Other·May 4, 2018

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 standard abbreviated survey regarding investigation of complaints conducted on 4/30/18. For Complaint CA00583678 regarding Admission, Transfer, and Discharge Rights, a federal deficiency was identified (see F626). In addition a Class "B" citation was 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: 38174, Health Facilities Evaluator Nurse.

F626 SS=D Permitting Residents to Return to Facility CFR(s): 483.15(e)(1)(2)

F626 §483.15(e)(1) Permitting residents to return to facility. A facility must establish and follow a written policy on permitting residents to return to the facility after they are hospitalized or placed on therapeutic leave. The policy must provide for the following. (i) A resident, whose hospitalization or therapeutic leave exceeds the bed-hold period under the State plan, returns to the facility to their previous room if available or immediately 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: W9LK11 Facility ID: CA070000043 If continuation sheet 1 of 4 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 (X3) DATE SURVEY COMPLETED A. BUILDING: ___________ B. WING: _______________ 056058 04/30/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALMADEN HEALTHCARE AND REHABILITATION CENTER 2065 Los Gatos-Almaden Road San Jose, CA 95124 (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 upon the first availability of a bed in a semiprivate room if the resident(A) Requires the services provided by the facility; and (B) Is eligible for Medicare skilled nursing facility services or Medicaid nursing facility services. (ii) If the facility that determines that a resident who was transferred with an expectation of returning to the facility, cannot return to the facility, the facility must comply with the requirements of paragraph (c) as they apply to discharges. §483.15(e)(2) Readmission to a composite distinct part. When the facility to which a resident returns is a composite distinct part (as defined in § 483.5), the resident must be permitted to return to an available bed in the particular location of the composite distinct part in which he or she resided previously. If a bed is not available in that location at the time of return, the resident must be given the option to return to that location upon the first availability of a bed there. This REQUIREMENT is not met as evidenced by: Based on interview and record review , the facility failed to ensure one of three residents (Resident 1) was readmitted to the facility after a hospitalization. Findings: Resident 1's clinical record was reviewed. Resident 1 was admitted to the facility with diagnoses including Alzheimer's disease (an irreversible, progressive brain disorder that slowly destroys memory, thinking skills, and eventually the ability to carry out the simple tasks). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: W9LK11 Facility ID: CA070000043 If continuation sheet 2 of 4 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 (X3) DATE SURVEY COMPLETED A. BUILDING: ___________ B. WING: _______________ 056058 04/30/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALMADEN HEALTHCARE AND REHABILITATION CENTER 2065 Los Gatos-Almaden Road San Jose, CA 95124 (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 1's progress notes indicated, on 3/13/18, at 12:45 p.m., Resident 1 was scheduled for a computed tomography (CT scan, use of computer-processed combinations of many X-ray measurements taken from different angles) due to worsening behavior such as uncooperative, combative, and refusal of care. Resident 1 was transferred to a psychiatric emergency service facility for evaluation via 911. During an interview with the administrator (AD), on 4/24/18, at 9:00 a.m., she indicated on 4/18/18, the facility received a referral from the acute care hospital for Resident 1's readmission. The referral form indicated Resident 1 would need a long term skilled nursing facility (SNF) with a dementia (memory loss) unit and in a locked SNF (safety measures for dementia). The AD stated the facility did not have a locked unit for dementia residents. She also stated she was advised by the legal department not to take Resident 1 back to the facility. The AD confirmed, on 4/20/18, she received psychiatry notes indicating Resident 1 did not require a locked facility but instead Resident 1 would require a Wanderguard (a monitoring system used by a facility to know residents' whereabouts.). She acknowledged the facility could provide a Wanderguard for Resident 1, but they still refused to accept Resident 1 due to safety concerns of going through other residents' rooms and out to the street. Review of Psychiatry Inpatient Consultation service notes dated 4/20/18, at 1:43 p.m., indicated Resident 1's disposition back to skilled nursing did not require a locked facility and it would be sufficient that Resident 1 use a Wanderguard to ensure Resident 1 would not exit the facility unsupervised. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: W9LK11 Facility ID: CA070000043 If continuation sheet 3 of 4 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 (X3) DATE SURVEY COMPLETED A. BUILDING: ___________ B. WING: _______________ 056058 04/30/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALMADEN HEALTHCARE AND REHABILITATION CENTER 2065 Los Gatos-Almaden Road San Jose, CA 95124 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of the facility's 9/02 policy "Readmission to the Facility" indicated a resident who was hospitalized would be readmitted immediately upon the first availability on an appropriate bed if the resident requires the services provided by the facility and was eligible for nursing services. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: W9LK11 Facility ID: CA070000043 If continuation sheet 4 of 4