Other·May 16, 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 a complaint and an entity reported incident conducted on 5/9/18. For Entity Reported Incident CA00582370 regarding Resident Rights, the Department did not substantiate a violation of federal or state regulations. For Complaint CA00585646 and Entity Reported Incident CA00584819 regarding Quality of Care/Treatment, a federal deficiency was identified (see F600). In addition, a Class "B" Citation was issued. Inspection was limited to the specific complaint and entity reported incidents 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.

F600 SS=D Free from Abuse and Neglect CFR(s): 483.12(a)(1)

F600 §483.12 Freedom from Abuse, Neglect, and Exploitation The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's 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: 6UN311 Facility ID: CA070000043 If continuation sheet 1 of 3 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 05/09/2018 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 medical symptoms. §483.12(a) The facility must§483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion; This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (1) was free from abuse when, certified nursing assistant A (CNA A), during the activities of daily living (ADL's) care, leaned over Resident 1, held her by both wrists and threatened her when she stated, "I'm going to hit you." This failure had the potential to compromise the physical and mental well-being of the resident. Findings: Review of Resident 1's clinical record indicated, Resident 1 had diagnoses including hemiplegia and hemiparesis (paralysis of one side of the body) resulting from a stroke and aphasia (loss of ability to understand or express speech, caused by brain damage). Review of Resident 1's Minimum Data Set (MDS, an assessment tool) dated 3/22/18 indicated, Resident 1 required extensive to total assist with most of her ADL's. Resident 1's MDS also indicated, she had a Brief Interview for Mental Status (BIMS, an assessment tool used to determine cognition and memory) of 99 indicative of Resident 1's inability to respond to questions. During an interview with registered nurse B (RN B) on 5/1/18 at 1:30 p.m., she stated, she saw CNA A lean over Resident 1 while holding FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6UN311 Facility ID: CA070000043 If continuation sheet 2 of 3 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 05/09/2018 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 both her wrists flat on the bed. RN B also stated, she saw CNA A's right arm and elbow raised above the bed with a clenched fist and heard CNA A state, "I'm going to hit you." Then, she heard a thump. RN B went to check the resident and saw CNA A got off Resident 1 quickly and stated, "She is kicking me." RN B assessed Resident 1 and noted redness to Resident 1's upper left chest and right hand. During an interview with the director of nursing (DON) on 5/8/18 at 10:15 a.m., she stated CNA A should not have held Resident 1 down by her wrists. He should have just asked someone to help him and waited until Resident 1 settled down and then provided the care. The DON also stated, CNA A should not have said, "I am going to hit you" and staff should never hit a resident. Review of the "Incident/Accident Post Review" dated 4/28/18, written by RN B indicated, Resident 1 had redness to the upper left chest and right hand following the incident. A review of the facility's policy," Abuse and Neglect Prohibition", indicated each resident has the right to be free from mistreatment and abuse. The policy further indicated the definition of abuse means the willful infliction of injury, intimidation or punishment. Mental abuse includes threats of punishment. Physical abuse includes hitting and controlling behavior through corporal punishment. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6UN311 Facility ID: CA070000043 If continuation sheet 3 of 3