Other·November 21, 2019

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during a stadard abbreviated survey regarding investigation of a complaint conducted on 11/15/19. For Complaint CA00656488 regarding Quality of Care/Treatment and Physical Evnironment: Roaches in Facility, federal deficiencies were identified (see F659, F687, F689, and F925) A class "B" Citation was also issued. Inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. Representing the California Department of Public Health: 34432, Health Facilities Evaluator Nurse.

F659 SS=D Qualified Persons CFR(s): 483.21(b)(3)(ii)

F659 12/10/2019 §483.21(b)(3) Comprehensive Care Plans The services provided or arranged by the facility, as outlined by the comprehensive care plan, must(ii) Be provided by qualified persons in accordance with each resident's written plan of care. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure residents received services provided by qualified staff when housekeeper A (HK A) provided personal care to the residents without a current certification 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: 8FB011 Facility ID: CA070000031 If continuation sheet 1 of 14 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES 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 11/15/2019 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 as a certified nursing assistant (CNA). This failure had the potential to result in unsafe delivery of care to the residents. Findings: During an interview with Resident 1's family member (FM) on 10/3/19 at 12:25 p.m., she stated during the week of 9/22/19 to 9/28/19, the FM informed the CNA Resident 1 needed an incontinence brief change. The FM stated the CNA did not return to the room, so HK A changed the brief. During an interview with HK A on 10/22/19 at 10:10 a.m., she stated, if there were not enough CNAs and they the CNAs need help, she has helped them as she used to be a CNA. HK A stated she may have helped the CNA with a resident's incontinece brief change as recently as two to three months ago but did not do this type of work very often. HK A stated she did not have a current CNA certification. Review of HK A's employment file indicated a job description for laundry supervisor, signed on 10/30/17, but no certification for CNA. During an interview with the director of nursing (DON) on 10/22/19 at 12:35 p.m., she stated HK A had approached her in the past and asked if she could help the CNA's but the DON told HK A to do her own job description. The DON stated she would never let HK A do CNA work. The DON stated facility staff were required to have a CNA certification or nursing license to provide personal care to the residents.

F687 SS=D Foot Care CFR(s): 483.25(b)(2)(i)(ii) FORM CMS-2567(02-99) Previous Versions Obsolete

F687 Event ID: 8FB011 12/10/2019 Facility ID: CA070000031 If continuation sheet 2 of 14 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES 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 11/15/2019 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(b)(2) Foot care. To ensure that residents receive proper treatment and care to maintain mobility and good foot health, the facility must: (i) Provide foot care and treatment, in accordance with professional standards of practice, including to prevent complications from the resident's medical condition(s) and (ii) If necessary, assist the resident in making appointments with a qualified person, and arranging for transportation to and from such appointments. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to refer and provide podietry services for one of three sampled residents (1) until six months after the family's request. This deficient practice placed the resident at risk for injury. Findings: During an interview with Resident 1's family member (FM) on 10/3/19 at 12:25 p.m., she stated in February 2019 she requested to the facility, a podiatry appointment for Resident 1 to cut his long toenails. The FM stated she continually informed the facility he needed to see the podiatrist, but each time they responded saying they would schedule the appointment. The FM stated Resident 1 finally was seen by the podiatrist on 10/1/19. Review of Resident 1's "Physician Orders" dated 10/4/18, indicated an order for Podiatry Treatment for mycotic and hypertrophied toe nails (abnormally thick). During an interview with the activity assistant (AA) on 10/22/19 at 12:45 p.m., he stated he FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8FB011 Facility ID: CA070000031 If continuation sheet 3 of 14 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES 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 11/15/2019 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 assisted the social work department to schedule podiatrist appointments beginning March, 2019. The AA stated, per the FM, he requested a podiatry appointment for Resident 1 for April or May, 2019. The AA stated the podiatry office staff later informed him, by their mistake, they had not included Resident 1 on the podiatry schedule. During an interview with the director of nursing (DON) on 10/22/19 at 12:35 p.m., she stated Resident 1 was scheduled for podiatry in June, 2019 but he was not seen because he did not have a consent for podiatry, required by his insurance company, in his record. The DON stated staff should have made sure there was a signed consent for podiatry. Review of the "Podiatry" schedule dated 6/12/19, indicated need for a consent next to Resident 1's name. Review of the podiatry schedule dated 5/15/19, 7/30/19 and 8/12/19 indicated Resident 1's name was not on the list to see the podiatrist. During an interview with the DSS on 10/4/19 at 3 p.m., she stated in response to the FM's complaint, she requested Resident1's podiatry appointment on 8/16/19. The DSS stated Resident 1 was then seen on 10/1/19. Review of Resident 1's "Podiatric Evaluation and Treatment" report dated 10/1/19, indicated nail trimming for ten long, dystrophic toe nails (nail damage from disease resulting in yellowed and thickened nails) with a recommendation for antifungal medications. During an interview with the DON on 11/1/19 at 9:50 a.m., she stated the facility did not have a director of social services (DSS) between March and July, 2019. The DON state the podiatry request fell through the cracks during FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8FB011 Facility ID: CA070000031 If continuation sheet 4 of 14 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES 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 11/15/2019 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 that time. The DON stated the request should have been followed-up by the nursing staff in the absence of the DSS. DON stated the facility did not have a policy on sceduling podiatry appointments.

F689 SS=D Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) 12/10/2019 §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 maintain an environment free of hazards and risks for five of seven sampled residents (2, 4, 5, 6 and 7) when: 1. Staff allowed residents to smoke cigarettes immediately next to the activity room patio door and Resident 2's bedroom window instead of in the designated smoking area (DSA). This failure had the potential to result in residents' exposure to second hand smoke. 2. Staff did not intervene but ignored Resident 2's complaints about smoke entering his window. This failure resulted in Resident 2's complaints of increased coughing and lung FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8FB011 Facility ID: CA070000031 If continuation sheet 5 of 14 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES 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 11/15/2019 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 excretions, becoming too hot because he had to keep his window closed, and feeling angry because he did "not have the right to breath." 3. Resident care plans provided unclear direction to staff regarding the resident's need for smoking supervision. Findings: 1. During an observation of the patio immediately adjacent to the activity room, with the director of nursing (DON) on 10/22/19 at 2:30 p.m., the DON acknowledged Residents 6 and 7 were observed smoking cigarettes. The DON stated the residents were only supposed to smoke in the (DSA) located on the other side of the building. The DON stated the patio of the activity room was too close to the building to be a DSA. During an observation of the activity room patio and interview with activity assistant I (AA I) on 10/22/19 at 2:45 p.m., Residents 4, 6 and 7 were observed smoking cigarettes. Smoking aprons, individual ashtrays and a "No Smoking" sign were not observed in the area. AA I stated he was the smoking supervisor. AA I stated residents were not supposed to smoke on the activity room patio. However, the residents refused to smoke in the DSA, even when staff offered to push them in their wheel chairs. During an interview with certified nursing assistant F (CNA F) on 10/22/19 at 2:45 p.m., he stated the residents were allowed to smoke on the patio immediately adjacent to the activity room during his past three month employment with the facility. During an interview with CNA G on 10/22/19 at 2:47 p.m., he stated he was not sure if the patio next to the activity room was a designated smoking area. CNA G stated the residents had FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8FB011 Facility ID: CA070000031 If continuation sheet 6 of 14 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES 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 11/15/2019 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 always smoked there during his two-year employment. During an interview with the activity director (AD) on 10/22/19 at 3:45 p.m., she stated the residents had smoked cigarettes on the patio adjacent to the activity room for about a year. During an observation of the activity room patio on 10/22/19 at 4 p.m., smoking aprons were now hanging on a hook on the patio. Two residents wore smoking aprons. Residents 4, 5 and 7 were smoking, had cigarettes and lighters on their laps, and were placing their cigarette ashes on the ground next to their wheelchairs. During an interview with Resident 4 on 10/22/19 at 4:05 p.m., she stated there was usually no one available to push her or the other 9 residents who smoked, over to the DSA. During an interview with Resident 6 on 10/22/19 at 4:15 p.m., he stated, "we always smoke here", not in the DSA. During an interview with the DON on 10/22/19 at 4:45 p.m., she stated the facility needed to put a system in place so smoking in the nonDSA would not happen again. Review of the facility's 2018 policy, "Smoking Policy - Residents", indicated smoking is only permitted in the resident DSA. 2. Review of Resident 2's clinical record indicated diagnoses of diabetes mellitus (inability to produce or respond to the hormone insulin, resulting sugar in the blood) with unspecified complications and legal blindness. Review of Resident 2's "Minimum Data Set (MDS, an assessment tool) dated 9/30/19 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8FB011 Facility ID: CA070000031 If continuation sheet 7 of 14 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES 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 11/15/2019 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 a brief interview for mental status (BIMS, a cognitive assessment tool) score of 14 (scores of 13-15 indicated intact cognition). During an interview with Resident 2 on 10/22/19 at 4:10 p.m., he stated the smoke coming from residents smoking on the activity room patio entered his window, smelled bad, made him cough and produce phlegm (lung secretions) and feel hot from having to keep the window closed. Resident 2 stated he preffered to keep the window open to get some fresh air. Resident 2 stated, "it makes me feel angry." Resident 2 stated, they should move away the window and from the building. In an angry tone of voice Resident 2 stated two times: "They have the right to smoke but I do not have the right to breathe." During an observation of Resident 2's bedroom window on 10/22/19 at 2:45 p.m., it was noted, Resident 2's window was directly above one end of the activity room patio. During an interview with the AD on 10/22/19 at 3:45 p.m., she stated Resident 2 had continually complained about residents smoking on the activity room patio. The AD stated Resident 2 would always cough and then state "they have the right to smoke, but I do not have the right to breathe." During an interview with the AD on 10/30/19 at 4:15 p.m., she stated Resident 2 had complained about the smoke for at least four to five months. The AD stated she reported Resident 2's complaint about smoking to the administrator (ADM) in the past. During an interview with the DON on 10/31/19 at 3:50 p.m., she stated facility staff had not informed her of Resident 2's complaints regarding smoking. The DON stated staff FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8FB011 Facility ID: CA070000031 If continuation sheet 8 of 14 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES 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 11/15/2019 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 should have notified her of the complaint, then she should have responded to Resident 2's complaint. 3. During an observation of the activity room patio on 10/22/19 at 2:45 p.m., Residents 4, 6 and 7 were observed smoking cigarettes, each with cigarettes and lighters on their laps. During an observation of the activity room patio on 10/22/19 at 4 p.m., Residents 4, 5, and 6 were observed smoking cigarettes, each with cigarettes and lighters on their laps. Review of Resident 4's "Smoking Safety Screen" dated 2/28/19, indicated she required supervision for smoking and should not store her own lighter and cigarettes. Review of Resident 4's smoking care plan (SMC), dated 2/15/19, indicated Resident 4 should smoke with supervision. The SMC with the same date indicated cigarettes/lighter will be locked and kept by staff. The SMC dated 3/5/19 indicated Resident 4 could smoke safely without supervision. The SMC dated 3/5/19 did not have revised interventions to direct staff regarding change to independent smoking. Review of Resident 6's "Smoking Safety Screen" dated 7/24/19, indicated he required supervision for smoking, should wear a smoking apron and should not store his own lighter and cigarettes. Review of Resident 6's SMC, dated 7/24/19, indicated Resident 6 should smoke with supervision and on the following line with the same date indicated Resident 6 could smoke safely without supervision. The SMC with the same date indicated Resident 6 was not compliant with using a smoking apron. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8FB011 Facility ID: CA070000031 If continuation sheet 9 of 14 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES 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 11/15/2019 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 7's "Smoking Safety Screen" dated 2/28/19, indicated he required supervision for smoking and should not store his own lighter and cigarettes. Review of Resident 7's SMC, dated 10/22/19, (the same day of the above observation) indicated Resident 7 should smoke with supervision and on the following line with the same date indicated Resident 7 could smoke safely without supervision. During an interview with AA I on 10/22/19 at 4:30 p.m., he stated the residents were not supposed to keep their own cigarettes and lighters but Resident 4 would get angry and would not surrender her cigarettes and lighter to the staff. AA I stated Resident's 6 and 7 were noncompliant with the smoking rules, they were not supposed to keep their own cigaretts and lighters but they would not surrender them to the staff. Review of the facility's policy, "Smoking Policy Residents", indicated residents with independent smoking privileges were permitted to keep cigarettes and other smoking articles in their possession ... residents without independent smoking privileges were not permitted to keep cigarettes and other smoking articles in their possession. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8FB011 Facility ID: CA070000031 If continuation sheet 10 of 14 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES 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 11/15/2019 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

F925 Maintains Effective Pest Control Program CFR(s): 483.90(i)(4)

F925 SS=D PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 12/10/2019 §483.90(i)(4) Maintain an effective pest control program so that the facility is free of pests and rodents. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to maintain an effective pest control program to prevent a cockroach (a small insect that causes allergies, asthma attacks and spread of bacteria) infestation. Cockroach observations were reported in the facility's kitchen and resident rooms following a five month lapse in pest control services for the facility. This failure had the potential to cause food contamination, and the spread of bacterial infections throughout the facility from an uncontrolled roach investation. Findings: During an interview with Resident 5 on 10/3/19 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8FB011 Facility ID: CA070000031 If continuation sheet 11 of 14 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES 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 11/15/2019 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 at 12:30 p.m., he stated there was a large cochroach on the wall above his bed on 10/1/19. Review of Resident 5's minimum data set (MDS, an assrssment tool) indicated a brief interview for mental status (BIMS, an assessment tool of cognition) score of 13 (Scores of 13-15 out of 15 questions indicates in tact cognition). During an interview with Resident 8 on 10/3/19 at 12:20 p.m., he stated he saw roaches in his room during the previous week. Review of Resident 8's MDS indicated a BIMS score of 15. During an inteview with Resident 9 on 10/3/19 at 12:15 p.m., he stated he saw roaches in the day room during the previous month. Review of Resident 9's MDS indicated a BIMS score of 15. Review of the facility's pest control company J (PCC J) invoice, indicated general pest services provided monthly in January, 2019 up until a service provided on 4/9/19. During an interview with the maintenance assistant (MA) on 10/3/19 at 3 p.m., he stated there was no pest control service at the facility between April and September, 2019 and no invoices for those months. During an interview with the director of nursing (DON) on 10/22/19 at 2:45 p.m., she stated there was no pest control services after 4/9/19 because the facility was behind in payments to PCC J. During a telephone interview with PCC J's office manager on 10/30/19 at 3:20 p.m., she confirmed the facility's pest control service was on hold from 4/9/19 to September due to the facility's lack of payment. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8FB011 Facility ID: CA070000031 If continuation sheet 12 of 14 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES 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 11/15/2019 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 the facility's PCC J invoice, indicated pest control service on 9/23/19. The PCC J invoice indicated the interior kitchen was treated for roaches and light activity observed by the PCC J technician at the time of service. During an observation and interview in the kitchen with the dietary supervisor (DS) on 10/22/19 at 10:45 a.m., roach traps were on the floor in six places in the kitchen and no cockroaches were obsurved during the kitchen tour. The DS stated she observed cockroaches in the kitchen in September, prior to pest control service of 9/23/19. The DS stated she has not observed cockroaches in the kitchen, since the above service. During a telephone interview with pest control technician C (PCT C) on 10/31/19 at 3:50 p.m., he stated during the pest control service of 9/23/19, he observed a facility wide cockroach problem. PCT C stated the cockroach problem had developed over some time and was the result of lack of pest control service since April, 2019. PCT C stated during the pest control service of 9/23/19 he observed 20 roaches in the facility's kitchen and treated several resident rooms where he observed cockroaches. PCT C stated some of residents told him there were "roaches runnng everywhere." PCT C stated a faciity staff member told him not to write anything down or tell anyone about the pest control problem which made him feel uncomfortable. During a telephone interview with PCT C on 10/31/19 at 4 p.m., he stated during pest control service the week of 10/21/19, kitchen staff stated they continued to see roaches in the kitchen, though fewer than those seen in September, 2019. PCT C stated to control the cockroach problem, the facility needed but FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8FB011 Facility ID: CA070000031 If continuation sheet 13 of 14 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES 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 11/15/2019 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 refused a special treatment which required staff to vacate the kitchen for four hours. During an interview with the DON on 10/22/19 at 2:50 p.m., she stated the facility is supposed to have a monthly pest control service to prevent an infectation of cockroaches or other insects. Review of the facility's 2018 policy, "Pest Control", indicated the facility would maintain an ongoing effective pest control program to ensure the building is kept free of insects and rodents. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8FB011 Facility ID: CA070000031 If continuation sheet 14 of 14