9 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: _______________ 555838 (X3) DATE SURVEY COMPLETED 12/07/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CAMDEN POSTACUTE CARE, INC. 1331 Camden Ave Campbell, CA 95008 (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 report Resident 1's injury that occurred on 10/26/17. When asked if the facility reported Resident 1's injury that occurred on 5/15/17, the DON stated, "I don't think so". When asked if the facility reported Resident 1's injury that occurred on 8/30/17, the DON stated, "No". A review of the facility's faxed report, "UNUSUAL OCCURRENCE" indicated the report detailing Resident 1's injury that occurred on 10/26/17 at 8:45 a.m. was faxed to the SSA on 10/27/17 at 7:11 p.m.. A call was received by the SSA on 10/27/17 at 5:26 p.m. reporting the incident. A review of the facility's policy, "UNUSUAL OCCURRENCE REPORTING" indicated "unusual occurrences shall be reported via telephone to appropriate agencies as required by current law and/or regulations within twentyfour (24) hours of such incident or as otherwise required by federal and state regulations". A review of the facility's policy, "ABUSEREPORTING & INVESTIGATIONS" indicated "the facility will report all allegations of abuse as required by law and regulations to the appropriate agencies. The facility promptly and thoroughly investigates reports of resident abuse... or injuries of an unknown source..."

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

F323 12/20/2017 (d) Accidents. The facility must ensure that (1) The resident environment remains as free from accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: E7PC11 Facility ID: CA070000031 If continuation sheet 4 of 9 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: _______________ 555838 (X3) DATE SURVEY COMPLETED 12/07/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CAMDEN POSTACUTE CARE, INC. 1331 Camden Ave Campbell, CA 95008 (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 (n) - Bed Rails. The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements. (1) Assess the resident for risk of entrapment from bed rails prior to installation. (2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation. (3) Ensure that the bed’s dimensions are appropriate for the resident’s size and weight. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure the fall care plans were updated after fall incidents for one of three sampled residents (Resident 1). This resulted in Resident 1's unwitnessed three falls with injuries occurring on 5/15/17 (separated right shoulder) , 8/30/17 (bump on the head), and 10/26/17 with loss of consciousness. Findings: A review of Resident 1's medical record indicated he was admitted on 2/26/15 with diagnoses including muscle weakness, history of falling, abnormal posture, altered mental status, abnormalities of gait and mobility, and Parkinson's disease (a progressive disorder that affects movement impairing posture and balance). Resident 1's Minimum Data Set (MDS, an assessment tool) dated 9/3/17, indicated the resident required staff assistance for mobility and that his balance during transitions and walking was "not steady, only FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: E7PC11 Facility ID: CA070000031 If continuation sheet 5 of 9 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: _______________ 555838 (X3) DATE SURVEY COMPLETED 12/07/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CAMDEN POSTACUTE CARE, INC. 1331 Camden Ave Campbell, CA 95008 (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 able to stabilize with staff assistance". A review of the medical record, "IDT POSTEVENT NOTE" for 5/15/17 at 8:10 p.m., indicated, "The nurse doing rounds saw the resident on the floor on the prone position. Resident was moaning and groaning. Assisted him back to wheelchair and ask what happened. Resident stated was reaching out for his TV lost balance and fell." A review of the medical record, "THERAPY POST-FALL SCREEN" for 5/15/17 completed by the IDT, indicated the root cause of the fall was determined to be related to "behavioral symptoms" and "non-compliant with safety precautions". A recommendation was made for a "physical therapy eval(uation)". A review of the medical record, "IDT POSTEVENT NOTE" for 8/30/17 at 11:00 a.m., indicated "Resident seen laying on the floor by his bedside incurring a head lump/bump... measuring 3.5 cm (length) x 3 cm (width)... When asked what happened, resident said that he bend over to reach this false teeth that fell on the floor in between his bed and his side table which caused him to fall and hit his frontal side of his head on the wall." A review of the medical record, "THERAPY POST-FALL SCREEN" for 8/30/17, completed by the IDT, indicated the root cause of the fall was determined to be related to "behavioral symptoms" and "poor safety awareness". A recommendation was made for "frequent monitoring" and "chair alarm-pressure". A review of the medical record, "IDT POSTEVENT NOTE" for 10/26/17 at 8:45 a.m., indicated, "CNA (1) went inside the room and found resident's wheelchair which was flipped to the side and found his head up to his FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: E7PC11 Facility ID: CA070000031 If continuation sheet 6 of 9 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: _______________ 555838 (X3) DATE SURVEY COMPLETED 12/07/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CAMDEN POSTACUTE CARE, INC. 1331 Camden Ave Campbell, CA 95008 (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 shoulder was inside the trash bin. Per CNA, she removed the head out of the trash bin by herself and called for help. Staff came and found resident unresponsive, no pulse, no breathing... CPR initiated... called 911." A review of the medical record indicated a "THERAPY POST-FALL SCREEN" had not been completed for 10/26/17. A review of the medical record "COMPREHENSIVE PLAN OF CARE" update dated 5/19/17, indicated "refused bed and tab alarm to alert staff." Update dated 5/21/17 indicated "be sure call light is within resident's reach." Update dated 8/29/17 indicated "adaptive devices as recommended by therapy or MD... Monitor/document to ensure appropriate use of safety/assistive devices." A review of the facility policy, "FALLS-RISK ASSESSMENT, IDENTIFICATION & REDUCTION" dated April 2005, indicated "Resident at risk for falls shall have a care plan that identifies the risk factors for that individual resident and appropriate interventions based on their individual risk factors... The IDT shall update the resident's plan of care accordingly to reduce the risk of further occurrences of a fall or related incident." A review of the facility policy, "COMPREHENSIVE PLAN OF CARE" dated April 2005, indicated "the comprehensive plan of care must include interventions to attempt to manage risk behaviors... re-evaluate and modify care plans as necessary to reflect changes in care, service and treatment." In an interview on 11/13/17 at 3:00 p.m., the director of nurses (DON) stated the care plan should have been updated after the falls. When asked what interventions were implemented for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: E7PC11 Facility ID: CA070000031 If continuation sheet 7 of 9 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: _______________ 555838 (X3) DATE SURVEY COMPLETED 12/07/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CAMDEN POSTACUTE CARE, INC. 1331 Camden Ave Campbell, CA 95008 (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 1 addressing falls related to reaching for objects, the DON stated, "We put an alarm. He really doesn't want anything done... We provided him a reacher." The DON said the interventions were documented in the shortterm care plan. When asked if they should be documented in the long-term care plan, the DON stated, "It should be in the long-term care plan." When asked how Resident 1 is supervised, the DON stated, "We monitor him. We don't have a specific time that we monitor. Not in place that we document every hour. Mostly it's the huddle we do every morning." In an interview on 11/13/17 at 8:46 a.m., certified nursing assistant 1 (CNA 1) stated on 10/26/17 at 8:45 a.m., "I walked near his bed and saw his wheelchair flat on its side. Then I saw his body... I saw his face in the trash can... it was to his shoulder. It had a liner...the plastic bag. I removed the wheelchair and removed the trash can and removed the liner." In an interview on 11/13/17 at 9:30 a.m., licensed vocational nurse 1 (LVN 1) stated, "He is told not to transfer himself but he does it anyway". In an interview on 11/13/17 at 9:41 a.m., registered nurse 1 (RN 1) stated, "We remind him of the call light. We tell him not to transfer alone. He says he can do it." In an interview on 11/13/17 at 10:00 a.m., restorative nurse assistant 1 (RNA 1) stated, "We know he is a fall risk". In an interview on 11/21/17 at 1:10 p.m., RNA 1 was asked if Resident 1 used his call bell. RNA 1 stated, "Most of the time he does not use that one." When asked about the grabber, RNA 1 stated, "I never saw him with the grabber... I did not know about that one." RNA FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: E7PC11 Facility ID: CA070000031 If continuation sheet 8 of 9 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: _______________ 555838 (X3) DATE SURVEY COMPLETED 12/07/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CAMDEN POSTACUTE CARE, INC. 1331 Camden Ave Campbell, CA 95008 (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 identified the "grabber" and the "reacher" as the same object. In an interview on 11/21/17 at 1:20 p.m., CNA 1 stated the grabber was not on the bedside table when she found Resident 1 on the floor on 10/26/17. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: E7PC11 Facility ID: CA070000031 If continuation sheet 9 of 9