Other·March 17, 2020

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 concurrent recertification and relicensing surveys conducted on 3/6/2020. The facility was licensed for 60 beds. The census at the time of the survey was 57. The sample size was 15. A "G" level deficiency was identified (see

F684). A class "B" citation was also issued. Representing the California Department of Public Health: 29258, Health Facilities Supervisor Nurse; 38573, Health Facilities Evaluator Nurse; 37959, Health Facilities Evaluator Nurse; 32398, Health Facilities Evaluator Nurse; 42819, Health Facilities Evaluator Nurse.

F580 SS=D Notify of Changes (Injury/Decline/Room, etc.) CFR(s): 483.10(g)(14)(i)-(iv)(15)

F580 04/05/2020 §483.10(g)(14) Notification of Changes. (i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention; (B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); (C) A need to alter treatment significantly (that 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: E0WG11 Facility ID: CA070000031 If continuation sheet 1 of 35 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 03/06/2020 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 is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or (D) A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii). (ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request to the physician. (iii) The facility must also promptly notify the resident and the resident representative, if any, when there is(A) A change in room or roommate assignment as specified in §483.10(e)(6); or (B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section. (iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident representative(s). §483.10(g)(15) Admission to a composite distinct part. A facility that is a composite distinct part (as defined in §483.5) must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations under §483.15(c) (9). This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to ensure the responsible party (RP, a person empowered to make decisions for the resident/ person legally responsible and liable for a decision or an action) for one of five sampled residents FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: E0WG11 Facility ID: CA070000031 If continuation sheet 2 of 35 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 03/06/2020 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 43) was notified when Resident 43 had a change of condition and was transferred to the acute hospital. This failure resulted in staff inability to follow an outlined process for communicating changes in condition to legal representatives or designated family members, which caused extreme anguish and lack of continuity of care for the resident. Findings: Review of Resident 43's clinical record indicated he had the diagnoses of anoxic brain damage (the brain is deprived of oxygen), epilepsy (disorder in which nerve cell activity in the brain is disturbed, causing seizures), gastrostomy (surgery that makes a small opening through the skin into the stomach or intestine), dysphagia (difficulty swallowing), spastic quadriplegia (cerebral palsy that affects all four limbs both arms and legs) cerebral palsy (a condition marked by impaired muscle coordination caused by damaged to the brain and type 2 diabetes (condition that affects the way the body processes blood sugar). Resident 43's minimum data set (MDS, an assessment tool), dated 10/21/19 and 1/20/2020, indicated he had memory problem and severely impaired decision making. During a telephone interview with Resident 43's family member on 3/2/2020 at 11:57 a.m., she stated that facility staff could not get hold of the father when they transferred Resident 43 to the acute hospital on 2/25/2020. She further stated that other emergency contact family members were not notified of the transfer to the acute hospital until two days after the transfer. Resident 43's family member added that she, herself, was not notified of the transfer until she FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: E0WG11 Facility ID: CA070000031 If continuation sheet 3 of 35 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 03/06/2020 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 visited Resident 43 in the facility. She further stated she was very much involved with Resident 43's plan of care and attending care plan conferences for Resident 43 with the approval of the resident's parents because she was living in the area locally and "felt bad". Resident 43 was alone in the acute hospital without any family members. Review of Resident 43's Situation, Background, Assessment, Recommendation (SBAR, an assessment tool used to facilitate prompt and appropriate communication of a problem), dated 2/25/2020, indicated Resident 43's gastrostomy tube (GT tube, a surgical opening into the stomach for administration of nutrition and medication) was clogged and he was transferred to the acute hospital. The licensed nurse tried to call Resident 43's RP, but the telephone could not accept any calls. During an interview and concurrent record review with the social service designee (SSD) on 3/3/2020 at 4:30 p.m., the SSD confirmed that Resident 43's face sheet indicated he was admitted to the facility on 9/29/2019 and the responsible party and family emergency contact numbers were listed from contact number 1-5. She further stated that if the first RP emergency contact person could not be reached and staff was not able to notify any change of condition for Resident 43, the 2nd, 3rd, 4th and fifth should have been contacted by the staff. During an interview and concurrent record review with the director of clinical services on 3/3/2020 at 4:19 p.m., she acknowledged the above SBAR and that there was no documentation in the clinical record indicating facility staff notified other emergency contact family members when Resident 43 was sent out to the hospital. She further stated facility FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: E0WG11 Facility ID: CA070000031 If continuation sheet 4 of 35 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 03/06/2020 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 staff should have contacted them as indicated on the face sheet. Review of the facility's policy and procedure, "Changes in Resident Condition," dated 4/2005, indicated legal representative or designated family members are notified when changes in condition or certain events occur ...The resident, attending physician and legal representative or family member are notified when there is: ...a significant change in the resident's physical, mental and psychosocial status; ...a decision to transfer the resident from the facility and etc.

F656 SS=E Develop/Implement Comprehensive Care Plan F656 CFR(s): 483.21(b)(1) 03/27/2020 §483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: E0WG11 Facility ID: CA070000031 If continuation sheet 5 of 35 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 03/06/2020 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 (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 review the facility failed to develop and implement a resident-centered care plan for three of ten sampled residents (Residents 7, 43 and 20) when: 1. Resident 7's care plan was not developed and revised after she had a fall with major injury, was sent out to the hospital and readmitted back to the facility. 2. Resident 43's non-compliant care plan was not resident centered. 3. Resident 20's care plan was not develop for refusal of range of motion (ROM) and therapy screening. A persolized care plan identifies resident's individualized concerns/needs that outlines the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: E0WG11 Facility ID: CA070000031 If continuation sheet 6 of 35 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 03/06/2020 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 services needed to meet their needs. 1. A review of Resident 7's progess notes indicated she had a fall incident on 11/4/19 and sustained an injury and was sent out to acute hospital for further evaluation and management. She was readmitted to the facility on 11/9/19 with diagnoses that included displaced type II dens fracture (a break in the bone that occurs through a specific part of C2, the second bone in the neck), left proximal humerus fracture (a break of the upper part of the bone of the arm). and nasal and maxillary fracture (a nasal fracture, commonly referred to as a broken nose, is a fracture of one of the bones of the nose that includes symptoms like bleeding, swelling, bruising, and an inability to breathe through the nose; a maxillary fracutre, a partial or full separation of parts or the entire tooth-bearing part of the maxilla, the jaw or jawbone). During a record review and concurrent interview on 3/3/2020 at 3:24 p.m., with registered nurse B (RN B), RN B reviewed Resident 7's medical record and did not find any interdisciplinary team (IDT) meeting done when Resident 7 was readmitted from the hospital. Resdient 7's fall care plan did not include any new inteventions that addressed resident's fall with injury. RN B stated, an IDT meeting was important to discuss and identify new or added interventions that would prevent Resident 7's further falls or injury; and the care plan should have been updated or revised. 2. Review of Resident 43's clinical record indicated he was admitted to the facility on 9/29/2019 with diagnoses of anoxic brain damage (the brain is deprived of oxygen), epilepsy (sudden uncontrollable body movement), contracture of muscle, multiple sites, gastrostomy (surgery that makes a small opening through the skin into the stomach or FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: E0WG11 Facility ID: CA070000031 If continuation sheet 7 of 35 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 03/06/2020 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 intestine), dysphagia (difficulty swallowing), spastic quadriplegia (cerebral palsy that affects all four limbs both arms and legs) and cerebral palsy (a condition marked by impaired muscle coordination caused by damaged to the brain). Resident 43's minimum data set (MDS, an assessment tool), dated 10/21/19 and 1/20/2020, indicated he had memory problem, severely impaired decision making, communication problem and had absence of spoken words. During multiple observations on 3/2/2020 at 7:55 a.m., 11:35 a.m., 1:45 p.m., and 3:45 p.m., Resident 43 was lying in bed non-verbal with no eye contact. Both hands were contracted with no contracture devices in both upper and lower extremities. Review of Resident 43's non-compliant care plan, dated 3/28/18, indicated he refused to wear the carrot/towel hand roll on both hands. During an interview on 3/4/2020 at 2:07 p.m., with restorative nursing aid H (RNA H), she stated that Resident 43 had a communication problem and could not talk. She further stated it was hard for the staff to understand if Resident 43 refused to have a carrot/towel on both hands. During an interview on 3/4/2020 at 2:14 p.m., with RNA I, she stated Resident 43 could not talk and it was hard for the staff to understand if he refused to have a carrot/towel on both hands. During a concurrent interview and record review with the director of clinical services on 3/4/2020 at 1:24 p.m., she acknowledged Resident 43's non-compliant care plan was not person centered. She further stated that it FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: E0WG11 Facility ID: CA070000031 If continuation sheet 8 of 35 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 03/06/2020 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 be person centered to address individualized care issues and identified needs. 3. Review of Resident 20's clinical record indicated he was admitted to the facility on 2/20/2019 with diagnosis of contracture of muscle, left lower leg, quadriplegia (paralysis of all four limbs) and abnormal posture. During an observation on 3/3/2020 at 9:42 a.m., Resident 20 was lying in bed with contractures on both lower extremities with no device. Resident 20's MDS, dated 9/24/19 and 12/24/19, indicated he had limited range of motion (ROM, measurement of movement around a joint) on both lower extremities. During a concurrent interview and record review on 3/4/2020 at 11:02 a.m. with DOCS, she confirmed there was no care plan for contractures of both lower extremities and refusal of ROM or therapy screening for Resident 20. She further stated there should be a person centered care plan to address individualized care issues and identified needs.

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

F684 04/05/2020 § 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: E0WG11 Facility ID: CA070000031 If continuation sheet 9 of 35 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 03/06/2020 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 observation, interview and record review, the facility failed to provide necessary care and services to one of one residents (Resident 7) when the facility: a) to provide intervention/s to keep Resident 7's skin clean and dry, b) to have a skin care plan related to the right breast and abdominal fold redness, c) to conduct IDT (interdisciplinary teamcomposed of different disciplines like nursing, etc.) skin meeting, and d) to notify the doctor and responsible party (RP) when staff identified and reported Resident 7's skin redness and rashes. These failures resulted in Resident 7's having pain and discomfort, potential for skin infection and expressed feelings of frustration and embarrassment. During the initial tour on 3/2/2020 at 9:16 a.m., Resident 7 was observed lying on her bed and upon entering her room, there was a bad smell noted, and Resident 7 noted the surveyor's facial expression. Subsequently Resident 7 voluntarily opened her shirt and showed her right breast and the whole abdominal folds which were both noted to be red, raw, and with scattered open areas. The surveyor took a picture of Resident 7's right breast and abdominal folds with Resident 7's verbal consent. Resident 7 stated, "the smell is awful" and expressed feeling "terrible and ashamed", and frustrated the wound was getting worse and painful and nobody was treating it. While still inside Resident 7's room, another surveyor entered the room at 9:20 a.m. When the surveyor commented, "smells bad in here", Resident 7 stated, "that's me and I'm sorry that FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: E0WG11 Facility ID: CA070000031 If continuation sheet 10 of 35 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 03/06/2020 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 is smells bad." Again, Resident 7 lifted the skin folds in her abdomen and right breast and showed the surveyor her skin and indicated it was very painful and apologized for the bad smell. Resident 7 stated, she did not refuse a shower and agreed right away when staff offered to give her a shower. During a follow-up observation and concurrent interview on 3/2/2020 at 10:36 a.m., when licensed vocational nurse A (LVN A), a treatment nurse assessed Resident 7, she confirmed the observation regarding Resident 7's wounds under her right breast and abdominal folds were red, raw, and with open areas that smelled bad. LVN A stated, "yes, it smells bad". LVN A stated, the resident needed a treatment order from the doctor. LVN A also stated she was responsible for treatments of non-pressure (i.e skin tear, abrasions, moisture related dermatitis, etc.) and pressure-related skin problems, and completion of Weekly Skin Evaluations. Review of Resident 7's Nurse's Progress notes and Skin/Wound notes dated November 2019 to March 2020 with LVN A, there were no documentation the MD and RP were notified; no MD order for wound treatment was taken and done; no change of condition (COC) for new skin problem; no care plan; no skin initial assessments/evaluation, and no IDT skin meeting were initiated. LVN A did not find documentation other than treatment and progress notes of redness on left groin dated 6/28/19. Review of Resident 7's treatment administration record (TAR) from November 2019 to March 2020, did not indicate any treatment done to Resident 7's under right breast and abdominal folds. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: E0WG11 Facility ID: CA070000031 If continuation sheet 11 of 35 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 03/06/2020 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 concurrent record review on 3/3/2020 at 3:09 p.m. with Registered Nurse B (RN B), and assistant director of nursing (ADON), RN B stated LVN A informed her that Resident 7's wounds were really bad, the certified nursing assistants (CNAs) should have reported to the nurse when they found the skin problem. RN B also stated, Resident 7 needed treatment for the skin problem promptly to prevent further deterioration of the skin problem. RN B reviewed Resident 7's progress notes dated 3/2/2020 which indicated, the MD and RP were notified on 3/2/2020 at 9:17 p.m. with treatments ordered for redness on right under breast, abdominal folds and groins (only after the surveyor called staff's attention that morning). A new treatment order dated 3/2/2020 for Nystatin (antifungal) powder apply topically (applied to skin or body surfaces) to abdominal fold, rt. groin and under breast every day shift for moisture-associated skin damage (MASD, is the general term for inflammation or skin erosion caused by prolonged exposure to a source of moisture such as urine, stool, sweat, wound drainage, saliva, or mucus. To prevent MASD, clinicians need to be vigilant both in maintaining optimal skin conditions and in diagnosing and treating minor cases of MASD prior to progression and skin breakdown) was ordered. During an interview on 3/3/2020 at 4:41 p.m., with certified nursing assistant C (CNA C), evening shift CNA, he stated having informed "many times" (but could not recall the dates) the evening charge nurse and treatment nurse when he and another female CNA first noted Resident 7's skin problems on right under breast and abdominal folds. During a follow-up observation and interview on 3/4/2020 at 7:52 a.m., Resident 7's right breast FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: E0WG11 Facility ID: CA070000031 If continuation sheet 12 of 35 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 03/06/2020 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 redness was observed less while under abdominal folds open areas and redness were also less and her pain had decreased and mainly on the right abdomen. Resident 7 stated, the pain had decreased and staff were treating the wound so it was improving. During an interview on 3/5/2020 at 9:40 a.m. with the director of nursing (DON), he stated Resident 7's MD and RP should have been informed of the new skin problems and if Resident 7 refused a shower on 2/25 and 2/28/2020, staff could have cleaned and treated the affected areas to prevent infection and deterioration. The DON concurred the skin problem did not happen overnight and so treatment should have been initiated and documentation of skin problems should have been done when identified. During an interview and concurrent record review on 3/5/2020 at 2:07 p.m., the ADON and medical record staff reviewed Resident 7's medical record from 6/29/19 to 3/2/2020 and did not find any skin assessments/reevaluation, a situation, background, assessment, recommendation (SBAR, an assessment/reporting tool), weekly IDT skin meeting done regarding Resident 7's identified skin problems under right breast and abdominal folds. Both staff stated, any charge nurse can initiate the skin sheet and SBAR when any new skin problem was identified. The only SBAR done was on 6/29/19 regarding redness on left groin and on 8/16/19 redness of left breast. No other SBAR done. A review of the facility's policy and procedure, "Pressure Ulcers/Skin Breakdown-Clinical Skin/Wound Management", dated January 2018, indicated the physician will authorize pertinent orders related to wound treatments, including wound cleansing and debridement FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: E0WG11 Facility ID: CA070000031 If continuation sheet 13 of 35 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 03/06/2020 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 approaches, dressings and application of topical agents if indicated for type of skin alteration. A review of the facility's policy and procedure, "Changes in Resident Condition", dated April 2005, indicated the attending physician and legal representative or designated family member are notified when there is a significant change in the resident's physical, mental and psychosocial status using the SBAR. Changes in the resident status that affect the problem(s), goals or approach(es) on his/her care plan are documented as revisions and communicated to the interdisciplinary caregivers. Documentation in the Interdisciplinary Progress Notes include the date, time and Who was notified, information communicated and response and/or orders received. A review of the facility's policy and procedure, "Comprehensive Care Plan", dated January 2018, indicated, each resident's comprehensive care plan has been designed to incorporate identified problem areas, reflect treatment goals and objectives, care plans are revised as changes in the resident's condition dictates.

F689 SS=D Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) 03/27/2020 §483.25(d) Accidents. The facility must ensure that §483.25(d)(1) The resident environment remains as free of accident hazards as is FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: E0WG11 Facility ID: CA070000031 If continuation sheet 14 of 35 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 03/06/2020 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 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 free of accident hazards for one of nine sampled residents (Resident 35) when Resident 35 had a cigarette lighter on top of her tray table in her room. This failure had the potential for accidents to happen and could possibly compromise Resident 35's safety. Findings: A review of Resident 35's diagnoses included idiopathic progressive neuropathy (condition resulting from damage to the nerves outside of the brain that can cause numbness and tingling in the feet and hands). During the initial tour on 3/2/2020 at 8:50 a.m., certified nursing assistant G (CNA G) was inside Resident 35's room assisting her with breakfast, and saw a lighter kit inside an empty cigarette pack on top of Resident 35's tray table. During the concurrent interview with CNA G, she confirmed the observation then put the Resident 35's lighter inside the resident's bag. CNA G stated, residents are not allowed to have lighters. A review of Resident 35's Smoking Safety Screen done on 11/28/19 and 2/28/2020, the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: E0WG11 Facility ID: CA070000031 If continuation sheet 15 of 35 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 03/06/2020 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 assessments indicated the facility needed to store resident's lighter and cigarettes. During an interview on 3/5/2020 at 8:27 a.m., with social service designee (SSD), she stated the resident was not allowed to have a lighter in her possession inside the room or bag for reasons. The SSD also stated the staff who supervised smoking should have taken the lighter after smoking was done. A review of the facility's policy and procedure, "Smoking Policy-Residents", dated January 2018, indicated residents who have independent smoking privileges are permitted to keep cigarettes, pipes, tobacco and other smoking articles in their possession. All other forms of lighters, including matches, are prohibited.

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

F757 04/05/2020 §483.45(d) Unnecessary Drugs-General. Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used§483.45(d)(1) In excessive dose (including duplicate drug therapy); or §483.45(d)(2) For excessive duration; or §483.45(d)(3) Without adequate monitoring; or §483.45(d)(4) Without adequate indications for its use; or FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: E0WG11 Facility ID: CA070000031 If continuation sheet 16 of 35 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 03/06/2020 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(d)(5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or §483.45(d)(6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the failed to act on the medication regimen review recommendation for one of five sampled residents (Resident 46). This failure had the potential for Resident 46 to receive unnecessary medication. Findings: A review of the clinical records indicated Resident 46 was admitted to the facility on 7/22/19, with diagnoses not limited to cannabis dependence, nicotine dependence and type 2 diabetes (high blood sugar). The Minimum Data Set (MDS, an assessment tool), dated 1/27/2020, indicated Resident 46 was cognitively (ability to understand, learn, remember, and make decisions) intact. During a review of Resident 46's physician orders, dated 7/22/2019, indicated to administer dulcolax suppository 10 milligram (mg. a unit of measurement) one suppository rectally as needed (PRN) and fleet enema 7-19 gm/133 milliliters (ml, a unit of measurement for volume) insert 1 application rectally as needed. A review of Resident 46's pharmacist consultation report dated 1/1/2020 thru 1/17/2020 and 2/1/2020 thru 2/22/2020, indicated to clarify the frequency of the prn FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: E0WG11 Facility ID: CA070000031 If continuation sheet 17 of 35 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 03/06/2020 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 bowel care orders fleet enema and dulcolax to indicate how often each order should be given per day. During a concurrent interview and record review on 3/5/2020 at 12:27 p.m., with the registered nurse B (RN B), she acknowledged the above recommendation by the pharmacist consultant and she stated that it was not being followed through by the nursing staff. She further stated that it should have been followed up every month.

F758 SS=D Free from Unnec Psychotropic Meds/PRN Use F758 CFR(s): 483.45(c)(3)(e)(1)-(5) 03/27/2020 §483.45(e) Psychotropic Drugs. §483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: (i) Anti-psychotic; (ii) Anti-depressant; (iii) Anti-anxiety; and (iv) Hypnotic Based on a comprehensive assessment of a resident, the facility must ensure that--§483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a 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; FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: E0WG11 Facility ID: CA070000031 If continuation sheet 18 of 35 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 03/06/2020 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(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and §483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in §483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. §483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to ensure residents were free from unnecessary psychotropic drugs (medications that are capable of affecting the mind, emotions, and behavior) for two of three sampled residents (Residents 8 and 35) when: 1. Resident 8's documentation of antipyschotic medication side effects monitoring was inaccurate. 2. Resident 35 had did not receive a gradual dose reduction (GDR) for antidepressant medication. These failures resulted in the unnecessary use of psychotropic medications. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: E0WG11 Facility ID: CA070000031 If continuation sheet 19 of 35 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 03/06/2020 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. A review of Resident 8's clinical record indicated admission on 11/22/19 with diagnoses of schizophrenia disorder (a mental disorder characterized by abnormal thought processes and deregulated emotions) and extrapyramidal and movement disorder (EPS, also called drug-induced movement disorders, describe the side effects caused by certain antipsychotic......caused by defects in the basal ganglia (part of the brain) which includes clinical manifestations such changes in the muscle tone, dyskinesia (abnormality or impairment of voluntary movement), and akinesia (loss or impairment of the power of voluntary movement.. A review of Resident 8's active physician orders that included Benstropine Mesylate (drug used to treat symptoms of Parkinson's disease or involuntary movements due to the side effects of certain psychiatric drugs) 0.5 milligrams (mg, unit of measurement) 1 tablet by mouth at bedtime for involuntary movements related to EPS dated 11/22/19, and Haloperidol (antipsychotic) 5 mg. half tablet by mouth at bedtime for Schizophrenia dated 1/8/2020. During an observation on 3/2/2020 at 12:34 p.m., while eating lunch, Resident 8 was noted with uncontrolled shaking of his hands while holding the bowl and spoon. During a concurrent interview with licensed vocational nurse D (LVN D), she confirmed the observation. She stated Resident 8 had this shaking since he was admitted. During an interview and concurrent record review on 3/5/2020 at 10:00 a.m., with the director of nursing (DON) and registered nurse B (RN B), the DON reviewed Resident 8's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: E0WG11 Facility ID: CA070000031 If continuation sheet 20 of 35 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 03/06/2020 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 administration record (MAR) from January to March 2020 and found zero (0) documented side effects of the antipsychotic use. Both RN B and the DON stated, involuntary movements of hands and upper extremities are considered EPS which is one of the side effects of antipsychotic medications. 2. A review of Resident 35 's face sheet indicated admission on 10/4/18 with diagnosis of major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Her physician order dated 10/5/18 indicated Duloxetine Hydrochloride (antidepressant) 40 mg by mouth daily for major depressive disorder manifested by verbalization of sadness. A review of Resident 35's Quarterly interdisciplinary team (IDT, composed of different disciplines like nursing, social service, activities, rehabilitation, dietary, who work together toward a common goal Behavioral Meeting from 7/11/19 to 1/23/2020, indicated one behavior episode documented since admission but no GDR was attempted. During a record review and concurrent interview on 3/5/2020 at 10:49 a.m., with the social service designee (SSD), she confirmed no GDR was done for a year. The SSD stated GDR should have been attemted and if no further behavior then medications should be discontinued.

F759 SS=D Free of Medication Error Rts 5 Prcnt or More CFR(s): 483.45(f)(1) FORM CMS-2567(02-99) Previous Versions Obsolete

F759 Event ID: E0WG11 03/27/2020 Facility ID: CA070000031 If continuation sheet 21 of 35 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 03/06/2020 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(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 14.81% medication error rate when four medication errors out of 27 opportunities were observed during medication passes for two residents (Residents 11 and 16 ). This failure has the potential to compromised the residents' health and medical condition. Findings: During review of Resident 16's physician orders indicated, she had an order for pro-stat liquid (nutritional supplement) 30 milliter (ml, unit of measurement) three times a day. During medication pass observation on 3/2/2020 at 8:37 a.m., LVN D had prepared and administered pro-stat liquid 30 milliter for Resident 16. LVN D was about to throw the plastic cup, when the plastic medication cup was noted to contain one half ml (0.5 ml) of pro-stat liquid. LVN D acknowledged the findings. During review of Resident 11's physician orders indicated, she had an order for vitamin C (diet supplements) 250 milligrams (mg, unit of measurement) one a tablet a day, multivitamin with minerals (diet supplement) one tablet a day, and senna (stool softener) 8.6 mg two tablets two times a day. During the medication pass observation on 3/2/2020 at 9:26 a.m., LVN E had prepared the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: E0WG11 Facility ID: CA070000031 If continuation sheet 22 of 35 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 03/06/2020 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 three tablets (vitamin C, multivitamin with minerals, and senna (stool softener) for Resident 11. The three tablets were crushed and mixed with applesauce. LVN E administered two scoops of the mixtures and immediately threw the medication cup in the waste container. LVN E was asked to checked the plastic medication cup from the waste container and by using his flash light, LVN E verified the medication cup contained some residue which was approximately one third of the plastic spoon. He also stated, "next time." During review of the facility's policy, "Administering Medications", dated 1/2008, indicated "Medications shall be administered in a safe and timely manner, and as prescribed."

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

F761 04/05/2020 §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 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: E0WG11 Facility ID: CA070000031 If continuation sheet 23 of 35 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 03/06/2020 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 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: 2. During medication room inspection on 3/2/2020, one prefilled syringe of fluarix quadrivalent (flu vaccine) was mixed with fluzone vaccine box (contained 10 prefilled syringes). 3. A multi-dose vial of afluria (flu vaccine) was open and dated 11/7/19. 4. One vial of purified protein derivatives (PPD) solution was open and undated. During an interview with the director of staff development (DSD) on 3/2/2020 at 8:48 a.m., she stated, the vial should be labeled and dated upon opening. During a review of the facility's policy, "Guide for Special Handling of Medications", dated 1/2013, indicated "Multiple dose vials for injection. Discard 28 days after opening." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: E0WG11 Facility ID: CA070000031 If continuation sheet 24 of 35 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 03/06/2020 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 ensure medication and biologicals were properly labeled, dated, and stored. This failure had the potential to affect resident health and medical condition. Findings: 1. During medication pass observation on 3/2/2020 at 8:37 a.m., an open carton of Resource 2.0 (complete liquid nutritional supplement) on top of the medication cart was undated.

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

F812 03/27/2020 §483.60(i) Food safety requirements. The facility must §483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities. (i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations. (ii) This provision does not prohibit or prevent FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: E0WG11 Facility ID: CA070000031 If continuation sheet 25 of 35 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 03/06/2020 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 facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. (iii) This provision does not preclude residents from consuming foods not procured by the facility. §483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure safe food storage practices would be implemented. This failure had the potential to cause food borne illnesses. Findings: During the initial dietary observation on 3/2/2020 at 7:45 a.m., five rotten bananas were found in the fruit basket with two fruit flies noted. Some dried, leftover cooked beef, and two slices of dried turkey were found inside the refrigerator. During an interview with the dietary staff on 3/2/2020 at 8:00 a.m., she agreed on the findings and food items identified were immediately discarded. During a review of an undated facility's policy, "Storage of Food Supplies", indicated "Food and supplies will be stored properly and in a safe manner." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: E0WG11 Facility ID: CA070000031 If continuation sheet 26 of 35 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 03/06/2020 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

F842 Resident Records - Identifiable Information CFR(s): 483.20(f)(5), 483.70(i)(1)-(5)

F842 SS=D PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 03/27/2020 §483.20(f)(5) Resident-identifiable information. (i) A facility may not release information that is resident-identifiable to the public. (ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so. §483.70(i) Medical records. §483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are(i) Complete; (ii) Accurately documented; (iii) Readily accessible; and (iv) Systematically organized §483.70(i)(2) The facility must keep confidential all information contained in the resident's records, regardless of the form or storage method of the records, except when release is(i) To the individual, or their resident representative where permitted by applicable law; (ii) Required by Law; (iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506; (iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: E0WG11 Facility ID: CA070000031 If continuation sheet 27 of 35 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 03/06/2020 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 permitted by and in compliance with 45 CFR 164.512. §483.70(i)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use. §483.70(i)(4) Medical records must be retained for(i) The period of time required by State law; or (ii) Five years from the date of discharge when there is no requirement in State law; or (iii) For a minor, 3 years after a resident reaches legal age under State law. §483.70(i)(5) The medical record must contain(i) Sufficient information to identify the resident; (ii) A record of the resident's assessments; (iii) The comprehensive plan of care and services provided; (iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State; (v) Physician's, nurse's, and other licensed professional's progress notes; and (vi) Laboratory, radiology and other diagnostic services reports as required under §483.50. This REQUIREMENT is not met as evidenced by: Based on interview and record review the facility failed to ensure the POLST (Physician Orders for Life Sustaining Treatment) form was complete for one of 5 residents (Resident 43). This failure had the potential for resident to receive incorrect life sustaining treatment and receive medication without the resident or resident representative consent. Review of Resident 43's clinical record indicated he was admitted to the facility on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: E0WG11 Facility ID: CA070000031 If continuation sheet 28 of 35 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 03/06/2020 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 9/29/2019 with diagnosis of, anoxic brain damage (the brain is deprived of oxygen), epilepsy (sudden uncontrollable body movement), gastrostomy (surgery that makes a small opening through the skin into the stomach or intestine), dysphagia (difficulty swallowing), spastic quadriplegic (cerebral palsy that affects all four limbs both arms and legs) cerebral palsy (a condition marked by impaired muscle coordination caused by damaged to the brain) and type 2 diabetes (high blood sugar). Resident 43's minimum data set (MDS, an assessment tool) dated 10/21/19 and 1/20/2020, indicated he had memory problem and his decision making was severely impaired. Resident 43's POLST dated 9/10/18, indicated it was signed by the physician. The POLST was not signed by the resident or a legally recognized decision maker. Review of Resident 43's physician order dated 5/9/17, indicated follow POLST. Review of the facility's policy and procedure, "Physician Order for Life Sustain Treatment" (POLST), dated 1/18, indicated the nurse should check the completeness of the POLST, the social worker should review the POLST with the resident, or if the resident lacks decision making, review with the legally decision maker. POLST shall be reviewed by the IDT quarterly.

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

F880 03/27/2020 §483.80 Infection Control FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: E0WG11 Facility ID: CA070000031 If continuation sheet 29 of 35 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 03/06/2020 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 must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. §483.80(a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: §483.80(a)(1) A system for preventing, 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 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: E0WG11 Facility ID: CA070000031 If continuation sheet 30 of 35 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 03/06/2020 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 least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and (vi)The hand hygiene procedures to be followed by staff involved in direct resident contact. §483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility. §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: 4. During an observation on 3/3/2020 at 10:30 a.m., Resident 36 was pacing back and forth in the hallways holding a wash cloth and plastic cup in his hand, spit on the plastic cup, then touched the plastic cups and medicine cups kept in the medication cart part in the hallways. Resident 36 also took sugar sachets from the nutrition cart. The director of nursing (DON) who was standing by the hallways was notified and he immediately called the resident's attention. The DON told one female staff who spoke Resident 36's language to explain to resident that he should not be touching things from the cart because his hands were dirty. The charge nurse replaced the medication and plastics cups. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: E0WG11 Facility ID: CA070000031 If continuation sheet 31 of 35 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 03/06/2020 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 assure proper infection control practices was followed when: 1. Resident 43's oxygen cannula (a device used to deliver supplemental oxygen or airflow) and tubing was not labeled; 2. During a medication pass observation Licensed Vocational Nurse D (LVN D) held one tablet with bare hands while cutting the tablet in half; 3. One soiled meal tray was mixed with four clean trays inside the meal tray cart; meal tray cart's door was left open after a meal tray was taken. 4. Resident 36 touched the plastic cups and medication cups kept in the medication cart parked by the hallway with his dirty hands. These deficient practiced had the potential to result in cross-contamination and the spread of infection. Findings: 1. During an initial tour observation on 3/2/2020 at 8:10 a.m., Resident 43's oxygen nasal cannula and tubing was not labeled. During a concurrent observation and interview with the LVN D on 3/2/19 at 8:13 a.m., LVN D confirmed the about observation and she further stated a nasal cannula tubing should have a date. Review of the facility's policy and procedure dated 1/18, "Policies and Practices-Infection Control", indicated the objectives of our infection control policies and practices are to: Prevent, detect, investigate, and control infections in the facility; Maintain a safe, sanitary, and comfortable environment for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: E0WG11 Facility ID: CA070000031 If continuation sheet 32 of 35 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 03/06/2020 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 personnel, residents, visitors, and the general public ....facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections. 2. During a medication pass observation on 3/2/2020 at 9:10 a.m., the licensed vocational nurse D (LVN D) held one tablet with bare hands while cutting the tablet in half. LVN D stated, "I should not" and immediately discarded the tablet. 3. During meal observation on 3/3/2020 at 12:45 p.m., the activity director (AD) placed one soiled meal tray inside the meal cart mixed with four clean trays. Meal cart's door was left open after a meal tray was taken. The AD acknowledged, took the tray out and closed the meal cart's door.

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

F911 03/27/2020 §483.90 (e)(1) Bedrooms must §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 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: E0WG11 Facility ID: CA070000031 If continuation sheet 33 of 35 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 03/06/2020 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 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=D Bedrooms Measure at Least 80 Sq Ft/Resident F912 CFR(s): 483.90(e)(1)(ii) 03/27/2020 §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 2 3 Beds 2 2 Sq Ft/Rm 146 148 FORM CMS-2567(02-99) Previous Versions Obsolete Sq Ft/Res 73 74 Event ID: E0WG11 Facility ID: CA070000031 If continuation sheet 34 of 35 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 03/06/2020 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) 4, 5, 6 7 8 9 10, 11, 12, 13 14 15, 16, 17, 18 19 3 3 2 2 2 2 2 3 225 222 156 144 146 148 140 228 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 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During observations and staff and resident interviews on 3/2/2020 at 8:13 a.m., and on 3/4/2020 at 1:43 p.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 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: E0WG11 Facility ID: CA070000031 If continuation sheet 35 of 35