Other·July 17, 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 an entity reported incident conducted on 7/16/18. For Entity Reported Incident CA00594264 regarding Resident Rights, a federal deficiency was identified (see F550). A Class 'B' citation was also issued. Inspection was limited to the specific entity reported incident investigated and does not represent the findings of a full inspection of the facility. Representing the California Department of Public Health: 29328, Health Facilities Evaluator Manager II

F550 SS=D Resident Rights/Exercise of Rights CFR(s): 483.10(a)(1)(2)(b)(1)(2)

F550 §483.10(a) Resident Rights. The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section. §483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. 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: Z0J311 Facility ID: CA070000047 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 A. BUILDING: ___________ B. WING: _______________ 555757 (X3) DATE SURVEY COMPLETED 07/16/2018 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 §483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source. §483.10(b) Exercise of Rights. The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States. §483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility. §483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to treat Resident 1 with respect and dignity when staff placed Resident 1 in a wheelchair with a sheet of bed linen tied around the wheelchair. This restricted Resident 1's ambulation. Findings: During an onsite visit on 7/6/18 at 7:05 p.m., Resident 1 was observed walking around the hallway with a family member. Resident 1 was not interviewable. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z0J311 Facility ID: CA070000047 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 A. BUILDING: ___________ B. WING: _______________ 555757 (X3) DATE SURVEY COMPLETED 07/16/2018 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 1's admission record indicated Resident 1 was admitted to the facility on 7/2/18 with diagnoses of Alzheimer's disease, anxiety disorders and malignant neoplasm of skin of breast. She was admitted under hospice care. During an interview with Resident 1's family member (FM) on 7/6/18 at 7:06 p.m., she stated she received a call from the facility on 7/3/18 at midnight informing her Resident 1 was agitated (including hitting staff around her) and if she could possibly come in to help her calm down. Resident 1's (FM) stated she came into the facility around 12:30 a.m. and found Resident 1 in a wheelchair, in front of the nursing station and with a bed linen sheet wrapped around Resident 1's wheelchair. The FM stated she untied the bed linen sheet from the wheelchair. During an interview with a certified nursing assistant (CNA) on 7/14/18 at 11:16 a.m., she confirmed Resident 1 was in a wheelchair by the nursing station with a bed linen sheet tied around the wheelchair. She stated Resident 1 kept sliding from the wheelchair so they used the bed linen sheet to prevent Resident 1 from falling. She confirmed she and two other staff were suspended for doing this to Resident 1. Review of the facility's policy "Use of Restraints" dated 2001, indicated "restraints will only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience or for prevention of falls". FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z0J311 Facility ID: CA070000047 If continuation sheet 3 of 3