Other·March 19, 2019

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 3/7/2019. The facility was licensed for 60 beds. The census at the time of the survey was 56. The sample size was 14. On 3/5/19 at 8:57 a.m., the survey team called an Immediate Jeopardy with the Administrator and Vice President of Operations related to the dishwasher (see F812). On 3/5/19 at 5:10 p.m., the survey team Abated the Immediate Jeopardy with the Administrator and Vice President of Operations related to the dishwasher, after the team received evidence of an acceptable Plan of Correction. For F686, the scope and severity was a "G". A Class "B" citation was also issued. For Entity Reported Incident CA00627942 regarding Accidents, a federal deficiency was identified (see F689) with a scope and severity of "G". A Class "B" citation was also issued. For Entity Reported Incident CA00627018 regarding Misappropriation of Property, the Department did not substantiate a violation of state or federal regulations. Representing the California Department of Public Health: 33651, Health Facilities Evaluator Supervisor; 38573, Health Facilities Evaluator Nurse; 39949, Health Facilities 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: 8BWG11 Facility ID: CA070000031 If continuation sheet 1 of 100 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 03/07/2019 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 Evaluator Nurse; 34383, Health Facilities Evaluator Nurse.

F557 SS=D Respect, Dignity/Right to have Prsnl Property CFR(s): 483.10(e)(2)

F557 04/10/2019 §483.10(e) Respect and Dignity. The resident has a right to be treated with respect and dignity, including: §483.10(e)(2) The right to retain and use personal possessions, including furnishings, and clothing, as space permits, unless to do so would infringe upon the rights or health and safety of other residents. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to provide privacy and dignity for three of 14 sampled residents (Residents 11, 21 and 30) and three non sampled (Residents 15, 32 and 44). These failures had the potential to affect the residents' self-esteem. Findings: 1. During a concurrent observation and interview with the licensed vocational nurse C (LVN C) on 3/3/19 at 11:14 a.m., LVN C was providing wound treatment to Resident 11's nose in the hallway. LVN C stated Resident 11's treatment should have done in his room not in the hallway. During an observation on 3/3/19 at 1:10 p.m., LVN L was providing treatment to Resident 11 in the dining room with one Resident and family member in the dining room present. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8BWG11 Facility ID: CA070000031 If continuation sheet 2 of 100 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 03/07/2019 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 During an interview with the LVN L on 3/3/19 at 1:15 p.m., LVN L confirmed the above observation. LVN L further stated wound treatment should have been done inside Resident's room for privacy. 2. During an observation on 3/3/19 at 9:27 a.m., Resident 44 was lying in bed with no blanket covering his lower body and was exposed to public view in the hallway from neck to his lower body. During a concurrent observation and interview with the LVN C on 3/3/19 at 9:30 a.m., LVN C confirmed the above observation and LVN C further stated the privacy curtain should be pulled all the way to protect resident 44's body parts exposure. During a concurrent observation and interview with the certified nursing assistant K (CNA K) on 3/3/19 at 9:30 a.m., CNA K confirmed the above observation. She further stated the privacy curtain should be pulled during activities of daily living (ADL's, a basic task for dressing, personal hygiene, toilet, and etc.) care to protect Resident 44's dignity and privacy. 3. During a concurrent observation and interview with the CNA M on 3/5/19 at 9:55 a.m., CNA M confirmed that Resident 21 was lying in bed no blanket covering his lower body from waist down and exposed to public view in the hallway. CNA M further stated the privacy curtain should be pulled to protect Resident 21's body parts exposure. 4. During a medication administration observation with registered nurse A (RN A) on 3/3/19 at 9:14 a.m., RN A did not close Resident 15's privacy curtain while RN A checked Resident 15's blood pressure (BP). Resident 15's half upper body exposed to the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8BWG11 Facility ID: CA070000031 If continuation sheet 3 of 100 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 03/07/2019 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 view of other two roommates. During an interview with RN on 3/3/19 at 9:28 a.m., he stated he forgot to pull the curtain for Resident 15 while checking the resident's BP. 5. During a medication administration observation with RN A on 3/3/19 at 12:28 p.m., RN A did not fully close Resident 30's privacy curtain when he administered eye drop medication to Resident 30. Resident 30 was exposed to the other four roommate residents' view. During an interview with RN A on 3/3/19 at 12:39 p.m., RN A stated he should pull the curtain fully to provide privacy for the resident during medication administration. 6. During a medication administration observation with LVN L on 3/3/19 at 12:52 p.m., LVN did not pull the curtain or close the door during medication administration for Resident 32. Resident 32 did not wear pants and his naked lower body parts exposed to public view in the hallway and exposed to the view of his roommate resident and another female resident when the female resident wandered in the room. During an interview with LVN L on 3/3/19 at 1 p.m., she stated during medication administration she should have closed the door and curtain for Resident 32. Review of the facility's policy, "Quality of LifeDignity" dated Jan 2018, indicated "..Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity...Residents shall be treated with dignity and respect at all times...Staff shall promote, maintain and protect resident privacy, including bodily privacy during assistance with personal FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8BWG11 Facility ID: CA070000031 If continuation sheet 4 of 100 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 03/07/2019 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 care and during treatment procedure."

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

F558 04/10/2019 §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: Based on observation, interview, and record review, the facility failed to ensure needs were accommodated for one of 14 sampled residents (6) and two non-sampled residents (13 and 35) when staff failed to ensure that call lights for Residents 6,13 and 35 were within reach. These failures had the potential to negatively affect the residents' physical and psychosocial well-being Findings: 1. Review of Resident 6's clinical record indicated she was admitted on 5/31/18 with diagnoses of dementia (memory disorder) and palliative care (a care for people living with a serious illness). Her Minimum Data Set (MDS, an assessment tool) dated 1/6/18, indicated she was cognitively impaired and required assistance with bed mobility, transfer, ambulation, toileting, and personal hygiene. During an observation with Resident 6 on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8BWG11 Facility ID: CA070000031 If continuation sheet 5 of 100 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 03/07/2019 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 3/3/19 at 8:41 a.m., she was lying on the right side of the bed, the call light was tied below the left side rail and the call light was not within reach. During an observation with Resident 6 on 3/7/19 at 10:57 a.m., Resident was lying on bed, the call light was inside the closed bedside drawer and the call light was not within reach. During a concurrent interview with licensed vocational nurse C (LVN C), she confirmed the call light was inside the closed bedside drawer and the resident would not reach the call light. 2. During a review of the clinical record for Resident 13, the Minimum Data Set (MDS, an assessment tool) dated 12/15/18, indicated Resident 13 was admitted on 6/13/18 with diagnoses of diabetes (increase blood sugar level) and hypertension (high blood pressure). Her MDS also indicated Resident 13 required extensive assistance with bed mobility, transfer, toileting and personal hygiene. During an observation on 3/3/19 at 9:36 a.m., Resident 13 was lying on the bed, the call light was on top of her bedside drawer. Resident 13 further stated that she was unable to reach her call light. During an observation and interview with the director of staff development (DSD) on 3/3/19 at 9:45 a.m., the DSD confirmed Resident 13 was unable to reach the call light on top of her bedside drawer. 3. Review of Resident 35's clinical record indicated he was admitted on 2/12/18 and readmitted on 11/5/18 with diagnoses of Alzheimer's disease (disease that destroys memory and mental functions), cerebral vascular accident (CVA/stroke, a condition resulting from a lack of oxygen in the brain potentially causing a loss of sensory and motor FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8BWG11 Facility ID: CA070000031 If continuation sheet 6 of 100 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 03/07/2019 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 function) and Parkinson's disease (disorder of the nervous systems that affects movement and can cause tremors). His Minimum Data Set (MDS, an assessment tool) dated 1/30/19, indicated he was cognitively impaired and required assistance with bed mobility, transfer, ambulation, toileting, and personal hygiene. During an observation with Resident 35 on 3/3/19 at 2:20 p.m., he was lying on bed in his back, the call light was tied around the call light wall and the call light was not within reach. During a concurrent observation and interview with certified nursing assistant O (CNA O), she confirmed the call light was tied around the call light wall and the resident would not reach the call light.

F565 SS=D Resident/Family Group and Response CFR(s): 483.10(f)(5)(i)-(iv)(6)(7)

F565 04/10/2019 §483.10(f)(5) The resident has a right to organize and participate in resident groups in the facility. (i) The facility must provide a resident or family group, if one exists, with private space; and take reasonable steps, with the approval of the group, to make residents and family members aware of upcoming meetings in a timely manner. (ii) Staff, visitors, or other guests may attend resident group or family group meetings only at the respective group's invitation. (iii) The facility must provide a designated staff person who is approved by the resident or FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8BWG11 Facility ID: CA070000031 If continuation sheet 7 of 100 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 03/07/2019 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 family group and the facility and who is responsible for providing assistance and responding to written requests that result from group meetings. (iv) The facility must consider the views of a resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility. (A) The facility must be able to demonstrate their response and rationale for such response. (B) This should not be construed to mean that the facility must implement as recommended every request of the resident or family group. §483.10(f)(6) The resident has a right to participate in family groups. §483.10(f)(7) The resident has a right to have family member(s) or other resident representative(s) meet in the facility with the families or resident representative(s) of other residents in the facility. This REQUIREMENT is not met as evidenced by: Based on interview and record review the facility failed to provide residents' monthly resident council meeting. This failure had a potential for residents' not able exercise their rights to have a monthly resident council meeting. Findings: During the resident council meeting on 03/04/19 at 2:06 p.m., Residents 52, 43, 38 and 19 voiced their concerns about not having a resident council meeting during the following months: September 2018 October 2018 November 2018 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8BWG11 Facility ID: CA070000031 If continuation sheet 8 of 100 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 03/07/2019 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 December 2018 During an interview and record review with the activity director (AD) on 3/4/19 at 1:48 p.m., the AD confirmed there was no evidence of resident council meeting during the months of September 2018, October 2018, November 2018 and December 2018. The AD also confirmed the resident council should be done on a monthly basis.

F584 SS=E Safe/Clean/Comfortable/Homelike Environment F584 CFR(s): 483.10(i)(1)-(7) 04/10/2019 §483.10(i) Safe Environment. The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. The facility must provide§483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. (i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. (ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft. §483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior; §483.10(i)(3) Clean bed and bath linens that are in good condition; FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8BWG11 Facility ID: CA070000031 If continuation sheet 9 of 100 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 03/07/2019 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 §483.10(i)(4) Private closet space in each resident room, as specified in §483.90 (e)(2) (iv); §483.10(i)(5) Adequate and comfortable lighting levels in all areas; §483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81°F; and §483.10(i)(7) For the maintenance of comfortable sound levels. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to maintain a clean home like orderly environment, placing residents at risk for low self-esteem and living in an unkempt environment when: 1. Shared bathroom for room C and room D had feces on top of the toilet seat 2. Residents room D smelled urine 3. Resident 49's bed smell urine Findings: 1. During an initial tour of the facility on 3/3/19 at 8:31 a.m., observed in a shared bathroom for residents in Room C and D, and smelled of feces on top of the toilet seat approximately 9 centimeters (cm, unit of measurement) long. During a concurrent observation in Room C and D bathroom on 3/3/19 at 8:34 a.m., with the registered nurse A and certified nursing assistant O (CNA O) both confirmed the above observation. During a concurrent observation in Resident 4's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8BWG11 Facility ID: CA070000031 If continuation sheet 10 of 100 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 03/07/2019 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 bathroom and interview with the Resident 4 on 3/3/19 at 8:32 a.m., he confirmed on top of the toilet seat had feces. Resident 4 further stated it happened all the time in his bathroom and he could not have used it. Review of Resident 4's Minimum Data Set (MDS, an assessment tool), dated 11/26/18, indicated he is cognitively intact with his brief interview for mental status (BIMS) was 13 and required assistance with bed mobility, transfer, ambulation, toileting, and personal hygiene. Review of Resident 4's clinical record indicated he was admitted on 11/19/18 and had the diagnoses of muscle weakness (decrease in strength in one or more muscles), difficulty of walking, type 2 diabetes mellitus (affects the way the body processes blood sugar glucose). 2. During a morning tour of the facility on 3/4/19 at 8:09 a.m., Room D smelled of urine. During an interview with the director of staff development (DSD) on 3/4/19 at 8:10 a.m., the DSD confirmed that Room D smelled of urine. The DSD further stated the housekeeper should have cleaned the room. 3. During a medication administration observation with registered nurse A (RN A) at Resident 49's room on 3/3/19 at 11:30 a.m., urine smelled from Resident 49's bed.

F656 SS=D Develop/Implement Comprehensive Care Plan F656 CFR(s): 483.21(b)(1) 04/10/2019 §483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8BWG11 Facility ID: CA070000031 If continuation sheet 11 of 100 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 03/07/2019 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 implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record. (iv)In consultation with the resident and the resident's representative(s)(A) The resident's goals for admission and desired outcomes. (B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8BWG11 Facility ID: CA070000031 If continuation sheet 12 of 100 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 03/07/2019 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 review the facility failed to implement a fall care plan for Resident 37 and developed a patient centered intervention after a fall for Resident 32. These failures had a potential to put resident at risk for injuries after a fall. Findings: During a review of the clinical record for Resident 37, the Order Summary Report dated 3/7/19 at 11:21 a.m., indicated Resident 37 was admitted on 12/29/17 and has diagnoses of schizoaffective disorder, vascular dementia with behavioral disturbance, muscle weakness and unspecified osteoarthritis. During a review of the clinical record for Resident 37, the CPAC-NURSING SBAR Communication Form and Progress Note dated 8/18/18 at 1:16 a.m., indicated Resident 37 had an unwitnessed fall on 8/18/18. According to the clinical records, Resident 37 was found lying on the floor with no injuries. During a review of the clinical record for Resident 37, the CPAC-NURSING SBAR Communication Form and Progress Note dated 12/21/18 at 3:26 p.m., indicated Resident 37 had an unwitnessed fall on 12/21/18. According to the clinical records, Resident 37 was found on the floor next to the bed with no injuries. During a review of the clinical record for Resident 37, the Fall Risk Assessment, dated 8/18/18 and 12/21/18, indicated Resident 37 as a high risk for fall. During an observation on 3/4/19 at 10:06 a.m., Resident 37 has no floor mat next to her bed. During an observation on 3/5/19 at 10:16 a.m., Resident 37 has no floor mat next to her bed. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8BWG11 Facility ID: CA070000031 If continuation sheet 13 of 100 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 03/07/2019 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 During an observation and interview with a licensed vocational nurse B (LVN B) pm 3/5/19 at 8:18 a.m., she confirmed there was no floor mat next to Resident 37's bed and found the floor mat folded away from Resident 37's bed. She confirmed Resident 37 should have a floor mat. During a review of Resident 37 fall care plan dated 12/21/18, indicated the use of a floor mat. During a review of the clinical record for Resident 32, the Order Summary Report dated 3/6/19 at 9:48 a.m., indicated Resident 32 has diagnoses of generalized epilepsy and epileptic syndromes (periods of long vigorous shaking), anoxic brain damage (injury to the brain due to a lack of oxygen) and contractures (is the result of stiffness or constriction in the connective tissues of your body). During a review of the Minimum Data Set (MDS, an assessment tool) dated 10/12/18, Resident 32 was totally dependent with staff performance related to bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture), dressing, eating, toilet use and personal hygiene (how resident maintains personal hygiene, including combing hair, brushing teeth, shaving, washing/drying face and hands). During a review of the clinical record for Resident 32, the SBAR - Actual/Suspected Fall dated 1/9/19, indicated certified nursing assistant J (CNA J) was providing care when Resident 32 fell. According to the clinical records, Resident 32 had redness on the left cheek and bleeding from the mouth most likely relate to the impact and transferred to an acute hospital. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8BWG11 Facility ID: CA070000031 If continuation sheet 14 of 100 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 03/07/2019 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 During an interview and record review with the assistant director of nursing (ADON) on 3/6/19 at 11:43 a.m., Resident 32's fall care plan initiated on 1/9/19 included new interventions to implement fall precautions and medication review regimen by a pharmacist. ADON confirmed that new intervention initiated on 1/9/19 was not appropriate for Resident 32. A review of facility policy, "Comprehensive Care Plan" dated 4/2005, indicated "each resident will have a comprehensive care plan developed that includes goals, measurable objectives, and timetables to meet their medical, nursing, mental, and psychosocial needs identified during the comprehensive assessment."

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

F657 04/10/2019 §483.21(b) Comprehensive Care Plans §483.21(b)(2) A comprehensive care plan must be(i) Developed within 7 days after completion of the comprehensive assessment. (ii) Prepared by an interdisciplinary team, that includes but is not limited to-(A) The attending physician. (B) A registered nurse with responsibility for the resident. (C) A nurse aide with responsibility for the resident. (D) A member of food and nutrition services staff. (E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8BWG11 Facility ID: CA070000031 If continuation sheet 15 of 100 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 03/07/2019 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 (F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident. (iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure a care plan was revised based on preferences and needs of the residents for two of 12 sampled residents (Residents 45 and 10). For Resident 45, the care plan for at risk for elopement (leave the facility without permission) was not revised when the resident left the facility unattended. For Resident 10, the facility failed to revised a fall care plan after physician discontinued an intervention. These failures had the potential for Resident not to receive the necessary care and services to achieve the highest practicable well-being and communicate necessary interventions to the staff. Findings: 1. Review of Resident 45's clinical record indicated she was admitted on 1/26/18 with the following diagnoses dementia (memory disorder), history of falling and abnormalities of gait and mobility. Her Minimum Data Set (MDS, an assessment tool) dated 2/5/19, indicated she was cognitively impaired, and required assistance with bed mobility, transfer, locomotion off the unit (how resident moves from off the unit such as dining, activities or treatment area) and toileting. During an observation on 3/3/19 at 9:30 a.m., Resident 45 wheeled her wheelchair outside FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8BWG11 Facility ID: CA070000031 If continuation sheet 16 of 100 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 03/07/2019 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 the facility with no facility staff. During an observation on 3/4/19 at 8:27 a.m., Resident 45 wheeled herself outside the facility and close to the highway with no facility staff. Review of Resident 45's Medication Administration Record dated 3/4/19, indicated the resident attempt to leave the building unattended or without supervision. Review of Resident 45's care plan for at risk for elopement dated 5/24/19, indicated the resident wandered out the facility. There was no new intervention when Resident 45 left the facility on 3/4/19. During an interview with the director of nursing on 3/7/19 at 10:09 a.m., she confirmed Resident 45 left the facility unattended on 3/4/19 and the care plan for at risk for elopement was not revised. She also stated the care plan for risk for elopement should have been revise for a new intervention if the intervention was not effective. During a review of the clinical record for Resident 10, the Order Summary Report dated 3/5/19 at 11:09 a.m., indicated Resident 10 was admitted on 3/18/17 with diagnoses of major depressive disorder (mental health disorder having episodes of psychological depression), dementia with behavioral disturbance (memory loss), Parkinson's disease (a chronic and progressive movement), mild cognitive impairment and muscle weakness. During an observation on 3/3/19 at 8:42 a.m., Resident 10 has no sensory pad alarm on while sitting on his wheelchair. During an observation on 3/5/19 at 1:13 p.m., Resident 10 has no sensory pad alarm on while FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8BWG11 Facility ID: CA070000031 If continuation sheet 17 of 100 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 03/07/2019 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 sitting on his wheelchair. During a review of the clinical record for Resident 10, the fall care plan initiated on 4/30/18 included an intervention of the use of sensory pad alarm. During an interview and record review with the ADON on 3/6/19 at 11:30 a.m., she confirmed the nurse failed to revised the care plan for falls when physician discontinued the used of sensory pad alarm on 9/11/18. The ADON confirmed care plan needs to be revised to reflect the physician's order. A review of facility policy, "Comprehensive Care Plan" dated 4/2005, indicated "reevaluate and modify care plans: as necessary to reflect changes in care, service, and treatment." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8BWG11 Facility ID: CA070000031 If continuation sheet 18 of 100 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 03/07/2019 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

F677 ADL Care Provided for Dependent Residents CFR(s): 483.24(a)(2)

F677 04/10/2019

F684 04/10/2019 SS=D PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.24(a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene; This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review the facility failed to provide adequate nail care for one of 18 sampled residents (31). This failure placed the resident at risk for infection and self-inflicted skin injury. Findings: During an observation on 3/5/19 at 8:38 a.m., Resident 31 was noted to have long fingernails and black residue under her fingernails. Resident 31 added that during a bed bath, she does not remember getting her finger nails cleaned. During an observation and interview with the director of nursing (DON) on 3/7/19 at 12:43 a.m., she confirmed Resident 31's fingernails were long and "dirty" and needed to be cleaned. A review of the facility's policy, "Giving a bed bath" dated 1/2018, indicated "The purposes of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin."

F684 SS=D Quality of Care CFR(s): 483.25 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8BWG11 Facility ID: CA070000031 If continuation sheet 19 of 100 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 03/07/2019 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 § 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 provide quality of care and services for two of 14 sampled residents (Residents 30 and 40) and three residents (Residents 15, 51 and 203) when: 1. For Resident 30, the facility failed to implement the care plan intervention for resident who smokes cigarette. 2. For Resident 40, a physician order to continue restorative nursing assistant (RNA, interventions that promote the resident's ability to adapt and adjust to living as independently and safely as possible) program was not provided to maintain the current range of motion and prevent contracture. 3. Nursing staff did not assess pain level prior to administering pain medications for Resident 15 and 203; 4. Nursing staff did not verify with the physician for unclear dosage of Spironolactone (medication to treat heart disease) for Resident 203; 5. Nursing staff did not verify with the physician for incorrect indication of Aspirin (medication for pain, fever) for Resident 15; These failures had the potential to affect residents' medical conditions, health and safety. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8BWG11 Facility ID: CA070000031 If continuation sheet 20 of 100 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 03/07/2019 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 Findings: 1. Review of Resident 30's face sheet indicated she was admitted on 7/30/14 with the diagnoses of psychotic disorder (mental disorders that cause abnormal thinking and perceptions), diabetes (increase blood sugar), and schizophrenia (mental disorder). Review of Resident 30's care plan for resident who smokes cigarette dated 5/15/18, indicated the intervention was to monitor clothing, skin for sign and symptoms of cigarette burns and to wear apron for safety. During an observation with Resident 30 on 3/3/19 at 11:07 a.m., she was observed smoking with no apron and holes in her clothes. During an observation and interview with the activity director (AD) on 3/4/19 at 11:08 a.m., she confirmed she got 13 holes in her clothes and she was not wearing apron. During an interview and record review with the assistant director of nursing (ADON) on 3/5/19 at 12:27 p.m., she stated she was unable to find the monitoring for Resident 30's clothing and skin for cigarette burns. She also stated Resident 30 should have wear apron when smoking. 2. Review of Residents 40's face sheet indicated he was admitted on 5/2/18 with the diagnoses of muscle weakness, paraplegia (a paralysis of the legs and lower body) and spinal stenosis (a narrowing of the spaces within your spine and can put pressure on the nerves that travel through the spine). His Minimum Data Set (MDS, an assessment too) dated 8/5/18, indicated he had limitation on both lower FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8BWG11 Facility ID: CA070000031 If continuation sheet 21 of 100 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 03/07/2019 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 extremities, could make decision, and required assistance for bed mobility, transfer, dressing, toileting, personal hygiene, and bathing. Review of Resident 40's physical therapy discharge summary dated 3/1/18, indicated Resident was refererred to RNA program for exercises to maintain the range of motion and prevent further contracture. Review of Resident 40's physicians progress note dated 6/15/18, indicated the assessment and plan to continue restorative nursing assistant program. During an interview with director of staff development (DSD) on 3/7/19 at 12:31 p.m., she stated Resident 40 was discharge for physical therapy on 3/1/18 and Resident 40 was not refererred to RNA program. During an interview with the director of nursing (DON) on 3/7/19 at 12:39 p.m., she stated Resident 40 physician progress note was to continue RNA but Resident 40 was not on RNA. The DON stated Resident 40 should have a RNA program to prevent him for further contracture and maintain his range of motion. 3a. During a medication administration observation with registered nurse A (RN A) on 3/3/19 at 9:14 a.m., RN did not assess Resident 15's pain level and administered Aspirin medication and record Resident 15's pain level as zero on medication administration record (MAR). During an interview with RN A on 3/3/19 at 9:28 a.m., he stated he "forgot" to assess Resident 15's pain level before he administered Aspirin to the resident and recorded Resident 15's pain level as zero based on visual checking and assuming the resident had no pain. RN A stated he should have assessed Resident 15's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8BWG11 Facility ID: CA070000031 If continuation sheet 22 of 100 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 03/07/2019 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 pain level before administering Aspirin. 3b. During a medication administration observation with licensed vocational nurse L (LVN L) on 3/3/19 at 9:38 a.m., LVN L did not assess pain level for Resident 203 prior administering Aspirin medication. LVN L recorded Resident 203's pail level as zero on MAR. During an interview with LVN L on 3/3/19 at 9:45 a.m., she stated she did not need to check Resident 203's pail level because Aspirin was a scheduled medication. LVN L stated she would "only" assess residents' pain level for as need pain medications. During an interview with the DON on 3/6/19 at 11:50 a.m., she stated nursing staff should assess all residents' pain level for both routine and as needed pain medications. Review of the facility's policy, "Pain Assessment and Management" dated Jan 2018, indicated staff should assess residents' pain level. 4. During a medication administration observation with LVN L on 3/3/19 at 9:38 a.m., she administered one tablet of Spironolactone 25 milligrams (mg: measurement unit) to Resident 203. Review of Resident 203's physician's order dated 2/28/19 indicated to administer one tablet of Spironolactone one time a day related to heart failure. The physician's order did not specify the dosage of Spironolactone. During an interview with LVN L on 3/3/19 at 3:22 p.m., she stated she should have clarified with the physician for the unclear dosage of Spironolactone. She stated she "just" FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8BWG11 Facility ID: CA070000031 If continuation sheet 23 of 100 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 03/07/2019 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 administered Spironolactone whatever pharmacy delivered and did not check the physician's order prior to administering the medication for Resident 203. 5. During a medication observation with RN A on 3/3/19 at 9:14 a.m., RN A administered one tablet of Aspirin 81mgs to Resident 15. Review of Resident 15's physician's order dated 3/24/18 indicated to administer Aspirin 81 mgs daily related to hypertension (high blood pressure). During an interview with RN A on 3/3/19 at 9:28 a.m., he stated he should have verified with the physician for the correct indication of Aspirin use. Review of the facility's policy, "Medication Administration-General Guidelines" dated October 2017, indicated nursing staff should clarify with the physician if the medication order was not related to resident's diagnosis or conditions.

F686 Treatment/Svcs to Prevent/Heal Pressure Ulcer F686 03/29/2019 SS=G CFR(s): 483.25(b)(1)(i)(ii) §483.25(b) Skin Integrity §483.25(b)(1) Pressure ulcers. Based on the comprehensive assessment of a resident, the facility must ensure that(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and (ii) A resident with pressure ulcers receives necessary treatment and services, consistent FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8BWG11 Facility ID: CA070000031 If continuation sheet 24 of 100 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 03/07/2019 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 with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to prevent the development of pressure ulcer (skin integrity caused by unrelieved pressure which results in damage to the underlying tissues) for one of three sampled residents (Resident 40) when treatment was not provided for three months on Resident 40's coccyx (tail bone) redness, and a high risk for pressure ulcer care plan was not developed upon admission. These failures resulted in Resident 40's sustaining a unstageable (a full thickness tissue loss in which the base of the ulcer is covered by slough (a yellow color, tan, and gray color in the wound bed) pressure ulcer in the coccyx. Findings: Review of Residents 40's face sheet indicated he was admitted on 5/2/18 with the diagnoses of muscle weakness, paraplegia (a paralysis of the legs and lower body) and spinal stenosis (a narrowing of the spaces within your spine and can put pressure on the nerves that travel through the spine). His Minimum Data Set (MDS, an assessment too) dated 8/5/18, indicated he was high risk for pressure ulcer, could make decision, and required assistance for bed mobility, transfer, dressing, toileting, personal hygiene, and bathing. There was no care plan for high risk pressure ulcer. Review of Resident 40's Nursing Admission Assessment dated 5/2/18, indicated the resident had redness on his coccyx. Review of Resident 40's Treatment FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8BWG11 Facility ID: CA070000031 If continuation sheet 25 of 100 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 03/07/2019 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 Administration Record, there was no indication the redness on his coccyx had treatment for the month of 5/2018, 6/2018, and 7/2018. Review of Resident 40's Wound Assessment dated 8/27/18, indicated the resident acquired a unstageable pressure ulcer on his coccyx with a slough on 8/27/18. Review of Resident 40's Braden Scale (a tool to assess the patients' risk of developing a pressure ulcer) dated 8/27/18, indicated he had a score of 14 (a score of 13-14 represents a moderate risk for pressure ulcer). During a wound observation, interview, and record review with licensed vocational nurse (LVN D) on 3/6/19 at 8:14 a.m., she stated Resident 40 had a redness on his coccyx, had an 80 percent slough with 20 percent granulation. LVN D stated Resident 40's redness on his coccyx was upon admission and she confirmed there was no treatment on 5/2018, 6/2018, and 7/2018. She acknowledged the licensed nurses should have treated the redness on his coccyx to prevent development of a pressure ulcer. LVN D stated she was unable to find the care plan for high risk pressure ulcer to prevent pressure. During an interview and record review with the director of nursing (DON) on 3/7/19 at 9:35 a.m., she confirmed Resident 40's unstageable pressure ulcer on his coccyx was acquired in the facility and he was high risk for pressure ulcer. The DON confirmed there was no treatment on the month of 5/2018, 6/2018, 7/2018 and the licensed nurse should have treated the redness on his coccyx to prevent pressure ulcer. The DON stated the licensed nurse should have develop a care plan for high risk pressure ulcer upon admission to prevent pressure ulcer. The DON acknowledged the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8BWG11 Facility ID: CA070000031 If continuation sheet 26 of 100 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 03/07/2019 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 unstageable pressure ulcer in coccyx could have prevented and avoided if the treatment was initiated upon admission and the high risk for pressure ulcer care plan was develop. Review of the facility's 1/2018, "Pressure Ulcer/Skin Breakdown-Clinical Breakdown", indicated the nursing staff will examine the skin of the new admission for alteration in skin or ulceration. Review of the facility's 1/2018, "Pressure Ulcer/Injury Risk Assessment", indicated to develop resident -centered care plan and interventions based on the risk factors identified in the assessments.

F689 SS=G Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8BWG11 03/29/2019 Facility ID: CA070000031 If continuation sheet 27 of 100 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 03/07/2019 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 §483.25(d) Accidents. The facility must ensure that §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to ensure that the resident environment remains as free of accident hazards as possible for one out of 14 sampled residents (Resident 11). This failure resulted in Resident 11's fall with an injury of acute nasal bone fracture. Findings: Review of Resident 11's clinical record indicated he was admitted on 6/12/15 and had the diagnoses of dementia (decline in mental capacity affecting daily function and impairs reasoning), legal blindness, abnormal posture, abnormalities of gait and mobility and history of falling. Review of Resident 11's fall risk assessment tool, dated 3/3/19 indicated Resident 11 had a fall risk score of 18, 5/30/18 score of 16, 2/27/18 score of 23 and 11/13/17 score of 20 (a score of 10 or above represents high risk for falls and environmental risk factors needed to be consider). Review of Resident 11's Minimum Data Set (MDS, an assessment tool), dated 12/14/18, indicated his brief interview for mental status (BIMS) score was 6, indicated his cognition was severely impaired and he required FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8BWG11 Facility ID: CA070000031 If continuation sheet 28 of 100 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 03/07/2019 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 extensive assistance (staff provide weight bearing support) for moving on and off the unit using the wheelchair. Review of Resident 11's Situation Background Assessment recommendation (SBAR) Communication Form (communication tool), dated 5/30/18, indicated he had a witnessed fall at 8:20 a.m., when staff was pushing resident's wheelchair without footrests on both feet to the smoking area; when it came across a rock that caused Resident 11 to fall out from his wheelchair with his right leg first on the ground and no footrests intervention. Review of Resident 11's nursing progress note dated 3/3/19, indicated "Activity Assistant (AC) was pushing resident 11's wheelchair without footrests to go to the patio to smoke at 11:00 a.m., and Resident 11 lost his balance and tripped off the ground due to the footwear that he was wearing and sustained skin tear at the bridge of his nose and left shin peeled off skin measuring seven centimeters (cm, unit of measurement) by 2 cm." Review of Resident 11's radiology results report, dated 3/4/19, indicated an X-ray result revealed acute nasal bone fracture. During an interview with the AC on 3/3/19 at 11:19 a.m., the AC confirmed on 3/3/19 at 11:00 a.m., he was the one who pushed Resident 11's wheelchair without the footrests on both feet in the patio going to the smoking area when Resident 11's right slipper caught on the uneven floor pavement and Resident 11 fell face down from his wheelchair. The AC further stated that he has no training in pushing resident's wheelchair in the facility and Resident 11 had no footrests for his feet every time he was in his wheelchair. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8BWG11 Facility ID: CA070000031 If continuation sheet 29 of 100 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 03/07/2019 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 During a concurrent interview and rehabilitation notes review dated 3/31/17 and 1/29/19 with the Director of Rehabilitation (DOR/PT, a type of rehabilitation therapy) on 3/5/19 at 1:00 p.m., she confirmed that rehabilitation staff forgot to document that Resident 11 should have footrests for his feet for safety. The DOR further stated rehab definitely recommended footrests when Resident 11 was in his wheelchair and wheeled by the staff members for safety. During a concurrent interview and record review with the Occupational Therapist (OT, a type of rehabilitation therapy) on 3/5/19 at 1:32 p.m., he stated rehab recommended footrests for Resident 11 when he was wheeled by staff members and to wear socks or regular sneakers. The OT further stated footrests would support proper positioning in the wheelchair as Resident 11 had a posture problem. The OT confirmed he did not document on the rehabilitation screening form dated 1/29/19 when he did the screening for Resident 11. During a concurrent observation in Resident 11's closet and interview with the DOR on 3/5/19 at 2:15 p.m., she confirmed that Resident 11's footrests were inside the closet and was recommended by the rehab staff to have them on when Resident 11 was in his wheelchair and wheeled by staff members for safety. The DOR further stated footrests needed to be in Resident 11's wheelchair and not inside the closet. During multiple observations on 3/3/19 at 11:32 a.m., Resident 11 was sitting in his wheelchair in the patio smoking without footrests and wearing brown slippers, on 3/3/19 at 1:20 p.m., was sitting in his wheelchair in the patio smoking without footrests and wearing brown FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8BWG11 Facility ID: CA070000031 If continuation sheet 30 of 100 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 03/07/2019 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 slippers, on 3/5/19 at 8:25 a.m., Resident 11 was sitting in his wheelchair in front of his room without footrests and barefooted and on 3/6/19 at 10:15 a.m., Resident 11 was sitting in his wheelchair in front of his room without footrests and bare footed. This was confirmed by Certified Nursing Assistant K (CNA K) on 3/6/19 at 10:15 a.m. During a concurrent observation of Resident 11's face and interview with the licensed vocational nurse D on 3/7/19 at 11:46 a.m., LVN D was measuring Resident 11's right eye discoloration measuring four centimeters (cm, unit of measurement) by 5.5 cm, left eye 3.5 cm by 6 cm and the nose is 5.5 cm by 2 cm. During a concurrent interview and record review with the director of nursing (DON) on 3/7/19 at 8:41 a.m., she confirmed Resident 11's falls on 5/30/18 and 3/3/19 had the same cause of incidents. The DON stated that there was no care plan and monitoring of refusal of foot rest for Resident 11. The DON further stated the fall on 3/3/19 would have been prevented if there were footrests on the wheelchair. The AC was trained by the rehabilitation staff or nursing for Resident 11's safe wheelchair mobility, right footwear was used not slippers and referral to therapy for his safe wheelchair mobility. Review of the facility's policy, "Falls and Fall Risk Managing" dated 11/17, indicated the staff, with the input of the attending physician, will identify appropriate interventions to reduce or minimize serious consequences of falling. The staff will monitor resident's response to interventions intended to reduce falling or the risk of falling. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8BWG11 Facility ID: CA070000031 If continuation sheet 31 of 100 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 03/07/2019 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

F698 Dialysis CFR(s): 483.25(l)

F698 SS=D PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 04/10/2019 §483.25(l) Dialysis. The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to provide necessary care and services for two of three sampled residents (Residents 34 and 52) when licensed nurses did not monitor and follow the physician order regarding fluid restriction for dialysis (a procedure by a trained professional to remove wastes and excess fluids from the body). This failure had the potential for medical complications and risk for fluid overload. Findings: 1. Review of Resident 34's face sheet indicated she was admitted on 1/22/19 with the following diagnoses of end stage renal disease (a medical condition in which a person's kidneys stop functioning) and hemodialysis (a machine used to clean the blood). Her Minimum Data Set dated 1/29/19 (MDS, an assessment tool), indicated she was could make decision and required assistance for bed mobility, transfer, dressing, toileting and personal hygiene. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8BWG11 Facility ID: CA070000031 If continuation sheet 32 of 100 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 03/07/2019 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 Review of Resident 34's physician order dated 2/14/19, indicated the fluid restriction of 1200 milliliters (ml, unit of measurement) per 24 hours. Review of Resident 34's look back Repot for intake, indicated on 2/20/19-1630 ml, 2/21/191800 ml, 2/23/19-1910 ml, 2/24/19-1560 ml, 2/25/19-1800 ml, 2/26/19-1440-ml, 2/27/191440, 2/28/19-1680, 3/1/19-1930 ml, 3/2/191680, and 3/4/19-1560 ml. During an interview and record review with licensed vocational nurse B (LVN B) on 3/7/19 at 9:27 a.m., she stated Resident 34 had a fluid restriction of 1200 ml and the resident intake was more than 1200 ml per 24 hours as ordered by the physician. She confirmed Resident 34's fluid intake should have been monitored and followed. 2. Review of Resident 52's face sheet indicated he was admitted on 7/10/16 with the following diagnoses of renal (kidney) dialysis and end stage renal disease. His MDS dated 2/13/19, indicated, he could make decision and required assistance for bed mobility, transfer, dressing, toileting and personal hygiene. Review of Resident 52's physician order dated 11/19/18, indicated the fluid restriction of 1000 cubic centimeter (cc, unit of measurement) in 24 hours. Review of Resident 52's look back Repot for intake, indicated on 2/21/19-2001 cc, 2/22/191320 cc, 2/23/19-1730 cc, 2/24/19-1610 cc, 2/26/19-1300 cc, 2/28/19-1860 cc, 3/2/191560, 3/3/19-1700 cc, and 3/5/19-3500 cc. During an interview with LVN B at 9:14 a.m., she confirmed Resident 52's fluid restriction FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8BWG11 Facility ID: CA070000031 If continuation sheet 33 of 100 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 03/07/2019 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 was 1000 cc in 24 hours but the resident was getting more fluid as prescribed by the physician. LVN B stated the licensed nurse should have monitored and followed the fluid restriction of Resident 52. During an interview with the director of nursing on 3/7/19 at 9:32 a.m., she stated the fluid restriction should have been monitored and followed for Residents 34 and 52. Review of facility's 1/2018 policy, "End Stage Renal Disease, Care of Dialysis Resident", indicated the resident would be cared for according to currently recognized standards of care and to minimize complications such as fluid overload.

F726 SS=D Competent Nursing Staff CFR(s): 483.35(a)(3)(4)(c)

F726 04/10/2019 §483.35 Nursing Services The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8BWG11 Facility ID: CA070000031 If continuation sheet 34 of 100 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 03/07/2019 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 facility assessment required at §483.70(e). §483.35(a)(3) The facility must ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. §483.35(a)(4) Providing care includes but is not limited to assessing, evaluating, planning and implementing resident care plans and responding to resident's needs. §483.35(c) Proficiency of nurse aides. The facility must ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure licensed nurses had sufficient knowledge necessary to care for residents' needs for two of 14 sampled residents (Residents 1 and 32) when: 1. The facility failed to provide appropriate laboratory recommendation associated with Coumadin (Blood Thinner) for Resident 1. 2. The facility failed to provide annual skills competency evaluation to one of the staff. These failures could affect the resident's safety and quality of care. Findings: 1. During a review of the clinical record for Resident 1, the Order Summary Report dated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8BWG11 Facility ID: CA070000031 If continuation sheet 35 of 100 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 03/07/2019 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 3/7/19 at 11:20 a.m., indicated the order for Coumadin two mg (milligrams, unit of measurement) give one tablet by mouth at bedtime. During a review of the clinical record for Resident 1, the Lab Results Report dated 1/8/19 at 7:39 a.m., indicated a note to recheck PT (Prothrombin Time, is a test used to help diagnose bleeding or clotting disorders)/INR (International Normalized Ratio, is a calculation based on results of a PT that is used to monitor treatment with the bloodthinning medication Warfarin) in two weeks. During a review of the clinical record for Resident 1, the Progress Notes dated 1/25/19 at 6:40 a.m., indicated "Resident 1 refused to have blood drawn for his PT/INR even if risks and benefits explained to him more than three times." During an interview with the assistant director of nursing (ADON) on 3/7/19 at 9:48 a.m., she confirmed no evidence of PT/INR lab results in Resident 1's clinical records. She also confirmed Resident 1 needs to have PT/INR drawn right away. A review of the facility policy, "Anticoagulation Clinical Protocol", dated 1/2017, indicated "The physician will order appropriate lab testing to monitor anticoagulant therapy and potential complications; for example, periodically checking hemoglobin/hematocrit, platelet, PT/INR and stool for occult blood." 2. During a review of the clinical record for Resident 32, the Order Summary Report dated 3/6/19 at 9:48 a.m., indicated Resident 32 had diagnoses of generalized epilepsy and epileptic syndromes (periods of long vigorous shaking), anoxic brain damage (injury to the brain due to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8BWG11 Facility ID: CA070000031 If continuation sheet 36 of 100 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 03/07/2019 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 a lack of oxygen) and contractures (is the result of stiffness or constriction in the connective tissues of your body). During a review of the Minimum Data Set (MDS, an assessment tool) dated 10/12/18, Resident 32 was totally dependent with staff performance related to bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture), dressing, eating, toilet use and personal hygiene (how resident maintains personal hygiene, including combing hair, brushing teeth, shaving, washing/drying face and hands). During a review of the clinical record for Resident 32, the SBAR - Actual/Suspected Fall dated 1/9/19, indicated certified nursing assistant J (CNA J) was providing care when Resident 32 fell. According to the clinical records, Resident 32 had redness on the left cheek and bleeding from the mouth most likely relate to the impact and transferred to an acute hospital. During a review of the general acute care provider notes for Resident 32, dated 1/9/19, indicated she rolled off the bed (two to three feet high) and landed on tile floor striking face at 11:00 a.m. During an interview with the director of staff development (DSD) on 3/6/19 at 2:05 p.m., she was unable to find evidence of facility skills competency evaluation for CNA J in 2018. The DSD also confirmed skills competency evaluation should be completed yearly. The DSD also stated that CNA J was no longer working in the facility. A review of the facility's policy, "Competency of Nursing Staff" dated 1/2018, indicated "Facility FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8BWG11 Facility ID: CA070000031 If continuation sheet 37 of 100 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 03/07/2019 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 and resident-specific competency evaluations will be conducted upon hire, annually and as deemed necessary based on facility assessment."

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

F755 04/10/2019 §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 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8BWG11 Facility ID: CA070000031 If continuation sheet 38 of 100 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 03/07/2019 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 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: 1. The controlled substance medications (medication with a high potential for abuse and addiction) were accurately accounted for on the medication administration record (MAR) and the controlled drug record (CDR) for five randomly selected residents (4, 8, 26, 32 and 48); 2. The access to the controlled substance medication was secure when the director of nursing (DON) shared her office with other staff and the key for controlled substance medications in DON's office was accessed to other staff; 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: 1a. Review of Resident 4's physician order dated 12/1/18 indicated to administer two tablets of Hydrocodone-Acetaminophen 5-325 milligrams (Norco, controlled medication for pain; mg: measure unit) by mouth every four hours as needed for pain. Review of Resident 4's CDR and MAR from 2/27/19 to 3/3/19 indicated nursing staff removed two tablets of Norco on 2/27/19 at 10:18 p.m. and two tablets on 3/1/19 at 9:18 p.m. However, there was no record on the MAR indicating nursing staff administered those four tablets of Norco for Resident 4. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8BWG11 Facility ID: CA070000031 If continuation sheet 39 of 100 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 03/07/2019 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 During an interview with licensed vocational nurse P (LVN P) on 3/6/19 at 3:27 p.m., she stated she signed Resident 4's CDR on 2/27/19 at 10:18 p.m. and 3/1/19 at 9:18 p.m. indicating LVN P removed total four tablets of Norco on these two days. However she "forgot" to sign out on the MAR. LVN P stated she should have signed on both the CDR and MAR for the controlled medication administration for Resident 4. LVN P stated the controlled medication administration status for Resident 4 should be matched on both the CDR and MAR. 1b. Review of Resident 8's physician's order dated 9/26/18, indicated to administer two tablets of Hydrocodone-Acetaminophen 5-325 mgs by mouth every six hours as needed for mild to moderate pain. Review of Resident 8's CDR and MAR from 11/5/18 to 2/3/19, indicated nursing staff removed one tablet of HydrocodoneAcetaminophen on 11/14/18 at 12 p.m. However, there was no record on the MAR indicating nursing staff administered this tablet for Resident 8. 1c. Review of Resident 32's physician's order dated 7/21/18, indicated to administer one tablet of Norco 5-325 mg every six hours as needed for moderate pain. Review Resident 32's CDR and MAR from 11/22/18 to 2/21/19, indicated nursing staff removed one tablet of Norco on 12/19/18 at 12 p.m. However, there was no record on MAR indicating nursing staff administered this medication for Resident 32. During an interview with LVN B on 3/6/19 at 9:40 a.m., she stated she signed Resident 8's CDR on 11/14/18 at 12 p.m. indicating LVN B removed one tablet of Norco for Resident 8. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8BWG11 Facility ID: CA070000031 If continuation sheet 40 of 100 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 03/07/2019 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 However she did not sign out on the MAR for Norco administration. LVN B stated she signed Resident 32's CDR on 12/19/18 at 12 p.m. indicating LVN B removed one tablet of Norco for Resident 32. However LVN B did not sign out on the MAR for Norco administration. LVN B stated she did not remember what happened. LVN B stated she should have signed on both the CDR and MAR for the controlled medication administration for Resident 8 and Resident 32. 1d. Review of Resident 48's physician order dated 12/31/18 indicated to administer one tablet of Norco 5-325 mg every eight hours as needed for moderate to severe pain. Review of Resident 48's CDR and MAR from 1/10/19 to 3/2/19 indicated nursing staff administered one tablet of Norco on 2/19/19 at 4:31 a.m., however, there was no record on CDR indicating nursing staff removed Norco from medication cart for Resident 48. During a telephone interview with registered nurse Q (RN Q) on 3/6/19 at 9:49 a.m., she stated she signed out on the MAR on 2/19/19 at 4:31 a.m. indicating she administered one tablet Norco to Resident 48. However she did not record on the CDR. RN stated she did not remember what happened. RN stated the controlled medication administration status for Resident 48 should be matched on both the CDR and MAR. 1e. Review of Resident 26's physician's order dated 10/4/18 indicated to administer one tablet Norco 5-325 mgs every six hours as need for mild to moderate pain. Review of Resident 26's CDR and MAR from 2/25/19 to 3/3/19 indicated nursing staff removed one tablet of Norco on 3/3/19 at 6 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8BWG11 Facility ID: CA070000031 If continuation sheet 41 of 100 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 03/07/2019 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 a.m. However, there was no record on MAR indicating nursing staff administered this medication for Resident 26. Review of the facility's policy, "Controlled Medications" dated August 2014, indicated " ...When a controlled medication 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 administration ...Amount administered." 2. During multiple observations from 3/3/19 to 3/6/19, the DON's office stayed open most of time in the day. The DON's office was shared with the administrator, the assistant of DON (ADON), director of staff development (DSD), administrator, receptionist, nurse consultant, clinical manager, and vice president of operations. Discontinued controlled medications stored in DON's office. During an interview with the DON on 3/6/19 at 11:30 a.m., she stated her office had been shared with other staff during the day and her office opened all the time during the day. She said the discontinued controlled medications stored in a locked cabinet in her office. She said the key to the controlled medication cabinet was kept inside an unlocked drawer in her office. The DON stated she should not share her office with other staff. She stated anyone in her office could have accessed to the key to the controlled medications. Review of the facility's policy, "Controlled Medications" dated August 2014, indicated " ...Only authorized licensed nursing and pharmacy personnel have access to controlled medications." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8BWG11 Facility ID: CA070000031 If continuation sheet 42 of 100 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 03/07/2019 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

F756 Drug Regimen Review, Report Irregular, Act On CFR(s): 483.45(c)(1)(2)(4)(5)

F756 SS=D PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 04/10/2019 §483.45(c) Drug Regimen Review. §483.45(c)(1) The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist. §483.45(c)(2) This review must include a review of the resident's medical chart. §483.45(c)(4) The pharmacist must report any irregularities to the attending physician and the facility's medical director and director of nursing, and these reports must be acted upon. (i) Irregularities include, but are not limited to, any drug that meets the criteria set forth in paragraph (d) of this section for an unnecessary drug. (ii) Any irregularities noted by the pharmacist during this review must be documented on a separate, written report that is sent to the attending physician and the facility's medical director and director of nursing and lists, at a minimum, the resident's name, the relevant drug, and the irregularity the pharmacist identified. (iii) The attending physician must document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8BWG11 Facility ID: CA070000031 If continuation sheet 43 of 100 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 03/07/2019 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 §483.45(c)(5) The facility must develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the consultant pharmacist (CP) failed to identify and report to the facility an irregularity related to: 1. Resident 15's medication order for Aspirin (medication for fever, pain) had the incorrect indication; 2. Resident 203's spironolactone (medication for heart disease) order had no dosage; 3. Emergency Kit (E-Kit, medications for emergency use when pharmacy unable to deliver the medication on time) stored multiple expired medications in medication room. 4. Two of two medication carts stored expired medications, insulin (medication to treat diabetes for high blood sugar) and eye drops had no open date or expiration date or no dates; two of two medication carts had multicolor substances. These failures had the potential for undetected medication irregularities and jeopardize residents' medical condition. Finding: 1. Review of Resident 15's physician's order dated 3/24/18 indicate to administer Aspirin 81 milligrams (mg: measurement unit) daily related to hypertension (high blood pressure). On medication administration record (MAR) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8BWG11 Facility ID: CA070000031 If continuation sheet 44 of 100 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 03/07/2019 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 indicated nursing staff monitor Resident 15 for pain when the resident received Aspirin. 2. Review of Resident 203's physician's order dated 2/28/19 indicated to administer one tablet of Spironolactone (medication to treat heart disease) one time a day related to heart failure. The physician's order did not specify the dosage of Spironolactone. 3. During medication room inspection with the nurse consultant (NC) and the director of staff development (DSD) on 3/3/19 at 5:10 p.m., multiple expired medications are stored in one E-Kit (see details at F761). 4a. During medication cart 2 (Med Cart 2) inspection with registered nurse A (RN A) on 3/3/19 at 2:21 p.m., multi-colored substances were observed in Med Cart 2 and multiple insulin expired, had no open or expiration date (see details at F761). 4b. During Med Cart 1 inspection with licensed vocational nurse L (LVN L) on 3/3/19 at 3:23 p.m., multi-colored substance and hair was observed in Med Cart 1 and multiple eye drop medications expired, had not open or expiration date (see details at F761). During a telephone interview with the CP on 3/6/19 at 4:25 p.m., she stated she did a quick audit for Med Carts and medication room check for her monthly visit. She said she had discussed with the nursing department regarding the ongoing issues of med carts for the cleanliness, expired medication and medications without open or expiration date. The CP stated she did the E-Kit audit during her last month visit but did not identify expired medications stored in the E-Kit. She stated she should have identified these expired medications in the E-Kit. The CP stated she did FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8BWG11 Facility ID: CA070000031 If continuation sheet 45 of 100 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 03/07/2019 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 drug regimen review for all residents for her monthly visit. She stated Resident 15's Aspirin indication for hypertension was incorrect and should have been corrected. Resident 203's unclear dosage of spironolactone order should have been identified. Review of the facility's policy, "Consultant Pharmacist Services Provided Requirements" dated October 2017, indicated "The consultant pharmacist provides on all aspects of the provision of pharmacy services in the facility ...Review the medication regimen (medication regimen review) of each resident at least monthly ...Checking the emergency medications supply at least monthly to ascertain that it is properly sealed and stored and that the content are not outdated ...Checking the medication storage areas, and the medication carts, for proper storage and labeling of medications, cleanliness, and removal of expired medications and/or supervising these activities."

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

F757 04/10/2019 §483.45(d) Unnecessary Drugs-General. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8BWG11 Facility ID: CA070000031 If continuation sheet 46 of 100 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 03/07/2019 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 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 §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: 2. Review of Resident 15's physician's order dated 3/24/18, indicated to administer Aspirin 81 milligrams (mg; measurement unit) daily related to hypertension (high blood pressure). During an interview with RN A on 3/3/19 at 9:28 a.m., he stated he should have verified with the physician for the correct indication of Aspirin use. 3. During a medication administration observation with LVN L on 3/3/19 at 9:38 a.m., she administered one tablet of Spironolactone 25 milligrams (medication to treat heart disease; mg: measurement unit) to Resident 203. Review of Resident 203's physician's order FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8BWG11 Facility ID: CA070000031 If continuation sheet 47 of 100 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 03/07/2019 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 dated 2/28/19 indicated to administer one tablet of Spironolactone one time a day related to heart failure. The physician's order did not specify the dosage of Spironolactone. During an interview with LVN L on 3/3/19 at 3:22 p.m., she stated she should have clarified with the physician for the unclear dosage of Spironolactone. During a telephone interview with the CP on 3/6/19 at 4:25 p.m., she stated she did drug regimen review for all residents for her monthly visit. She stated Resident 15's Aspirin indication for hypertension was incorrect and should have been corrected. Resident 203's unclear dosage of spironolactone order should have been identified. Review of the facility's policy, "Consultant Pharmacist Services Provider Requirements" dated October 2017, indicated the consultant pharmacist should review residents' medication regimen at least monthly to make sure "...A resident's drug regimen must be free of unnecessary drugs. An unnecessary drug is any drug when used in:...Without adequate indication for its use." Based on interview and record review, the facility failed to: 1. Ensure the pharmacist's drug regimen review (DRR) recommendations for Resident 32 were acted upon; 2. Ensure Resident 15's medication order of Aspirin (medication for fever, pain) had the correct indication; 3. Ensure Resident 203's spironolactone (medication for heart disease) order had the right dosage. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8BWG11 Facility ID: CA070000031 If continuation sheet 48 of 100 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 03/07/2019 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 These failures have the potential for residents to receive unnecessary medications and to suffer unnecessary adverse side effects that could negatively impact his/her physical, mental, and psychosocial well-being. Findings: 1. During a review of the clinical record for Resident 32, the DRR dated 10/25/18, indicated a duplicated therapy for Baclofen (muscle relaxant), Tizanidine (muscle relaxant) and Dantrolene (muscle relaxant). During a review of the clinical record for Resident 32, the DRR dated 10/25/18, indicated a need to clarify an area to where Triamcinolone Acetonide Cream (TAC) (topical cream used to treat a variety of skin conditions) 0.1% be applied. During an interview and record review with the assistant director of nursing (ADON) on 3/7/19 at 9:40 a.m., the ADON stated Dantrolene was already discontinued on 10/29/18. The ADON also confirmed there was no evidence in Resident 32's chart related to clarification of Baclofen and Tizanidine. The ADON stated she needs to clarify orders with the physician. During an interview and record review with the ADON on 3/7/19 at 9:40 a.m., the ADON confirmed there was no evidence in Resident's 32's clinical record related to areas where to apply Triamcinolone Acetonide Cream.

F758 SS=D Free from Unnec Psychotropic Meds/PRN Use F758 CFR(s): 483.45(c)(3)(e)(1)-(5) 04/10/2019 §483.45(e) Psychotropic Drugs. §483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8BWG11 Facility ID: CA070000031 If continuation sheet 49 of 100 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 03/07/2019 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 include, but are not limited to, drugs in the following categories: (i) Anti-psychotic; (ii) Anti-depressant; (iii) Anti-anxiety; and (iv) Hypnotic Based on a comprehensive assessment of a resident, the facility must ensure that--§483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record; §483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs; §483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and §483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in §483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. §483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8BWG11 Facility ID: CA070000031 If continuation sheet 50 of 100 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 03/07/2019 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 This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure 6 of 14 sampled residents (Residents 26, 32, 37, 20, 6, and 45) were free from unnecessary psychotropic medications (medications capable of affecting the mind, emotions and behavior) when: 1. For Resident 26, the facility did not document specific manifested behaviors of the resident. 2. For Resident 32, the facility did not document specific manifested behaviors of the resident. 3. For Resident 37, the facility did not document specific manifested behaviors of the resident. 4. For Resident 20, the facility did not document specific manifested behaviors of the resident. 5. For Resident 6, the facility had no specific behavior monitoring for Trazodone (a medication for depression). 6. For Resident 45, the facility had no gradual dose reduction (GDR, tapering the dosage) for Ativan (a medication for anxiety). These failures could potentially result in unnecessary medication for the residents. Findings: 1. During a review of the clinical record for Resident 26, the Order Summary Report dated 3/7/19 at 11:21 a.m., indicated an order for Alprazolam (affects chemicals in the brain that may be unbalanced in people with anxiety) tablet 0.25 mg (milligrams, a unit of measurement) give one table by mouth two times a day for anxiety (an emotion FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8BWG11 Facility ID: CA070000031 If continuation sheet 51 of 100 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 03/07/2019 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 characterized by feelings of tension, worried thoughts and physical changes like increased blood pressure) manifested by inability to relax. During a review of the clinical record for Resident 26, the Order Summary Report dated 3/7/19 at 11:21 a.m., indicated an order to monitor episodes of inability to relax. During an interview with the assistant director of nursing (ADON) on 3/5/19 at 1:59 p.m., she confirmed behavior should be patient specific to what Resident 26 was manifesting. A review of the facility policy, "Psychotropic Medication Use" dated 2/2017, indicated "psychotropic medications to treat behaviors will be used appropriately to address specific underlying medical or psychiatric causes of behavioral symptoms." 2. During a review of the clinical record for Resident 32, the Order Summary Report dated 3/6/19 at 9:48 a.m., indicated an order for Diazepam (affects chemicals in the brain that may be unbalanced in people with anxiety) solution 5mg/5ml (milliliters, unit of measurement) give two ml by mouth two times a day related to anxiety disorders manifested by inability to relax. During a review of the clinical record for Resident 32, the Order Summary Report dated 3/6/19 at 9:48 a.m., indicated an order to monitor episodes of inability to relax. During an interview with the assistant director of nursing (ADON) on 3/7/19 at 9:09 a.m., she confirmed behavior should be patient specific to what Resident 32 was manifesting. A review of the facility policy, "Psychotropic FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8BWG11 Facility ID: CA070000031 If continuation sheet 52 of 100 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 03/07/2019 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 Medication Use" dated 2/2017, indicated "psychotropic medications to treat behaviors will be used appropriately to address specific underlying medical or psychiatric causes of behavioral symptoms." 3. During a review of the clinical record for Resident 37, the Order Summary Report dated 3/7/19 at 11:27 a.m., indicated an order for Klonopin table 0.5 mg (Clonazepam, affects chemicals in the brain that may be unbalanced in people with anxiety) give 0.5 mg by mouth two times a day related to schizoaffective disorder bipolar type (chronic mental health condition) manifested by inability to relax. During a review of the clinical record for Resident 37, the Order Summary Report dated 3/7/19 at 11:27 a.m., indicated an order to monitor episodes of inability to relax. During an interview with the assistant director of nursing (ADON) on 3/7/19 at 10:23 a.m., she confirmed behavior should be patient specific to what Resident 32 was manifesting. A review of the facility policy, "Psychotropic Medication Use" dated 2/2017, indicated "psychotropic medications to treat behaviors will be used appropriately to address specific underlying medical or psychiatric causes of behavioral symptoms." 4. During a review of the clinical record for Resident 20, the Order Summary Report dated 3/7/19 at 4:34 p.m., indicated an order for Lorazepam (affects chemicals in the brain that may be unbalanced in people with anxiety) tablet 1 mg give 1 tablet by mouth at bedtime for anxiety manifested by inability to relax. During a review of the clinical record for Resident 20, the Order Summary Report dated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8BWG11 Facility ID: CA070000031 If continuation sheet 53 of 100 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 03/07/2019 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 3/7/19 at 4:34 p.m., indicated an order to monitor episodes of inability to relax. During an interview with the assistant director of nursing (ADON) on 3/7/19 at 4:24 p.m., she confirmed behavior should be patient specific to what Resident 20 was manifesting. A review of the facility's policy, "Psychotropic Medication Use" dated 2/2017, indicated "psychotropic medications to treat behaviors will be used appropriately to address specific underlying medical or psychiatric causes of behavioral symptoms." 5. Review of Resident 6's face sheet indicated she was admitted on 5/31/18 with diagnoses including Alzheimer's disease (progressive brain disorder) and dementia (is the loss of cognitive functioning-thinking, remembering, and reasoning). Her Minimum Data Set (MDS, an assessment tool) dated 12/6/18, indicated she could not make decision and required assistance with the bed mobility, transfer, dressing, eating, personal hygiene, and bathing. Review of Resident 6's physician order dated 8/30/18, indicated to give one tablet by mouth at bedtime for depression manifested by inability to sleep. Review of the Resident 6's physician order dated 8/29/18, indicated to monitor of inability to sleep and record the number of hours of slept every evening and night. During an interview and record review with the ADON on 3/5/19 at 12:05 p.m., she stated Resident 6 had a monitoring for inability for sleep and the numbers of hours of slept are combined. The ADON stated the monitoring for inability to sleep and a monitoring for the hours of sleep should have not combined. She state FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8BWG11 Facility ID: CA070000031 If continuation sheet 54 of 100 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 03/07/2019 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 she was not sure if the numbers was for inability to sleep or the hours of sleep. Review of the facility's 2/2017 policy, "Psychotropic Medication Use", indicated all medications used to treat behavior must have a clinical indication and all residents receiving medications used to treat behaviors should have been monitored for efficacy, risk, benefits, harm and adverse effect. 6. Review of Resident 45's clinical record indicated she was admitted on 1/26/18 with the following diagnoses dementia (memory disorder), history of falling and abnormalities of gait and mobility. Her Minimum Data Set (MDS, an assessment tool) dated 2/5/19, indicated she was cognitively impaired, and required assistance with bed mobility, transfer, locomotion off the unit (how resident moves from off the unit such as dining, activities or treatment area) and toileting. Review of Resident 45's physician order dated 67/18, indicated Ativan (anxiety medication) 0.5 milligrams (mg, unit of measurement) one tablet by mouth twice daily for anxiety manifested by yelling and hitting staff. Review of Resident 45's medication regimen review (MRR) dated 2/15/19, indicated Resident 45 was currently on Ativan 0.5 mg 1 tab by mouth twice daily for anxiety and asking for GDR. During an interview with the assistant director of nursing (ADON) on 3/7/19 at 4:25 p.m., she acknowledged the MRR should have been reviewed and signed by the physician. Review of the facility's 2/2017 policy, "Psychotropic Medication Use", indicated the facility should ensure the ordering physician FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8BWG11 Facility ID: CA070000031 If continuation sheet 55 of 100 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 03/07/2019 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 reviews the medication plan and consider a gradual dose reduction of psychotropic medications for the purpose of finding the lowest effective dose.

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

F759 04/10/2019 §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 14.81% medication error rate when four medication errors during 27 opportunities were observed during the medication passes for three of seven observed residents (Residents 27, 32, and 50). These failures had the potential to jeopardize residents' medical condition and health. Findings: 1. During an observation on 3/3/19 at 12:52 p.m., licensed vocational nurse L (LVN L) prepared Resident 32's medications. LVN L crushed Tizaidine (medication to treat muscle spasms and cramp) tablet, some powder of the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8BWG11 Facility ID: CA070000031 If continuation sheet 56 of 100 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 03/07/2019 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 medication was spilled on the medication cart. LVN L administered Cephalexin (medication to treat infection) and Tizaidine to Resident 32 via gastrostomy tube (G-tube, a tube inserted through the abdomen delivering nutrition and medications directly into the stomach). Both Cephalexin and Tizaidine did not dissolve completely with water, a layer of white powder was on the bottom of each medication cup after LVN L finished medication administration. Review of Resident 32's physician order dated 2/27/19 indicated to give Cephalexin 500 milligrams (mg; measure unit) via G-Tube four times a day for urinary tract infection for seven days. Physician order dated 4/12/18 indicated to give Tizanidine 4 mgs via G-Tube four times a day related to cramps and spasm. During an interview with LVN L on 3/3/19 at 1 p.m., she stated she spilled some Tizaidine on the medication cart and did not dissolve both Cephalexin and Tizaidine completely. LVN L stated there were some powders left of both medications on the bottoms of the cups. LVN L stated she did not give the full dosage of Cephalexin and Tizaidine to Resident 32. 2. During an observation on 3/4/19 at 8:13 a.m., LVN C administered five medications to Resident 50. When LVN C administered Symbicort (Budesonite-Formoterol) 80 MCG (inhaler medication to treat breathing problem; MCG; microgram, measurement unit) two puffs to the resident. LVN C waited two to three seconds between two puffs administration. Review of Resident 50's physician order dated 2/13/19, indicated to give BudesoniteFormoterol 8-4.5MCG, two puffs inhale two times a day for wheezing and short of breath. During an interview with LVN C on 3/4/19 at FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8BWG11 Facility ID: CA070000031 If continuation sheet 57 of 100 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 03/07/2019 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 9:15 a.m., she stated she should have waited for at least one minute between two puffs of Budesonite-Formoterol administration for Resident 50. 3. During an observation on 3/4/19 at 9:09 a.m., LVN C administered two tablets of metformin 500 mg (medication to treat diabetes to control blood sugar) to Resident 27. LVN C administered Metformin with water, no meal or snack provided with the medication. Review of Resident 50's physician order dated 6/2/19 indicated to give two tablets of Metformin 500 mg two times a day, gave the medication with food. Review of Resident 50's Medication Administration Record (MAR) for the month of March 2019, indicated Resident 50's Metformin medication was scheduled at 7:30 a.m. and nurse staff should give Metformin with food. During an interview with restorative nurse assistant N (RNA N) on 3/4/19 at 9:12 a.m., RNA N stated Resident 50 ate breakfast at 7:30 a.m. in the dining room on 3/4/19. During an interview with LVN C on 3/4/19 at 9:15 a.m., she stated she should have followed Resident 50's physician's order to administer Metformin at 7:30 a.m. with food. LVN C stated she was not familiar with Resident 50's medications. Review of "Lexi-comp" online (www.lexi.com), a nationally recognized drug information resource, indicated metformin should be taken with meals. Review of the facility's policy, "Medication Administration-General Guidelines" dated October 2017, indicated "...Medications are FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8BWG11 Facility ID: CA070000031 If continuation sheet 58 of 100 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 03/07/2019 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 administered in accordance with written orders of the attending physician." The policy also indicated "...Personnel authorized to administer medications do so only after they have familiarized themselves with the medication."

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

F761 04/10/2019 §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. §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 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8BWG11 Facility ID: CA070000031 If continuation sheet 59 of 100 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 03/07/2019 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 medications in a safe and sanitary condition when: 1. Medication Cart 2 (Med Cart 2) had multicolored substances and sticky substance, medication pills spilled inside the med cart; med cart stored expired insulin and eye drops, multiple insulin injection (medication for high blood sugar) had no open date or expiration date; pill crusher (device to crush medication into powder form) had multi-color substances; nasal spray medications stored with oral medications, inhaler medication stored with oral medication; 2. Med Cart 1 had multi-colored substances and sticky substance and hair; medication pills spilled inside the med cart; pill crusher and pill cutter (device to cut the medication into small pieces) had multi-color substance; nasal spray medications stored with oral medications; med cart stored expired eye drop medications, multiple eye drops had no open date or expiration date; insulin medication had no open date or expiration date; 3. Medication room (Med Room) had one medication refrigerator; medication refrigerator temperature check on logs were incomplete; 4. Emergency Kit (E-Kit, medications for emergency use when pharmacy unable to deliver the medication on time) in Med Room stored multiple expired medications; These failures had the potential for the residents to receive used, contaminated, and/or deteriorated medications. Findings: 1. During a medication cart inspection with registered nurse A (RN A) on 3/3/19 at 2:21 p.m., observed the following at Med Cart 2: a. White, black, orange, and gray substances noted inside Med Cart; b. One white medication tablet, one blue FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8BWG11 Facility ID: CA070000031 If continuation sheet 60 of 100 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 03/07/2019 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 capsule cap, paper, rubber band, and residents' identification paper noted inside Med Cart; c. Pink and orange sticky substances noted inside Med Cart; yellow and pink substances noted on the medication bottles; d. Black, orange and gray substances noted on a pill crusher. There was only one pill crusher for Med Cart 2; e. Resident 11's opened saline nasal spray (medication spray into nostril to treat allergy) bottle stored next to two opened oral medication bottles; f. Resident 3's inhaler medication stored next to three opened oral medication bottles; g. Resident 27's Admelog solostar 100 unit/ml (insulin injection medication; ml: milliliter, measurement unit) labeled with open date of 1/26/19 and expiration date 2/24; h. Resident 4's Ademelog Solostar 100 unit/ml had no open date or expiration date; i. Resident 44's Humulin R (insulin injection medication) 100 unit/ml labeled with expiration date of 2/27. During an interview with RN A on 3/3/19 at 2:59 p.m., he stated the medication cart and pill crusher should maintain clean and sanitary status. RN A stated resident's nasal spray and inhaler medications should not store with oral medications. RN stated residents' insulin injection medications should be discarded in 28 days after the open date. Unopened insulin injection medication should store in the refrigerator. Review of "Lexi-comp" online (www.lexi.com), a nationally recognized drug information resource, indicated Admelog and Humulin R insulin injection medication could be used for up to 28 days at room temperature once it opened; Unopened insulin injection medications should be stored in a refrigerator FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8BWG11 Facility ID: CA070000031 If continuation sheet 61 of 100 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 03/07/2019 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 and throw away expired medications. 2. During a medication cart inspection with licensed vocational nurse L (LVN L) on 3/3/19 at 3:23 p.m., observed the following at Med Cart 1: a. White, black, orange, gray substance and hair noted inside the med cart; b. One pill crusher had black, orange, and gray substances; one pill cutter had white and black substances. There was only one pill crusher and one pill cutter at Med Cart 1; c. One orange medication pill spilled inside med cart; d. Six opened nasal spray medication bottles stored next to four opened oral medication bottles; e. Resident 20's opened bottle of Timolol (eye drop medication for eye disease) 0.5% eye drop labeled with open date of 1/12/19 and expiration date of 2/23/19; f. Resident 203's opened bottle of Ciprofloxacin (eye drop medication for infection) 0.3% eye drop had no open date or expiration date; g. Resident 13's two opened bottles of Moxifloxacin (eye drop medication for eye infection) 0.5% eye drop had no open date or expiration date; h. Resident 303's opened bottle of Latanoprost 0.005% (eye drop medication for eye disease) eye drop had no open date or expiration date, the eye drop label indicated to discard the medication 42 days after opening; i. An opened bottle of refresh tear lubricant eye drops labeled with 6A and date of 12/18. There was no indication for date of 12/18 (unclear open year), no indication specific resident's name. Room number of 6A could be any resident in case of room change for residents; j. An open bottle of refresh tear lubricant eye drop labeled with 5B, had no date on the opened bottle. There was no indication which resident used the eye drop; FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8BWG11 Facility ID: CA070000031 If continuation sheet 62 of 100 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 03/07/2019 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 k. An opened bottle of refresh tear lubricant eye drop labeled with 7A and date of 12/18 (unclear year). There was no cap to cover the opened eye drop bottle. There was no indication of date of 12/18, no indication specific resident's name. l. Resident 52's opened Basaglar Kwikpen (insulin injection medication) 100 u/ml(unit per milliliter, measurement unit) had no open date or expiration date. "Lexi-comp" online (www.lexi.com), a nationally recognized drug information resource, indicated Basaglar insulin pen could be used for up to 28 days at room temperature storage once it opened. "Lexi-comp" indicated to store intact bottles of latanoprost under refrigeration. Once opened, the container may be stored at room temperature up to 6 weeks. During an interview with LVN L on 3/3/19 at 4:21 p.m., she stated the med cart was "dirty" and should have been cleaned and sanitized. She stated nursing staff should clean the pill crusher and pill cutter; nasal spray medications should not be stored with oral medications; opened eye drops and insulin medications should have labeled with an open date and expiration date; and expired medications should not store in the med cart. Review of the facility's policy, "Storage of Medications" dated April 2008, indicated "...Orally administered medications are kept separate from externally used medications...Medication storage are kept clean." 3. During Med Room inspection with the nurse consultant (NC) and director of staff development (DSD) on 3/3/19 at 5 p.m. There FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8BWG11 Facility ID: CA070000031 If continuation sheet 63 of 100 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 03/07/2019 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 was one medication refrigerator in Med Room. It stored with purified protein derivative (PPD; skin test medication to test if resident affect by tuberculosis infection, lung infection,), pneumonia vaccine (vaccine for lung infection), insulin injection medications, eye drops, liquid medications and oral medications. Medication refrigerator temperature check logs posted on the refrigerator. The logs indicated nursing staff should check and record the refrigerator temperature twice a day on day and evening shift. Review the logs for month of January, February and March 2019, indicated staff did not check and record refrigerator temperatures for the following days: ---on 1/19/19 (both day and evening shift); ---on 2/3/19, 2/10/19, 2/21/19, 2/25/19, 2/27/19 and 2/28/19 (evening shift); ---on 3/1/19 (day shift), 3/2/19 and 3/3/19 (both day and evening shift); During an interview with the NC on 3/3/19 at 5 p.m., she stated nursing staff should check and record medication refrigerator twice a day. Review of the facility's policy, "Storage of Mediations" dated April 2008, indicated medications that required to be stored in refrigeration should be kept in a refrigerator with a thermometer to monitor the temperature. 4. During Med Room inspection with the NC and DSD on 3/3/19 at 5:10 p.m., multiple expired medications stored in one E-Kit, a label posted on the top of E-Kit box indicated medication early expiration on 1/31/19. The expired injection medications were: a. Three vials of cefazolin (1 gram/via, gram: measurement unit; measure to treat infection) expired in 1/2019; b. Two vials of 0.9% sodium chlorine injection FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8BWG11 Facility ID: CA070000031 If continuation sheet 64 of 100 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 03/07/2019 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 (10 ml per via, ml: milliliter; solution uses to replace body fluid and salt lost. It also uses as sterile irrigation solution.) expired on 3/1/2019; c. One vial of vancomycin (1 gram/via, medication to treat infection) expired in 2/2019; d. One via of Digoxin (500 mcg/2 ml, mcg: microgram, measurement unit; medication for heart disease) expired in 1/2019; e. Two vials of Gentamicin (80 mg/2ml, mg: milligram, measurement unit; medication to treat infection) expired 2/2019; f. Two vials of Diphehydramine (50 mg/ml, medication to treat allergy) expired in 1/2019; g. One vial of Heparin (5000 unit/ml, medication to prevent blood clot) expired in 2/2019; h. One vial of Kenalog (40 mg/ml, medication to treat inflammation) expired in 2/2019; i. One vial of Gentamicin (80mg/2ml) expired on 2/1/2019; j. One vial of Naloxone (0.4 mg/ml, medication to treat for opioid overdose) expired in 3/2019. During an interview with the NC on 3/3/19 at 5:15 p.m., she stated the facility should not store the expired medications in the E-Kit. Review of the facility's policy, "Storage of Medications" dated April 2008, indicated the facility should remove the outdated and contaminated medications from storage.

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

F801 Event ID: 8BWG11 04/10/2019 Facility ID: CA070000031 If continuation sheet 65 of 100 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 03/07/2019 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 §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: 8BWG11 Facility ID: CA070000031 If continuation sheet 66 of 100 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 03/07/2019 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 §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 and interview 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. Both registered dietitian (RD) and dietary supervisor (DS) did not identify dishwasher temperature and sanitizer log issues when dishwasher temperature and sanitizer concentration level did not meet manufacturer's requirement since September 2018; FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8BWG11 Facility ID: CA070000031 If continuation sheet 67 of 100 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 03/07/2019 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 2. RD and DS did not provide training for dietary staff regarding proper dishwasher temperature check; 3. RD and DS did not provide training for dietary staff regarding how to manually sanitize dishes and check quaternary sanitizer (sanitizer used to clean kitchen surface and used to manually sanitize dishes.) level; 4. RD and DS were not aware that the facility should follow a standard diet manual (A diet guide in prescribing diets, and aid in planning and preparing regular and therapeutic diet menus) when prepared diets for residents; The lack of knowledge of the RD and DS created the potential for dietary staff to be inadequately trained and supervised to carry out their job functions properly and ensure sanitary conditions in the kitchen. Findings: 1. Review of the facility's "DISH MACHINE TEMPERATURE LOG" from September 2018 to February 2019, indicated the wash temperatures must be at least 120F, use manufacturer guidelines on machine for range of wash and rinse temperatures, and sanitizer chlorine should be 50 to 100 PPM. There were multiple records did not meet the manufacturer requirement level as following: a. September 2018: 77 of 90 records of wash temperatures were less than 120F; nine of 90 rinse temperature were less than 120F, 84 of 90 sanitizer level were out of normal range; b. October 2018: Dietary staff did not check and record dishwasher temperature and sanitizer level for three times; 90 of 90 wash temperature were less than 120F; two of 90 rinse temperature were less than 120F; c. November 2018: 86 of 90 wash temperature were less than 120F; d. December 2018: one of 93 wash FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8BWG11 Facility ID: CA070000031 If continuation sheet 68 of 100 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 03/07/2019 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 temperature was less than 120F; 10 of 93 sanitizer level were out of normal range; e. January 2019: Dietary staff did not check and record dishwasher temperature and sanitizer level for three times. f. February 2019: Eight of 84 wash temperatures were less than 120F; 17 of 84 rinse temperatures were less than 120F; 18 of 84 sanitizer level were out of normal range. During an interview with the DS on 3/4/19 at 3 p.m., she stated the dietary staff checked and recorded the dishwasher temperature three times a day. The DS stated she checked the dishwasher temperature and sanitizer concentration log daily and did not identify any issues. During an interview with the RD on 3/5/19 at 1:46 p.m., she stated did not identify dishwasher issues from the dishwasher temperature and sanitizer concentration logs. The RD stated she "only" audited the logs for completion, not the accuracy of the logs. 2. During an observation and interview on 3/4/19 at 2:30 p.m., dietary aide H (DA H) washed dishes with the dishwasher. He checked the dishwasher wash temperature and stated the temperature was 100 Fahrenheit (F, temperature measure unit). The actual temperature reading from the thermometer on the dish machine was 80 F. DA H stated he could not see the temperature reading on the thermometer clearly and just guessed the reading as 100F. He said he needed to check and make sure dishwasher wash and rinse temperatures to reach to 100F. DA H did not know what to do when dishwasher temperature was 80 F. During an observation and interview on 3/4/19 at 2:39 p.m., DA I washed dishes with the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8BWG11 Facility ID: CA070000031 If continuation sheet 69 of 100 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 03/07/2019 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 dishwasher. She checked the wash and rinse temperatures and stated the temperature was 80 F. DA B stated she needed to check and make sure the dishwasher's wash and rinse temperature to reach to 100 F. DA I did not know what to do when dish machine temperature was 80 F. During an interview with the DS on 3/4/19 at 3 p.m., she reviewed the in-service (training) record and stated RD "only" provided in-service on 1/18/19. The DS stated she "only" provided dietary staff in-service on 9/10/18, 9/20/18 and 2/4/19. She stated both the RD and her inservices were not related to dishwasher temperature and sanitizer level check, quaternary sanitizer level check, or manually sanitize dishes. During an interview with the RD on 3/5/19 at 1:46 p.m., she stated she "only" gave total three in-service on 1/18/19 to dietary staff regarding safety, handwashing and portion control. The RD stated she did not give any other in-services to dietary staff since she was hired by an agency in August 2018. The RD stated she did not check dietary staff if they were able to check dishwasher temperature and sanitizer level correctly. 3a. During an interview with DA H on 3/4/19 at 2:30 p.m., he stated the facility only had two compartments of wash and rinse sinks for manual sanitizing dishes. He stated he used rinse sink as sanitizer sink to sanitize dishes. DA H stated he did not know how to sanitize dishes manually and how long the dishes need to be sanitized. During an interview with DA I on 3/4/19 at 2:39 p.m., she stated the facility only had two compartments for wash and rinse, therefore there was no need to sanitize the dishes when FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8BWG11 Facility ID: CA070000031 If continuation sheet 70 of 100 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 03/07/2019 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 manually sanitize dishes. DA I stated she just washed and rinsed the dishes, and then just dry the dishes. Review the facility's undated policy, "2Compartment Sink Dishwashing Procedure", indicated dishes needed to immerse into the sanitizer for 30 second for sanitizing. 3b. During an observation on 3/4/19 at 10:44 a.m., DA F tested quaternary sanitizer with a test strip. She dipped the test strip into the sanitizer less than one second and took the trip out right away. DA F stated she would wait for two to three minutes and then check the test strip against the color chart for the sanitizer concentration level. During an observation on 3/4/19 at 11:58 a.m., DA H removed one test strip with his wet finger to test quaternary sanitizer. He dipped the test strip into the sanitizer solution for three times for total three seconds, then he compared the test strip with color chart in one second. DA H stated he should follow manufacturer guide to check the sanitizer concentration correctly. Review the quaternary test strip instruction indicated " ...use dry fingers to remove strip from vial. Remove one strip and dip strip for one second into solution to be tested. Allow 5 to 10 seconds to develop, then compare to color chart below." During an interview with DS on 3/4/19 at 12:30 p.m., she stated there was no documents indicated she gave in-service to dietary staff regarding sanitizer concentration check or how to sanitize dishes manually. 4. There was no diet manual in the facility. There were no documents indicated RD reviewed or discussed the diet manual with the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8BWG11 Facility ID: CA070000031 If continuation sheet 71 of 100 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 03/07/2019 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 Interdisciplinary Team (IDT: heads from department discuss and review residents' care). During an interview with the DS on 3/5/19 at 9:52 a.m., she stated the facility did not have any diet manual and she did not know the facility should have a diet manual guide for food preparation. During an interview with the administrator (Admin) on 3/5/19 at 10:30 a.m., the Admin stated the IDT did not specific reviewed or discussed the diet manual with RD. During an interview with the RD on 3/5/19 at 1:46 p.m., she stated she did not know the facility should follow a standard diet manual when preparing diet for residents. The RD stated she "only" followed the agency's instruction. The RD stated she was new graduate and it was her first job to work with the facility. Review of the facility's 2018 policy, "Registered Dietitian: Job Description", indicated RD should "...Routinely inspect the food service area(s) ...Provide in-service training to Nursing and Dietary staff on topics related to Nutrition and Food Service as needed."

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

F812 04/10/2019 §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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8BWG11 Facility ID: CA070000031 If continuation sheet 72 of 100 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 03/07/2019 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 (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: Part One (IJ and IJ abated) Based on observation, interview and record review, the facility failed to ensure the dishwasher machine follow the manufacturer requirement to maintain the proper temperature and sanitizer concentration level; the facility failed to ensure dietary staff know how to check dishwasher machine temperature correctly; the facility failed to ensure dietary staff know what to do when the dishwasher temperature did not meet manufacturer's requirement. These failures placed all residents at risk to acquire food related gastrointestinal (GI; stomach and intestine, digest system) illness outbreak when dishes were not sanitized properly. On 3/5/19 at 8:57 a.m., the survey team called an Immediate Jeopardy (IJ; immediate danger or harm to residents or potential to harm residents if not correct immediately) with the administrator (Admin) and vice president of operations (VPO) related to the dishwasher machine when the dishwasher did not maintain the proper temperature and sanitizer concentration per manufacturer's requirement. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8BWG11 Facility ID: CA070000031 If continuation sheet 73 of 100 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 03/07/2019 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 Dietary staff did not know how to check dishwasher machine temperature correctly and dietary staff did not know what to do when the dishwasher temperature did not meet the manufacturer's requirement. On 3/5/19 at 5:10 p.m., the survey team abated the Immediate Jeopardy with the Admin and VPO related to the dishwasher, after the team received evidence of an acceptable plan of correction (POC). Findings: During an observation on 3/4/19 at 2:29 p.m., there was only one dishwasher in the kitchen. The dietary supervisor (DS) stated the facility used this low temperature dishwasher machine to sanitize all dishes for residents. During an observation and interview on 3/4/19 at 2:30 p.m., dietary aide H (DA H) washed dishes with the dishwasher. He checked the dishwasher wash temperature and stated the temperature was 100 Fahrenheit (F, temperature measure unit). The actual temperature reading from the thermometer on the dish machine was 80 F. DA H stated he could not see the temperature reading on the thermometer clearly and just guessed the reading as 100F. He said he needed to check and make sure the dishwasher wash and rinse temperatures reached to 100F. DA H did not know what to do when the dishwasher temperature was 80 F. During an observation and interview on 3/4/19 at 2:39 p.m., DA I washed dishes with the dishwasher. She checked the wash and rinse temperatures and stated the temperature was 80 F. DA B stated she needed to check and make sure the dishwasher's wash and rinse temperature to reach to 100 F. DA I did not FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8BWG11 Facility ID: CA070000031 If continuation sheet 74 of 100 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 03/07/2019 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 know what to do when dish machine temperature was 80 F. During an observation and interview with the DS on 3/4/19 at 2:51 p.m., she washed the dishes with dishwasher, she stated she could not see the temperature reading from the thermometer on the dishwasher due to her vision problem. The dishwasher's wash and rinse temperature were 80 F. The DS stated the wash and rinse temperature should be 120 F per manufacturer requirement. She stated the maintenance department was responsible to provide the hot water to the dishwasher. The DS stated the dishwasher's temperature could not reach to 120 F during the day time because everyone was using hot water in the facility. The DS stated when the dishwasher temperature did not reach to 120 F, there was no need to call the manufacturer and she just notified the maintenance department to fix the hot water issues. During an interview with the DS on 3/4/19 at 3 p.m., she stated the dietary staff checked and record the dishwasher temperature three times a day. DS stated she checked the dishwasher temperature and sanitizer concentration log daily and did not identify any issues. During an observation and interview with cook E (Cook E) on 3/5/19 at 7:50 a.m., she washed dishes with dishwasher. She checked dishwasher wash and rinse temperature and sanitizer concentration. Cook E stated the dishwasher temperature was 80 F and the sanitizer concentration was 10 parts per million (PPM: concentration measurement unit). Cook E stated when the dishwasher temperature did not reach to 120 F, she just needed to run the dishwasher a few times. Cook E ran the dishwasher two time and the temperatures were 100 F and 110F. Cook E stated the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8BWG11 Facility ID: CA070000031 If continuation sheet 75 of 100 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 03/07/2019 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 dishwasher temperature normally couldn't reach to 120 F in the day time because everyone was using hot water in the facility. Cook E stated the dishwasher temperature had been like this for a while. Cook E stated the dishwasher sanitizer concentration should be between 50 ppm and 100 ppm per manufacturer requirement. During an interview with the dishwasher manufacturer field technician (DMFT) on 3/5/19 at 12:50 p.m., he stated the the dishwasher rinse temperature should be maintained for at least 120F and sanitizer concentration should be 50-100 ppm. The DMFT stated the facility heater booster in the kitchen was not working and unable to provide the hot water to dishwasher. Review the facility's undated policy, "Dish Washing", indicated "...The dishwasher will run the dish machine until the temperature is within the manufacturer's recommendations...If you cannot achieve this temperature, alert the dietary supervisor or cook who will alert the maintenance personnel and stop washing dishes." Due to the facility's failure to: 1. Dishwasher did not maintain the proper temperature and sanitizer concentration per manufacturer's requirement; 2. Dietary staff did not know how to check dishwasher machine temperature correctly. 3. Dietary staff did not know what to do when the dishwasher temperature did not meet manufacturer's requirement. On 3/5/19 at 8:57 a.m., the survey team called an Immediate Jeopardy and informed the Admin and VPO to provide the survey team with immediate measures that would be taken to ensure the safety of the residents to prevent FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8BWG11 Facility ID: CA070000031 If continuation sheet 76 of 100 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 03/07/2019 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 the GI outbreak. On 3/5/19 at 5:10 p.m., the survey team reviewed the evidence of POC provided by the facility. According to the POC: 1. Facility used paper plates and portable utensils for residents until the dishwasher temperature and sanitizer concentration met the manufacturer's requirement. 2. Facility called the dishwasher manufacturer immediately to fix the dishwasher. Manufacturer replaced a new dishwasher heater booster. Dishwasher temperature and sanitizer concentration met the manufacturer requirement. 3. Facility would monitor dishwasher temperature and sanitizer concentration every one hour for 72 hours and notified manufacturer if not met the requirement. 4. Facility checked all residents for any symptoms and signs of vomiting, nausea, diarrhea, and any GI issues. No residents had issues. Facility notified all residents' responsible parties and physicians. The facility would continue to monitor all residents for 72 hours; care plans for residents regarding the risk of GI symptoms were in place; 5. Facility gave in-service to all dietary staff regarding how to check the dishwasher temperature and sanitizer concentration correctly; 6. Facility gave in-service to all dietary staff regarding what to do when the dishwasher temperature did not meet the manufacturer requirement. The survey team accepted the POC and informed the Admin and VPO on 3/5/19 at 5:10 p.m., that the Immediate Jeopardy was abated. Part Two (Other kitchen issues) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8BWG11 Facility ID: CA070000031 If continuation sheet 77 of 100 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 03/07/2019 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 Based on observation, interview, and record review, the facility failed to maintain a sanitary condition when: 1. Dietary staff did not wash hands after she touched the water bottle in the washing sink and proceeded to clean kitchen stove and counter; 2. Dietary staff did not cover their hair completely with a hairnet; 3. The can opener had black and orange substances; 4. The ice machine had black substance on the wall and frame of the ice bin (the bin inside the ice machine where the ice is collected) and black & gray substances at exterior of ice machine; 5. The refrigerators and freezer had black and orange substance; 6. The freezer stored a damaged carton of ice cream; ice cream spilled in freezer; the opened ice cream carton did not cover with food wrap completely; 7. Cook G wore the same pair of gloves to prepare the hot food, touched meal carts, plates, lids, resident diet cards, kitchen stove surfaces and counters during tray line (Food preparation system, used in the facility, in which trays move along an assembly line.) 8. Dietary staff did not know how to check quaternary sanitizer (sanitizer used to clean kitchen surface and counter, used to manually sanitizer dishes) 9. Dietary staff did not know how to manually sanitize dishes; 10. Dietary staff did not know how to calibrate the thermometer; 11. DS and RD did not identify dishwasher temperature and sanitizer log issues when dishwasher temperature and sanitizer concentration level did not meet manufacturer's requirement since September 2018; These failures had the potential to cause FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8BWG11 Facility ID: CA070000031 If continuation sheet 78 of 100 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 03/07/2019 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 foodborne illness for residents. Findings: 1. During an initial kitchen tour observation on 3/3/19 at 8:05 a.m., cook E's (Cook E) gloved hand touched a water bottle in the washing sink. She continued to clean the kitchen stove and counter with the same pair of gloves. Cook E stated she should have removed the gloves and washed her hands after she touched the water bottle in the sink. Review the facility's policy, "Handwashing Hand Hygiene" dated Jan 2018, indicated " ...All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors." 2a. During an observation and interview on 3/3/19 at 8:05 a.m., Cook E's hair on the sides and back were not completely covered with a hairnet. Cook E stated she should covered her hair completely with a hairnet. 2b. During an observation and interview on 3/3/19 at 8:11 a.m., DA F's hair on the sides and back were not covered completely with a hairnet. DA F stated she should cover her hair completely with a hairnet. 2c. During an observation and interview on 3/4/19 at 7:30 a.m., Cook G's hair on the sides and back were not covered completely with a hairnet. Cook G stated she should cover her hair completely with a hairnet. 2d. During an observation and interview on 3/4/19 at 10:50 a.m., the dietary supervisor's (DS) hair on the back was not covered completely with a hairnet. DS stated she should cover her hair completely with a hairnet. She FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8BWG11 Facility ID: CA070000031 If continuation sheet 79 of 100 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 03/07/2019 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 stated it was hard to cover all the hair with a hairnet. 2e. During an observation and interview on 3/4/19 at 11:48 a.m., DA H's hair on the back was not covered completely with a hairnet. DA H stated he should cover his hair completely with a hairnet. 2f. During an observation and interview on 3/4/19 at 2:25 p.m., DA I's hair on the back was not covered completely with a hairnet. DA I stated she should cover her hair completely with a hairnet. Review of the facility's revised policy's "Dress Code" dated 2015, indicated dietary staff should cover the hair completely with a hair net or hat. 3. During an initial kitchen tour with Cook E on 3/3/19 at 8:17 a.m., Cook E stated there was only one can opener in the kitchen. The can opener had noted with black and orange substances at the top, base, blade and blade surrounding areas. Cook E stated the can opener should have been cleaned after each use. Review of the facility's policy, "Can Opener and Base" dated 3/13, indicated " ...Proper sanitation and maintenance of the can opener and base is important to sanitary food preparation ...The can opener must be thoroughly cleaned each work shift and, when necessary, more frequently." 4. During an initial kitchen tour with Cook E on 3/3/19 at 8:17 a.m., Cook E stated there was only one ice machine in the kitchen for the facility. Ice machine had noted with black substance on the ice bin walls and frames; black and gray substances noted on ice FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8BWG11 Facility ID: CA070000031 If continuation sheet 80 of 100 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 03/07/2019 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 machine lid and exterior walls. Cook E stated the staff should clean the ice machine inside and outside. Review of the facility's policy's "Ice Machine Cleaning Procedures" dated 2015, indicated " ...The ice machine (bin and internal components), need to be cleaned monthly ...Clean inside of ice machine with a sanitizing agent per the manufacturer's instructions ...Be sure special attention is paid to cleaning the door molding and the lid of the machine." 5. During an initial kitchen tour with Cook E on 3/3/19 at 8:38 a.m., black substance had noted on gaskets (rubber area inside the refrigerator and freezer to seal the door), walls, bases of the two refrigerators and freezer; orange substances had noted on the racks inside the refrigerators and freezer. During an interview with Cook E on 3/3/19 at 8:45 a.m., she stated there were only two dietary staff work in the kitchen, they did not have time to clean the refrigerators and freezer. 6. During an initial kitchen tour with Cook E on 3/3/19 at 8:38 a.m., one opened carton of ice cream was not fully covered with food wrap, the food wrap dated with open date of 2/28/19. The bottom of the ice cream carton was damaged, the yellow ice cream spilled inside the freezer. During an interview with Cook E on 3/3/19 at 8:45 a.m., she stated the opened carton of ice cream should be fully covered with a food wrap. She stated the ice cream carton was damaged with ice cream leaking in the freezer. Cook E stated the facility still used the ice cream for residents because the DS did not give instruction to discard the ice cream yet. Review of the facility's policy, "Storeroom, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8BWG11 Facility ID: CA070000031 If continuation sheet 81 of 100 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 03/07/2019 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 Refridgerator/Freezer", dated 2015, indicated " ...The general cleanliness and care of the storeroom, supplies, and refrigerator & freezer are important to insure safe wholesome food ... Leaking or severely dented cans and spoiled foods should be disposed of promptly to prevent contamination of other foods ...All will be cleaned weekly." 7. During a tray line observation on 3/4/19 at 12 p.m., Cook G wore the same pair of gloves to prepare all the hot food for residents, her gloved hands touched meal carts, plates, lids, resident diet cards, kitchen stove surfaces and counters. She did not change to a new pair of gloves or wash her hands. During an interview with the DS on 3/4/19 at 12:30 p.m., she stated Cook G should have performed hand hygiene after the gloved hands touched all these surfaces during tray line. 8. During an observation on 3/4/19 at 10:44 a.m., DA F tested quaternary sanitizer with a test strip. She dipped the test strip into the sanitizer less than one second and took the trip out right away. DA F stated she would wait for two to three minutes and then check the test strip against the color chart for the sanitizer concentration level. During an observation on 3/4/19 at 11:58 a.m., DA H removed one test strip with his wet finger to test quaternary sanitizer. He dipped the test strip into the sanitizer solution for three times for total three seconds, then he compared the test strip with color chart in one second. DA H stated he should have followed the manufacturer guide to check the sanitizer concentration correctly. Review the quaternary test strip instruction indicated " ...use dry fingers to remove strip FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8BWG11 Facility ID: CA070000031 If continuation sheet 82 of 100 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 03/07/2019 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 from vial. Remove one strip and dip strip for one second into solution to be tested. Allow 5 to 10 seconds to develop, then compare to color chart below." During an interview with the DS on 3/4/19 at 12:30 p.m., she stated dietary staff should follow the manufacturer guide for the correct quaternary sanitizer concentration check. 9. During an interview with DA H on 3/4/19 at 2:30 p.m., he stated the facility only had two compartments of wash and rinse sinks for manual sanitizing dishes. He stated he used rinse sink as sanitizer sink to sanitize dishes. DA H stated he did not know how to sanitize dishes manually and how long the dishes need to be sanitized. During an interview with DA I on 3/4/19 at 2:39 p.m., she stated the facility only had two compartments for wash and rinse. Therefore there was no need to sanitize the dishes when manually sanitize dishes. DA I stated she washed and rinsed the dishes, and then dried the dishes. Review the facility's undated policy, "2Compartment Sink Dishwashing Procedure", indicated dishes needed to immerse into the sanitizer for 30 second for sanitizing. 10. During an observation on 3/4/19 at 11:56 a.m., DA F did thermometer calibration (process of adjusting the thermometer to an accurate reading). She put the thermometer into an ice water glass. The ice tubes flowing on the top of the water. The tip of the thermometer touched the side of the glass. DA F put the thermometer in the ice water for 15 seconds and then calibrated the thermometer. DA F was unable to answer how long the thermometer need to be submerged into the ice FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8BWG11 Facility ID: CA070000031 If continuation sheet 83 of 100 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 03/07/2019 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 water before calibration. Review of the facility's undated policy, "Thermometer Calibration", indicated " ...Food thermometers are to be calibrated to ensure accurate temperature reading ...Fill a large glass with crushed ice and clean tap water until the glass is full. Stir the mixture well ...Put the thermometer or probe stem into the ice water so that the sensing area is completely submerged. ..Do not let the stem touch the bottom or sides of the glass. Wait 30 seconds. (Note: the thermometer stem or probe must remain in the ice mater the full 30 seconds and during calibration.) 11. Review of the facility's "DISH MACHINE TEMPERATURE LOG" from September 2018 to February 2019 indicated the wash temperatures must be at least 120F, use manufacturer guidelines on machine for range of wash and rinse temperatures, and sanitizer chlorine should be 50 to 100 PPM. There were multiple records did not meet the manufacturer requirement level as following: a. September 2018: 77 of 90 records of wash temperatures were less than 120F; nine of 90 rinse temperature were less than 120F, 84 of 90 sanitizer level were out of normal range; b. October 2018: Dietary staff did not check and record dishwasher temperature and sanitizer level for three times; 90 of 90 wash temperature were less than 120F; two of 90 rinse temperature were less than 120F; c. November 2018: 86 of 90 wash temperature were less than 120F; d. December 2018: one of 93 wash temperature was less than 120F; 10 of 93 sanitizer level were out of normal range; e. January 2019: Dietary staff did not check and record dishwasher temperature and sanitizer level for three times. f. February 2019: Eight of 84 wash FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8BWG11 Facility ID: CA070000031 If continuation sheet 84 of 100 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 03/07/2019 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 temperatures were less than 120F; 17 of 84 rinse temperatures were less than 120F; 18 of 84 sanitizer level were out of normal range. During an interview with the DS on 3/4/19 at 3 p.m., she stated the dietary staff checked and recorded the dishwasher temperature three times a day. The DS stated she checked the dishwasher temperature and sanitizer concentration log daily and did not identify any issues. During an interview with the registered dietitian (RD) on 3/5/19 at 1:46 p.m., she stated did not identify dishwasher issues from dishwasher temperature and sanitizer concentration logs.

F849 SS=D Hospice Services CFR(s): 483.70(o)(1)-(4)

F849 04/10/2019 §483.70(o) Hospice services. §483.70(o)(1) A long-term care (LTC) facility may do either of the following: (i) Arrange for the provision of hospice services through an agreement with one or more Medicare-certified hospices. (ii) Not arrange for the provision of hospice services at the facility through an agreement with a Medicare-certified hospice and assist the resident in transferring to a facility that will arrange for the provision of hospice services when a resident requests a transfer. §483.70(o)(2) If hospice care is furnished in an LTC facility through an agreement as specified in paragraph (o)(1)(i) of this section with a hospice, the LTC facility must meet the following requirements: (i) Ensure that the hospice services meet professional standards and principles that FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8BWG11 Facility ID: CA070000031 If continuation sheet 85 of 100 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 03/07/2019 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 apply to individuals providing services in the facility, and to the timeliness of the services. (ii) Have a written agreement with the hospice that is signed by an authorized representative of the hospice and an authorized representative of the LTC facility before hospice care is furnished to any resident. The written agreement must set out at least the following: (A) The services the hospice will provide. (B) The hospice's responsibilities for determining the appropriate hospice plan of care as specified in §418.112 (d) of this chapter. (C) The services the LTC facility will continue to provide based on each resident's plan of care. (D) A communication process, including how the communication will be documented between the LTC facility and the hospice provider, to ensure that the needs of the resident are addressed and met 24 hours per day. (E) A provision that the LTC facility immediately notifies the hospice about the following: (1) A significant change in the resident's physical, mental, social, or emotional status. (2) Clinical complications that suggest a need to alter the plan of care. (3) A need to transfer the resident from the facility for any condition. (4) The resident's death. (F) A provision stating that the hospice assumes responsibility for determining the appropriate course of hospice care, including the determination to change the level of services provided. (G) An agreement that it is the LTC facility's responsibility to furnish 24-hour room and board care, meet the resident's personal care and nursing needs in coordination with the hospice representative, and ensure that the level of care provided is appropriately based on the individual resident's needs. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8BWG11 Facility ID: CA070000031 If continuation sheet 86 of 100 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 03/07/2019 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 (H) A delineation of the hospice's responsibilities, including but not limited to, providing medical direction and management of the patient; nursing; counseling (including spiritual, dietary, and bereavement); social work; providing medical supplies, durable medical equipment, and drugs necessary for the palliation of pain and symptoms associated with the terminal illness and related conditions; and all other hospice services that are necessary for the care of the resident's terminal illness and related conditions. (I) A provision that when the LTC facility personnel are responsible for the administration of prescribed therapies, including those therapies determined appropriate by the hospice and delineated in the hospice plan of care, the LTC facility personnel may administer the therapies where permitted by State law and as specified by the LTC facility. (J) A provision stating that the LTC facility must report all alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property by hospice personnel, to the hospice administrator immediately when the LTC facility becomes aware of the alleged violation. (K) A delineation of the responsibilities of the hospice and the LTC facility to provide bereavement services to LTC facility staff. §483.70(o)(3) Each LTC facility arranging for the provision of hospice care under a written agreement must designate a member of the facility's interdisciplinary team who is responsible for working with hospice representatives to coordinate care to the resident provided by the LTC facility staff and hospice staff. The interdisciplinary team member must have a clinical background, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8BWG11 Facility ID: CA070000031 If continuation sheet 87 of 100 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 03/07/2019 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 function within their State scope of practice act, and have the ability to assess the resident or have access to someone that has the skills and capabilities to assess the resident. The designated interdisciplinary team member is responsible for the following: (i) Collaborating with hospice representatives and coordinating LTC facility staff participation in the hospice care planning process for those residents receiving these services. (ii) Communicating with hospice representatives and other healthcare providers participating in the provision of care for the terminal illness, related conditions, and other conditions, to ensure quality of care for the patient and family. (iii) Ensuring that the LTC facility communicates with the hospice medical director, the patient's attending physician, and other practitioners participating in the provision of care to the patient as needed to coordinate the hospice care with the medical care provided by other physicians. (iv) Obtaining the following information from the hospice: (A) The most recent hospice plan of care specific to each patient. (B) Hospice election form. (C) Physician certification and recertification of the terminal illness specific to each patient. (D) Names and contact information for hospice personnel involved in hospice care of each patient. (E) Instructions on how to access the hospice's 24-hour on-call system. (F) Hospice medication information specific to each patient. (G) Hospice physician and attending physician (if any) orders specific to each patient. (v) Ensuring that the LTC facility staff provides orientation in the policies and procedures of the facility, including patient rights, appropriate forms, and record keeping requirements, to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8BWG11 Facility ID: CA070000031 If continuation sheet 88 of 100 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 03/07/2019 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 hospice staff furnishing care to LTC residents. §483.70(o)(4) Each LTC facility providing hospice care under a written agreement must ensure that each resident's written plan of care includes both the most recent hospice plan of care and a description of the services furnished by the LTC facility to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, as required at §483.24. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure a communication process occurred between the facility and the hospice (a specialized type of care for those facing a life-limiting illness) provider for one of 12 sampled residents (Resident 6). Resident 6 had no hospice scheduled visits in regards with the activities of daily living (ADL's, such as bathing, toileting, personal hygiene, and shower) and the care plan for the hospice provider was not develop. These failures had the potential not to meet the needs of the hospice resident. Findings: Review of Resident 6's face sheet indicated she was admitted on 5/31/18 with diagnoses including Alzheimer's disease (progressive brain disorder) and dementia (is the loss of cognitive functioning-thinking, remembering, and reasoning). Her Minimum Data Set (MDS, an assessment tool) dated 12/6/18, indicated she could not make decision and required assistance with the bed mobility, transfer, dressing, eating, personal hygiene, and bathing. Review of Resident 6's physician order dated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8BWG11 Facility ID: CA070000031 If continuation sheet 89 of 100 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 03/07/2019 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 10/3/18, indicated the resident was under the care of hospice provider. During an interview with licensed vocational nurse C (LVN C) on 3/5/19 at 9:55 a.m., she stated she was the assigned charge nurse for Resident 6 but she was not sure about the hospice provider scheduled visits regarding ADL's for Resident 6. LVN C stated she was unable to find the schedule visit of the hospice provider in the clinical record. LVN C also stated the hospice provider had no care plan for Resident 6. During an interview with the director of nursing (DON) on 3/5/19 at 10:03 a.m., she stated the hospice provider should have communicated to the facility regarding the schedule visits and there was no care plan develop for hospice resident. Review of the facility's 4/17/18 hospice provider contract, "Coordinating, Supervising, and Evaluating The Care and Services Provided", indicated the hospice services would be coordinated and supervised by the hospice provider specifically by the registered nurse, and provision of services. The plan of care was developed once the initial visit has been made and in collaboration with the members.

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

F880 04/10/2019 §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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8BWG11 Facility ID: CA070000031 If continuation sheet 90 of 100 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 03/07/2019 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 §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, 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 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8BWG11 Facility ID: CA070000031 If continuation sheet 91 of 100 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 03/07/2019 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 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. §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 proper infection control practices was followed for one of 14 sampled resident (Resident 30) and five residents (15, 32, 36, 50 and 203) when: 1. Resident 36's unlabeled oxygen nasal cannula (a device used to deliver supplemental oxygen or airflow) and tubing was exposed and touching the oxygen concentrator. 2. Resident 36's unlabeled oxygen nasal cannula and tubing was exposed , hanging and touching from the portable oxygen tank and on the floor 3. Nursing staff did not perform hand hygiene (wash hand or use hand sanitizer to sanitize hands) for Resident 15 during medication administration; 4. Nursing staff did not follow infection control practice during medication administration for Resident 203; 5. Nursing staff did not wash hand or perform hand hygiene prior to administer eye drops to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8BWG11 Facility ID: CA070000031 If continuation sheet 92 of 100 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 03/07/2019 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 30; 6. Nursing staff did not perform hand hygiene prior to administering medications to Resident 32; 7. Nursing staff did not follow infection control practice during medication administration for Resident 28; 8. Nursing staff did not follow infection control practice during checking Resident 32's gastrostomy tube (G-tube, a tube inserted through the abdomen delivering nutrition and medications directly into the stomach); 9. Nursing staff did not follow infection control practice during medication administration for Resident 50; These deficient practiced had the potential to result in cross-contamination and the spread of infection. Findings: 1. During an initial tour observation on 3/3/19 at 8:21 a.m., Resident 36's unlabeled oxygen nasal cannula and tubing was exposed and was touching the oxygen concentrator. 2. During an initial tour observation on 3/3/19 at 8:23 a.m., Resident 36's unlabeled oxygen nasal cannula and tubing was exposed, hanging and touching from the portable oxygen tank and on the floor. During a concurrent observation and interview with the RN A on 3/3/19 at 8:25 a.m., RNA A confirmed the about observation and he further stated nasal cannula tubing should have a date and inside the plastic bag for infection prevention. Review of the facility's policy, "Scope of Infection Control Program", dated 8/16, indicated the infection control program is a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8BWG11 Facility ID: CA070000031 If continuation sheet 93 of 100 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 03/07/2019 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 comprehensive compilation of policies and procedures for implementation at the facility. The scope of the program includes prevention, detection, management and control of spread of infection. 3. During a medication administration observation with registered nurse A (RN A) on 3/3/19 at 9:14 a.m., after RN A prepared medications and did not perform hand hygiene prior to administering medicatons to Resident 15. During an interview with RN A on 3/3/19 at 9:28 a.m., he stated he "forgot" to do hand hygiene prior to administering medications to Resident 15. 4. During a medication administration observation with licensed vocational nurse L (LVN L) on 3/3/19 at 9:38 a.m., observed following when LVN L prepared medications for Resident 203: a. LVN L did not perform hand hygiene before prepared medications for Resident 203; b. LVN L used her left bare hand to pick up two medications into a medication cup; c. LVN L rubbed her eyes with her right hand; d. LVN L did not perform hand hygiene prior to checking Resident 203's blood pressure (BP); e. LVN L did not perform hand hygiene after checking Resident 203's BP; f. LVN L did not perform hand hygiene prior to administering medications to Resident 203; g. LVN L put portable BP machine with BP cuff on Resident 203's bed sheet and did not clean or disinfect BP machine and cuff after use. Uncleaned BP machine and cuff placed next to water pitcher and apple sauce bowl on the medication cart; During an interview with LVN L on 3/3/19 at 9:45 a.m., she stated she should wash her hands before prepare medication and before FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8BWG11 Facility ID: CA070000031 If continuation sheet 94 of 100 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 03/07/2019 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 administering medications. LVN L stated she should wash her hands after she touched her eyes and Resident 203. She stated she should not place BP machine and cuff on the resident's bed sheet and on medication cart. LVN L stated she should disinfect the BP machine after resident use. 5. During a medication administration observation with RN A on 3/3/19 at 12:50 p.m., RN A administered lubricant eye drop medication to Resident 30. RN A did not wash his hand or perform hand hygiene after he touched table and his gloved hands touched curtain, RN A proceed to administer eye drops to Resident 30 without washing his hands. During an interview with RN A on 3/3/19 at 12:51 p.m., he stated he should have washed his hands before he administered eye drops to Resident 30. Review of the facility's policy, "Eye Drop Administration" dated April 2008, indicated nursing staff should wash hands prior to administering eye drops for residents. 6. During an observation with LVN L on 3/3/19 at 12:52 p.m., she did not perform hand hygiene prior to administering medications to Resident 32. During an interview with LVN L on 3/3/19 at 1 p.m., she stated should wash her hands prior to administering medications to Resident 32. 7. During an observation with LVN D on 3/3/19 at 5:16 p.m., she did not wash her hands or perform hand hygiene prior to administering insulin injection (medication for diabetes for high blood sugar) to Resident 28. LVN D put a chain of 11 keys around her left wrist while she administered injection to Resident 28's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8BWG11 Facility ID: CA070000031 If continuation sheet 95 of 100 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 03/07/2019 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 abdomen area. The keys touched Resident 28's bare skin on abdomen area and bed sheet. LVN D did not clean or disinfect the keys. During an interview with LVN D on 3/3/19 at 5:30 p.m., she stated she should perform hand hygiene prior to administering injection to Resident 28. LVN D stated she should not bring all the keys to the resident's room. She stated those keys were for medication carts and medication room. 8. During an observation with LVN D on 3/3/19 at 6:10 p.m., she removed her gloves after she checked Resident 32's G-Tube replacement, she did not perform hand hygiene after removal gloves. LVN D hold a tray of prepared medications to the hallway and talked to the director of nursing (DON). The DON came in Resident 32's room and did not perform hand hygiene before she put on gloves and checked Resident 32's G-Tube During an interview with LVN D and the DON on 3/3/19 at 6:23 p.m., LVN D stated she should perform hand hygiene after removal gloves. The DON stated she should perform hand hygiene before she checked Resident 32. 9. During an observation with LVN C on 3/4/19 at 8:13 a.m., LVN C stored Resident 50's uncovered and prepared medications in a medication cup inside the medication cart while she was checking Resident 50's BP and verified medication order with pharmacy. LCN C did not perform hand hygiene when she prepared one BP medication for Resident 50. LVN C did not perform hand hygiene prior to administering medications to Resident 50; She did not clean or disinfect medication tray after she came out of the resident's room; LVN C did FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8BWG11 Facility ID: CA070000031 If continuation sheet 96 of 100 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 03/07/2019 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 not do hand hygiene after touched uncleaned med tray and continued to document on computer. During an interview with LVN C on 3/4/19 at 8:50 a.m., she stated she should not store the prepared medication in the med cart; she should perform hand hygiene whenever she touched surfaces and prior to administering medications to the resident. She stated she should clean and disinfect med tray after use and wash hand before she documented on computer. Review of the facility's policy, "Handwashing Hand Hygiene" dated Jan 2018, indicated " ...All personnel shall follow the handwashing/ hand hygiene procedure to help prevent the spread of infections to other personnel, residents, and visitors."

F911 SS=B Bedroom Number of Residents CFR(s): 483.90(e)(1)(i)

F911 04/10/2019 §483.90 (e)(1) Bedrooms must FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8BWG11 Facility ID: CA070000031 If continuation sheet 97 of 100 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 03/07/2019 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 §483.90(e)(1)(i) Accommodate no more than four residents. For facilities that receive approval of construction or reconstruction plans by State and local authorities or are newly certified after November 28, 2016, bedrooms must accommodate no more than two residents. This REQUIREMENT is not met as evidenced by: Based on observation and interview, the facility failed to ensure a resident room accommodated no more than four residents when Room A had six beds and six residents and Room B had five beds and five residents. Having more than four residents per room had the potential of compromising the quality of life and quality of care the residents received. Findings: During the survey, six residents were observed in Room A and five residents were observed in Room B. The room had adequate space for the residents to move about and for care to be given. Each resident had a bed, a privacy curtain, a nightstand, and a closet. The beds did not block any closets, bathrooms, or exits. There was no safety hazard or privacy concerns. During interviews with randomly selected residents and staff, there were no quality of care issues identified concerning the size of the room and the number of occupants. Recommend continuance of the room waiver.

F912 SS=B Bedrooms Measure at Least 80 Sq Ft/Resident F912 CFR(s): 483.90(e)(1)(ii) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8BWG11 04/10/2019 Facility ID: CA070000031 If continuation sheet 98 of 100 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 03/07/2019 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 §483.90(e)(1)(ii) Measure at least 80 square feet per resident in multiple resident bedrooms, and at least 100 square feet in single resident rooms; This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the following multi-resident rooms provided less than 80 square feet per resident. Findings: Room Ft/Res 2 3 4, 5, 6 7 8 9 10, 11, 12, 13 14 15, 16, 17, 18 19 Beds Sq Ft/Rm Sq 2 2 3 3 2 2 2 2 2 3 146 148 225 222 156 144 146 148 140 228 73 74 75 74 78 72 73 74 70 76 20 21 Room A Room B 3 3 6 5 225 228 432 323.4 75 76 72 64.68 During observations and staff and resident interviews on 3/3/19 at 8:22 a.m., and on 3/4/19 at 10:32 a.m., there were no care issues with the lack of space or privacy identified regarding the size of resident rooms. The residents were observed in their rooms throughout the survey. The nursing care and services were not impacted by the shortage of space. The closet and storage spaces were FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8BWG11 Facility ID: CA070000031 If continuation sheet 99 of 100 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 03/07/2019 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 sufficient to accommodate the needs of the residents. Review of the facility's room variance reports recommend the waiver remain in place. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8BWG11 Facility ID: CA070000031 If continuation sheet 100 of 100