Other·August 10, 2017

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 recertification survey conducted from 8/1/17 to 8/3/17. A "G" level deficiency was identified (see F323, 483.25(d)(1)(n)(1)-(3)). A Class "B" citation was also issued. The facility was licensed for 35 beds. The census at the time of the survey was 32. The sample size was 10. Representing the California Department of Public Health: 36623, Health Facilities Evaluator Nurse; 38068, Health Facilities Evaluator Nurse; and 38573, Health Facilities Evaluator Nurse.

F281 SS=D SERVICES PROVIDED MEET PROFESSIONAL STANDARDS CFR(s): 483.21(b)(3)(i)

F281 08/18/2017 (b)(3) Comprehensive Care Plans The services provided or arranged by the facility, as outlined by the comprehensive care plan, must(i) Meet professional standards of quality. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to provide services that meet professional standards for one of 10 sampled residents (6) when a nurse provided 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: VRDN11 Facility ID: CA070000047 If continuation sheet 1 of 24 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: _______________ 555757 (X3) DATE SURVEY COMPLETED 08/03/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MILPITAS CARE CENTER 120 Corning Ave Milpitas, CA 95035 (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 6 with regular water (thin liquids) instead of thickened water (used for people with difficulty swallowing thin liquids and can help prevent choking and stop fluid from entering the lungs) as ordered by the physician. This failure had the potential to cause health complications for the resident. Findings: Review of Resident 6's clinical record indicated she was admitted to the facility with diagnoses including Parkinson's disease (disorder of the nervous systems that affects movement and can cause tremors) and dysphagia (difficulty swallowing). Review of Resident 6's physician orders indicated she had a diet order, dated 3/25/17, which included nectar thick liquid consistency. During medication pass observation on 8/2/17 at 4:10 p.m., licensed vocational nurse H (LVN H) prepared one medication for Resident 6 and dissolved the medication in water. During a concurrent interview, when asked if Resident 6 can drink thin liquids, LVN H stated that Resident 6 does not need thickened water and she does well with regular water. LVN H held the cup of water and medication to Resident 6's mouth. Resident 6 slowly sipped the water with medication and coughed multiple times. During an interview on 8/2/17 at 4:25 p.m., the registered dietician (RD) stated that staff should not give regular thin liquids to Resident 6. She stated any water given to Resident 6 should be thickened water. Review of the facility's undated policy, "Thickened Liquids," indicated thickened liquids FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VRDN11 Facility ID: CA070000047 If continuation sheet 2 of 24 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: _______________ 555757 (X3) DATE SURVEY COMPLETED 08/03/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MILPITAS CARE CENTER 120 Corning Ave Milpitas, CA 95035 (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 served at the appropriate consistency as ordered by a physician, and nursing should have a procedure for how to give thickened liquids with medications.

F309 SS=D PROVIDE CARE/SERVICES FOR HIGHEST WELL BEING CFR(s): 483.24, 483.25(k)(l)

F309 08/18/2017 483.24 Quality of life Quality of life is a fundamental principle that applies to all care and services provided to facility residents. Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident’s comprehensive assessment and plan of care. 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, including but not limited to the following: (k) Pain Management. The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents’ goals and preferences. (l) Dialysis. The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VRDN11 Facility ID: CA070000047 If continuation sheet 3 of 24 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: _______________ 555757 (X3) DATE SURVEY COMPLETED 08/03/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MILPITAS CARE CENTER 120 Corning Ave Milpitas, CA 95035 (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 person-centered care plan, and the residents’ goals and preferences. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review the facility failed to provide necessary care and services consistent with the comprehensive plan of care for two of 10 sampled residents (5 and 8). For Resident 5, a fall intervention was not implemented. For Resident 8, the assessment of an AV fistula (connection made between an artery and a vein to create an access for dialysis [a medical procedure using special machines to filter waste and excess water from the body]) and intake and output monitoring were not consistently done. These failures had the potential to affect the residents' health and safety. Findings: 1. Review of Resident 5's clinical record indicated she had diagnoses including osteoporosis (bone weakness) and dementia. Review of Resident 5's Situation Background Assessment Recommendation (SBAR) Communication Form (communication tool) and progress notes, indicated she fell on 4/15/17. Review of Resident 5's Morse Fall Scale (an assessment tool that can predict the likelihood that a person will fall), dated 4/15/17, indicated her score was 75. A score of 45 and higher indicated a high risk for falls. Review of Resident 5's fall care plan indicated an intervention to put a star label on the door to alert staff that the resident is a high fall risk. During an observation on 8/3/17 at 10:30 a.m., FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VRDN11 Facility ID: CA070000047 If continuation sheet 4 of 24 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: _______________ 555757 (X3) DATE SURVEY COMPLETED 08/03/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MILPITAS CARE CENTER 120 Corning Ave Milpitas, CA 95035 (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 there was no star label on Resident 5's door. During a concurrent interview with LVN F, she confirmed there was no star label on Resident 5's door. LVN F confirmed the star label intervention was in Resident 5's care plan and stated the star label should be on her door. Review of the facility's 12/2007 policy, "Managing Falls and Fall Risk," indicated staff will try various interventions based on assessment of the nature or category of falling. 2. Review of Resident 8's clinical record indicated she was admitted to the facility with diagnoses including end stage renal disease (kidneys no longer function well enough) and congestive heart failure (inability of the heart to pump enough blood). Review of Resident 8's physician order, dated 5/10/17, indicated hemodialysis (process of purifying the blood of a person whose kidneys are not working normally) three times a week on Tuesdays, Thursdays, Saturdays at 12 p.m., fluid restrictions 1200 milliliters (ml, unit of measurement) per day and to monitor intake and output every shift. Review of Resident 8's intake and output records indicated there were missing entries of the amount she drank or voided from the periods of 7/20/17 to 7/28/17 and 7/30/17 to 8/2/17. Review of Resident 8's nursing care plan dated 5/11/17 indicated to monitor intake and output. During an interview on 8/2/17 at 3:15 p.m. with certified nursing assistant M (CNA M) she stated CNA's should have recorded Resident 8's intake and output every shift from 7/20/17 to 7/28/17 and 7/30/17 to 8/2/17. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VRDN11 Facility ID: CA070000047 If continuation sheet 5 of 24 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: _______________ 555757 (X3) DATE SURVEY COMPLETED 08/03/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MILPITAS CARE CENTER 120 Corning Ave Milpitas, CA 95035 (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 on 8/2/17 at 3:17 p.m., with licensed vocational nurse F (LVN F), she confirmed that there were no entries on Resident 8's intake and output record to indicate the amount that Resident 8 drank or voided from the period of 7/20/17 to 7/28/17 and 7/30/17 to 8/2/17. She stated the CNA's should have recorded Resident 8's intake and output on those days. During an interview on 8/3/17 at 11:00 a.m. with the director of nursing (DON), he stated intake and output for Resident 8 should have been recorded because there was a physician order. Review of the undated facility's policy and procedure entitled, "Intake, Measuring and Recording", indicated to maintain an accurate measurement of the resident's intake and output and assess fluid balance on residents with specific physicians' orders for measurement on intake and output and of residents with an order for specific total fluid intake. 3. Review of Resident 8's physician order, dated 5/10/17, indicated to monitor for the presence of a bruit (whooshing sound heard on listening auscultation) and thrill (vibration felt by palpation) on the AV (arteriovenous fistula-a passageway between an artery and a vein made in order to cleanse the blood of waste products and water when the kidney can no longer perform that function.) fistula every shift. Review of Resident 8's hemodialysis (the process of cleansing the blood) communication record indicated monitoring of bruit and thrill of the AV fistula on the right arm was not done by the facility's licensed staff on 7/1/17, 7/6/17, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VRDN11 Facility ID: CA070000047 If continuation sheet 6 of 24 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: _______________ 555757 (X3) DATE SURVEY COMPLETED 08/03/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MILPITAS CARE CENTER 120 Corning Ave Milpitas, CA 95035 (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 7/11/17, 7/15/17, 7/17/17, 7/20/17, 7/25/17, 7/27/17, and 8/1/17. During an interview on 8/3/17 at 7:55 a.m. with registered nurse L (RN L), the RN L confirmed there was no documentation that licensed staff in the facility monitored the bruit and thrill of Resident 8's AV fistula on the above dates. During an interview on 8/3/17 at 11:25 a.m., Resident 8 stated staff in the facility did not check her right arm. The resident stated only staff in the dialysis center check her right arm whenever she goes there for dialysis. Review of Resident 8's Minimum Data Set (MDS, a resident assessment tool) dated 6/9/17 indicated her cognition (ability to remember, judge and reason out) was intact. During an interview on 8/3/17 at 11:46 a.m., LVN F stated licensed nurses should monitor the bruit and thrill on Resident 8's right arm AV fistula as ordered by the physician every shift to prevent possible complications. Review of the facility's policy and procedure dated 4/2013 entitled, "Hemodialysis Catheters", indicated the general medical nurse should document in the resident's medical record every shift as follows: if dialysis was done during shift and observation post dialysis.

F315 SS=E NO CATHETER, PREVENT UTI, RESTORE BLADDER CFR(s): 483.25(e)(1)-(3)

F315 08/18/2017 (e) Incontinence. (1) The facility must ensure that resident who is continent of bladder and bowel on admission receives services and assistance to maintain FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VRDN11 Facility ID: CA070000047 If continuation sheet 7 of 24 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: _______________ 555757 (X3) DATE SURVEY COMPLETED 08/03/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MILPITAS CARE CENTER 120 Corning Ave Milpitas, CA 95035 (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 continence unless his or her clinical condition is or becomes such that continence is not possible to maintain. (2)For a resident with urinary incontinence, based on the resident’s comprehensive assessment, the facility must ensure that(i) A resident who enters the facility without an indwelling catheter is not catheterized unless the resident’s clinical condition demonstrates that catheterization was necessary; (ii) A resident who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident’s clinical condition demonstrates that catheterization is necessary and (iii) A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible. (3) For a resident with fecal incontinence, based on the resident’s comprehensive assessment, the facility must ensure that a resident who is incontinent of bowel receives appropriate treatment and services to restore as much normal bowel function as possible. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to do periodic assessments of bowel and bladder status for 5 of 10 sampled residents (Residents 1, 2, 3, 5, and 6). These failures had the potential to not identify and provide appropriate treatments and services to restore normal bowel and bladder function of the residents. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VRDN11 Facility ID: CA070000047 If continuation sheet 8 of 24 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: _______________ 555757 (X3) DATE SURVEY COMPLETED 08/03/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MILPITAS CARE CENTER 120 Corning Ave Milpitas, CA 95035 (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. Resident 1 was admitted to the facility with diagnoses including Parkinson's disease (disease of nervous system marked by tremor, muscle rigidity and slow, imprecise movement ) and dementia (brain disease marked by personality changes, memory and reasoning decline). Review of Resident 1's Minimum Data Set (MDS, a resident assessment tool) dated 9/8/16 indicated she was frequently incontinent of bladder and continent of bowel. Review of Resident 1's MDS, dated 6/15/17, indicated she was occasionally incontinent of bowel and bladder function. Review of Resident 1's clinical record indicated her last bowel and bladder program screening was done on 3/22/16 and no more bowel and bladder assessments were done. During an interview on 8/2/17 at 8:17 a.m. with certified nursing assistant J (CNA J), she stated Resident 1 was incontinent of bladder and continent of bowel. During an interview on 8/2/17 at 10:25 a.m. with licensed vocational nurse F (LVN F), she confirmed the last bowel and bladder assessment was done on 3/22/16 and that it should be completed quarterly and annually for Resident 1. During an interview on 8/2/17 at 10:46 a.m. with the director of nursing (DON), he confirmed there were no bowel and bladder assessments done since 3/22/16 for Resident 1. 2. Resident 2 was admitted to the facility with FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VRDN11 Facility ID: CA070000047 If continuation sheet 9 of 24 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: _______________ 555757 (X3) DATE SURVEY COMPLETED 08/03/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MILPITAS CARE CENTER 120 Corning Ave Milpitas, CA 95035 (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 diagnoses including dementia. Review of Resident 2's MDS is dated 2/28/17 and 5/28/17 indicated she was frequently incontinent of both bowel and bladder. Review of Resident 2's clinical record indicated there were no bowel and bladder assessments completed since 5/25/16. During an interview on 8/2/17 at 8:16 a.m. with CNA J, he stated Resident 2 was occasionally incontinent of bladder and continent of bowel most of the time. During an interview on 8/2/17 at 10:46 a.m. with the DON, he confirmed there were no bowel and bladder assessments done since 5/25/16 for Resident 2. 3. Review of Resident 3's clinical record indicated he had diagnoses including hemiparesis (weakness affecting one side of the body) and dementia. Review of Resident 3's MDS, dated 7/12/17, indicated he was always incontinent of both bowel and bladder. There was no annual or quarterly bowel and bladder assessment for Resident 3 in the last year. 4. Review of Resident 5's clinical record indicated she had diagnoses including osteoporosis (bone weakness) and dementia. Review of Resident 5's MDS, dated 4/24/17, indicated she was always incontinent of both bowel and bladder. There were no annual or quarterly bowel and bladder assessments for Resident 5 in the last year. 5. Review of Resident 6's clinical record indicated she had diagnoses including FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VRDN11 Facility ID: CA070000047 If continuation sheet 10 of 24 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: _______________ 555757 (X3) DATE SURVEY COMPLETED 08/03/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MILPITAS CARE CENTER 120 Corning Ave Milpitas, CA 95035 (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 Parkinson's disease and repeated falls. Review of Resident 6's MDS, dated 7/15/17, indicated she was always continent of bowel and frequently incontinent of bladder. There were no annual or quarterly bowel and bladder assessments for Resident 6 in the last year. During an interview on 8/3/17 at 11:45 a.m., the DON stated Resident 3, Resident 5, and Resident 6 did not have bowel and bladder assessments done per facility policy. The DON stated bowel and bladder assessments should be done on admission, quarterly, and annually. Review of the facility's undated policy and procedures entitled, "Bowel and Bladder Training", indicated after the seven days of assessment, licensed nurses will assess and evaluate residents for appropriateness. The licensed nurse will then record and complete the "Bladder and Bowel Assessment and Management" form on the seventh day and scores out resident's capability. On a quarterly basis, the form is filled out by the licensed nurse.

F323 SS=G FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES CFR(s): 483.25(d)(1)(2)(n)(1)-(3)

F323 08/30/2017 (d) Accidents. The facility must ensure that (1) The resident environment remains as free from accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VRDN11 Facility ID: CA070000047 If continuation sheet 11 of 24 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: _______________ 555757 (X3) DATE SURVEY COMPLETED 08/03/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MILPITAS CARE CENTER 120 Corning Ave Milpitas, CA 95035 (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 (n) - Bed Rails. The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements. (1) Assess the resident for risk of entrapment from bed rails prior to installation. (2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation. (3) Ensure that the bed’s dimensions are appropriate for the resident’s size and weight. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to implement the intervention of placing a wheelchair alarm to prevent falls for two of 10 sampled residents (Resident 4 and Resident 6). These failures resulted in a fall, scalp laceration that required staples and hospitalization for Resident 4, and recurrent falls and the potential for injury for Resident 6. Findings: 1. Review of Resident 4's clinical record indicated she had diagnoses of dementia (decline in mental capacity affecting daily function) and history of falling. Review of Resident 4's Morse Fall Scale (an assessment tool that can predict the likelihood that a person will fall), dated 10/24/16, indicated her score was 90. A score of 45 and higher indicated a high risk for falls. Review of Resident 4's fall care plan, dated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VRDN11 Facility ID: CA070000047 If continuation sheet 12 of 24 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: _______________ 555757 (X3) DATE SURVEY COMPLETED 08/03/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MILPITAS CARE CENTER 120 Corning Ave Milpitas, CA 95035 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 10/24/16 indicated an intervention that staff should ensure a chair/bed electronic alarm device was in place. There was no documentation that indicated staff ensured Resident 4 had a chair electronic alarm in place. Review of Resident 4's Minimum Data Set (MDS, an assessment tool), dated 11/6/16, indicated her cognition was moderately impaired and she required extensive assistance with activities of daily living (ADL, daily self-care tasks, e.g., bathing, toileting, and transferring). Review of Resident 4's Situation Background Assessment Recommendation (SBAR) Communication Form (communication tool) and progress notes, dated 1/17/17, indicated that at 4 p.m., registered nurse A (RN A) saw Resident 4 on the floor in the dining room and blood was dripping from her head. RN A applied pressure to the cut with a clean cloth until the bleeding stopped. It further indicated Resident 4 said she was trying to reach for something when she fell. Review of the facility's investigation summary, dated 1/17/17, indicated activity assistant B (AA B) was attending to the needs of another resident, heard a "thump," and saw Resident 4 lying on the floor. It further indicated Resident 4 had a lacerated wound to her head measuring five centimeters (cm, unit of measurement) by 0.5 cm with moderate bleeding. Review of Resident 4's Non-pressure Skin Condition Report, dated 1/23/17, indicated she had nine staples in her occipital (back of the head) area, measuring five cm by 0.5 cm. During an observation on 8/1/17 at 12:05 p.m., Resident 4 was in the dining room, sitting in a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VRDN11 Facility ID: CA070000047 If continuation sheet 13 of 24 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: _______________ 555757 (X3) DATE SURVEY COMPLETED 08/03/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MILPITAS CARE CENTER 120 Corning Ave Milpitas, CA 95035 (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 wheelchair with no alarm in place. During an interview on 8/1/17 at 12:10 p.m., certified nursing assistant C (CNA C) stated Resident 4 did not have a wheelchair alarm. CNA C stated she was unsure if Resident 4 needed a wheelchair alarm. During observations on 8/1/17 at 12:25 p.m. and 2:45 p.m., Resident 4 was in the dining room, sitting in a wheelchair with no alarm in place. During observations on 8/2/17 at 9:15 a.m. and 10 a.m., Resident 4 was in the dining room, sitting in a wheelchair with no alarm in place. During an interview on 8/2/17 at 10:40 a.m., CNA D stated every time Resident 4 was up in her wheelchair, there was no wheelchair alarm attached. During an interview on 8/2/17 at 10:42 a.m., CNA E stated Resident 4 did not have a wheelchair alarm when in her wheelchair. CNA E stated she was not aware that Resident 4 needed a wheelchair alarm. During an interview on 8/2/17 at 10:45 a.m., licensed vocational nurse F (LVN F) stated Resident 4 needs a bed and wheelchair alarm for fall prevention because she had a history of falls and was a high risk for falls. LVN F confirmed Resident 4 was in her wheelchair without an alarm, and should have one. During an interview on 8/2/17 at 11:05 a.m., the director of nursing (DON) stated Resident 4 had a history of falls and her care plan included interventions of a wheelchair alarm when up in a wheelchair. During an interview on 8/2/17 at 2:25 p.m., FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VRDN11 Facility ID: CA070000047 If continuation sheet 14 of 24 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: _______________ 555757 (X3) DATE SURVEY COMPLETED 08/03/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MILPITAS CARE CENTER 120 Corning Ave Milpitas, CA 95035 (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 4 stated staff placed an alarm on her wheelchair "today". Resident 4 stated she never had a wheelchair alarm before this day. During an interview on 8/2/17 at 3:05 p.m., certified nursing assistant G (CNA G) stated he worked with Resident 4 on 1/17/17, assisted her from bed to the wheelchair, and brought her to the dining room. He stated Resident 4's wheelchair did not have an alarm in place. CNA G stated he was not aware that Resident 4 should have an alarm when up in the wheelchair. During a telephone interview on 8/2/17 at 4:35 p.m., RN A stated she was working on 1/17/17 and was by the door of the dining room when Resident 4 fell. RN A stated Resident 4 fell back with her wheelchair and hit the edge of the wall. RN A stated there was no sound of a wheelchair alarm and was unsure if Resident 4 had a wheelchair alarm. During a telephone interview on 8/3/17 at 10:30 a.m., AA B stated on 1/17/17 Resident 4 did not have an alarm on her wheelchair and her wheelchair was not locked. AA B stated Resident 4 fell with her wheelchair when she was trying to reach something. AA B stated Resident 4 hit the edge of the wall. AA B stated she was assisting another resident when Resident 4 fell. 2. Review of Resident 6's clinical record indicated she had diagnoses including Parkinson's disease (disorder of the nervous systems that affects movement and can cause tremors) and repeated falls. Review of Resident 6's fall care plan, dated 7/8/16, indicated an intervention that staff should ensure a chair/bed electronic alarm device was in place. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VRDN11 Facility ID: CA070000047 If continuation sheet 15 of 24 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: _______________ 555757 (X3) DATE SURVEY COMPLETED 08/03/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MILPITAS CARE CENTER 120 Corning Ave Milpitas, CA 95035 (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 6's Morse Fall Scale, dated 10/15/16, indicated her score was 65. A score of 45 and higher indicated a high risk for falls. Review of Resident 6's SBAR Communication Form and progress notes, dated 10/30/16, indicated Resident 6 was in bed at 12 a.m. The notes further indicated at 3 a.m., Resident 6 was found lying on the floor. The notes did not indicate whether there was a bed alarm in place. There was no documentation that indicated what staff would do to prevent future falls. Review of Resident 6's SBAR Communication Form and progress notes, dated 1/4/17, indicated Resident 6 was in a wheelchair in the dining room and slipped from the wheelchair. The notes did not indicate whether there was a wheelchair alarm in place. There was no documentation that indicated what staff would do to prevent future falls. Review of Resident 6's SBAR Communication Form and progress notes, dated 1/31/17, indicated Resident 6 fell to the floor in the dining room from a standing position. There was no documentation that indicated what staff would do to prevent future falls. Review of Resident 6's SBAR Communication Form and progress notes, dated 3/17/17, indicated Resident 6 was found lying on the floor mat next to her bed. The notes did not indicate whether there was a bed alarm in place. There was no documentation that indicated what staff would do to prevent future falls. During an observation on 8/2/17 at 3:15 p.m., Resident 6 was up in her wheelchair with no alarm in place, and staff wheeled her to the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VRDN11 Facility ID: CA070000047 If continuation sheet 16 of 24 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: _______________ 555757 (X3) DATE SURVEY COMPLETED 08/03/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MILPITAS CARE CENTER 120 Corning Ave Milpitas, CA 95035 (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 dining room. During medication pass observation on 8/2/17 at 4:10 p.m., LVN H confirmed Resident 6 did not have a wheelchair alarm. When asked if Resident 6 needed a wheelchair alarm, LVN H replied, "No." During an observation on 8/2/17 at 4:35 p.m., Resident 6 was in the dining room, sitting in her wheelchair with no alarm in place. During an interview on 8/2/17 at 4:35 p.m., CNA I stated Resident 6 did not have an alarm while up in her wheelchair. CNA I stated she did not think Resident 6 was supposed to have an alarm in her wheelchair. During an observation on 8/3/17 at 11 a.m., Resident 6 was in the dining room, sitting in her wheelchair with no alarm in place. During an interview on 8/3/17 at 11 a.m., CNA J confirmed Resident 6 did not have a wheelchair alarm. During an interview on 8/3/17 at 11:05 a.m., DON stated Resident 6 needed a wheelchair and bed alarm, and the nurses and CNAs should be aware that Resident 6 needed the alarms in place. The DON stated there should be an interdisciplinary team (IDT, a group of health care professionals from diverse fields who work toward a common goal for residents) meeting when a resident has multiple falls. The DON stated he could not find documentation of IDT meetings after each of Resident 6's falls. The DON confirmed there was no documentation of any new interventions to prevent future falls after each of Resident 6's falls. During an interview on 8/3/17 at 2 p.m., LVN K FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VRDN11 Facility ID: CA070000047 If continuation sheet 17 of 24 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: _______________ 555757 (X3) DATE SURVEY COMPLETED 08/03/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MILPITAS CARE CENTER 120 Corning Ave Milpitas, CA 95035 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE stated she was unsure if Resident 6 had a wheelchair alarm. LVN K stated she should check to make sure Resident 6's wheelchair alarm was in place. Review of the facility's 12/2007 policy, "Managing Falls and Fall Risk," indicated "staff will identify appropriate interventions to reduce the risk of falls." The policy also indicated, "if falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remain relevant." It further indicated, "staff will monitor and document each resident's response to interventions."

F371 SS=E FOOD PROCURE, STORE/PREPARE/SERVE F371 - SANITARY CFR(s): 483.60(i)(1)-(3) 08/18/2017 (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 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. (i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. (i)(3) Have a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VRDN11 Facility ID: CA070000047 If continuation sheet 18 of 24 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: _______________ 555757 (X3) DATE SURVEY COMPLETED 08/03/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MILPITAS CARE CENTER 120 Corning Ave Milpitas, CA 95035 (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 storage, handling, and consumption. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to maintain safe and sanitary conditions in the kitchen when flies, a rotten-appearing onion, and overripe bananas were found in the dry storage area. These failures had the potential to cause food borne illnesses (diseases caused by eating contaminated foods) due to pest and contaminated food served to the residents who receive their food from the kitchen. Findings: During the initial tour of the kitchen on 8/1/17 at 7:35 a.m. with the dietary cook (DC), four small flies were found in the dry storage area; one onion with black powdery material was found with several fresh onions in a plastic container; and several soft overripe bananas with black peels were found in another plastic container in the same dry storage area. On a concurrent interview with the DC, she confirmed the above observations and she stated soft overripe bananas with black peels and an onion with black powdery material should have been thrown away yesterday. During an interview on 8/2/17 at 8:30 a.m. with the dietary supervisor (DS), she stated a rottenappearing onion and soft overripe bananas with black peels should have been thrown away. She also stated that a pest control company was already called that morning, because of the flies. Review of the facility's policy and procedure, dated 3/2013, entitled, "Storing Produce", indicated to check boxes of fruit and vegetables FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VRDN11 Facility ID: CA070000047 If continuation sheet 19 of 24 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: _______________ 555757 (X3) DATE SURVEY COMPLETED 08/03/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MILPITAS CARE CENTER 120 Corning Ave Milpitas, CA 95035 (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 for rotten items. One rotten tomato, apple or potato in a box can cause the rest of the produce to spoil faster. Throw away all spoiled items. Review of the facility's undated policy and procedure entitled, "Sanitation", indicated, on a monthly basis, a pest control company will inspect and service the dietary department. If any time additional servicing is needed, pest control company will be notified.

F425 SS=E PHARMACEUTICAL SVC - ACCURATE PROCEDURES, RPH CFR(s): 483.45(a)(b)(1)

F425 08/18/2017 (a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. (b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who-(1) Provides consultation on all aspects of the provision of pharmacy services in the facility; This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to ensure medications were appropriately acquired, received, and dispensed when two of the three emergency medication kits (E-kits) were not sealed and replaced within 72 hours after opening, and the controlled drug medication E-kit contained expired medications. These failures had the potential to result in delayed treatments during emergency situations and placed residents at FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VRDN11 Facility ID: CA070000047 If continuation sheet 20 of 24 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: _______________ 555757 (X3) DATE SURVEY COMPLETED 08/03/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MILPITAS CARE CENTER 120 Corning Ave Milpitas, CA 95035 (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 risk for receiving expired medications. Findings: During an observation of the medication room on 8/1/17 at 9:03 a.m. with LVN F, the refrigerator medication E-kit was not sealed and was missing two medications. The oral medication E-kit was not sealed. A note inside the oral medication E-kit indicated a medication was taken from the oral E-kit on 7/17/17. The label outside the controlled drug E-kit indicated there were eight out of 12 medications that expired 2/2017. During a concurrent interview, LVN F confirmed the above observations and said she was unsure when the refrigerator E-kit was opened. LVN F stated the E-kits should have been sealed and replaced within 24 hours after opening. LVN F stated staff should have called the pharmacy to replace the controlled drug Ekit. During an interview on 8/2/17 at 7:30 a.m., LVN F stated the refrigerator E-kit was opened on 7/24/17. During a telephone interview on 8/3/17 at 8:45 a.m., the consultant pharmacist (CP) stated the consultant pharmacist's responsibility was to check for expired medications. The CP stated when there are expired medications and when E-kits are opened, they should be replaced. Review of the facility's revised 2013 policy, "Medication Ordering and Receiving from Pharmacy," indicated opened kits are replaced with sealed kits within 72 hours of opening. The policy further indicated when a controlled substance medication expires, it is destroyed at the facility by DON and consultant pharmacist. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VRDN11 Facility ID: CA070000047 If continuation sheet 21 of 24 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: _______________ 555757 (X3) DATE SURVEY COMPLETED 08/03/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MILPITAS CARE CENTER 120 Corning Ave Milpitas, CA 95035 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

F431 DRUG RECORDS, LABEL/STORE DRUGS & BIOLOGICALS CFR(s): 483.45(b)(2)(3)(g)(h)

F431 SS=D PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 08/18/2017 The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g) of this part. The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse. (a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. (b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who-(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and (3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. (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. (h) Storage of Drugs and Biologicals. (1) In accordance with State and Federal laws, the facility must store all drugs and biologicals FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VRDN11 Facility ID: CA070000047 If continuation sheet 22 of 24 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: _______________ 555757 (X3) DATE SURVEY COMPLETED 08/03/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MILPITAS CARE CENTER 120 Corning Ave Milpitas, CA 95035 (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 in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. (2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to ensure safe and secure medication storage. This failure had the potential for residents, staff and visitors to access medications. Findings: During a medication pass observation on 8/2/17 at 7:40 a.m., licensed vocational nurse K (LVN K) removed a medication from the medication cart and went into a resident's room to administer the medication. LVN K did not lock the medication cart. During a concurrent interview, LVN K confirmed the medication cart was left unlocked and out of sight. LVN K stated the cart should be locked. Review of the facility's 4/2017 policy, "Administering Medications," indicated during administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VRDN11 Facility ID: CA070000047 If continuation sheet 23 of 24 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: _______________ 555757 (X3) DATE SURVEY COMPLETED 08/03/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MILPITAS CARE CENTER 120 Corning Ave Milpitas, CA 95035 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

F458 BEDROOMS MEASURE AT LEAST 80 SQ FT/RESIDENT CFR(s): 483.90(e)(1)(ii)

F458 SS=B PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 08/18/2017 (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 facility failed to provide 80 square feet per resident in three rooms (6, 7, and 10). Each room was occupied by four residents. Having less than 80 square feet per resident could potentially compromise the care and services the residents receive in the facility. Findings: During the initial tour, on 8/1/17 at 9:00 a.m., Rooms 6 and 7 were observed with four residents and Room 10 was observed with four beds with three residents. The residents' bedroom measurements were as follows: Room Capacity feet/Resident 6 4 7 4 10 4 Square 66 67 70 During observations and staff and resident interviews throughout the survey, there were no care issues identified regarding the size of resident rooms. The residents and staff verbalized no complaints or concerns regarding space and privacy. Recommend renewal of room waiver to continue. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VRDN11 Facility ID: CA070000047 If continuation sheet 24 of 24