Other·July 2, 2019

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 on 6/19/19. Class "B" citation was issued (see H&S Code, Regulation 1265.4). The facility was licensed for 35 beds. The census at the time of the survey was 33. The sample size was 12. Representing the California Department of Public Health: 38068, Health Facilities Evaluator Nurse; 29765, Health Facilities Evaluator Supervisor; 36045, Health Facilities Evaluator Supervisor; 27000, Pharmacy Consultant; and 40903, Pharmacy Consultant.

F554 SS=D Resident Self-Admin Meds-Clinically Approp CFR(s): 483.10(c)(7)

F554 07/19/2019 §483.10(c)(7) The right to self-administer medications if the interdisciplinary team, as defined by §483.21(b)(2)(ii), has determined that this practice is clinically appropriate. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure one of three sampled resident reviewed for selfadministration of medication (Resident 236) received a complete assessment for selfadministration of medication. This failure had the potential for unsafe and improper administration of medication. During an observation on 6/18/19 at 2:45 p.m., Resident 236 had an open wound on the right 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: YO5Z11 Facility ID: CA070000047 If continuation sheet 1 of 53 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 06/19/2019 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 forehead. An open tube of 1% hydrocortisone ointment (a topical medicine used to treat redness, swelling, itching, and discomfort of various skin conditions) was on top of her overhead table. During a concurrent interview with Resident 236, she acknowledged using her personal ointment to treat her facial wound. Resident 236 stated the facility nurses were aware because she refused the doctor's order on her skin treatment. During an interview with licensed nurse C (LN C), on 6/18/19 at 4:30 p.m., she stated Resident 236 had refused her facial wound treatment. LN C also acknowledged she was aware Resident 236 had a personal ointment on top of her overhead table. She was not sure if Resident 236 had completed a selfadministration assessment prior to administering her own medication. During a review of the clinical record for Resident 236, the physician's order dated 5/31/19, indicated an order of triple antibiotic ointment daily for open wound to face. Her Minimum Data Set (MDS, an assessment and care screening tool) indicated she was cognitively intact. During an interview with the director of nursing (DON), he confirmed the facility did not conduct an assessment for Self-Administration of Medication. The DON acknowledged the medication should be stored in a safe and secure place and should not be accessible by other residents. The facility policy and procedure, "SelfAdministration of Drugs" dated August 2006, indicated the staff and practitioner will assess each resident's mental and physical abilities, to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YO5Z11 Facility ID: CA070000047 If continuation sheet 2 of 53 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 06/19/2019 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 determine whether a resident is capable of selfadministering. Self-administered medications must be stored in a safe and secure place. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YO5Z11 Facility ID: CA070000047 If continuation sheet 3 of 53 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 06/19/2019 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

F641 Accuracy of Assessments CFR(s): 483.20(g)

F641 SS=D PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 07/19/2019 §483.20(g) Accuracy of Assessments. The assessment must accurately reflect the resident's status. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure the minimum data set (MDS, assessment tool) was accurately done for one of 12 sampled residents (16). Resident 16's MDS did not indicate Resident 16 was edentulous. This failure had the potential for Resident 16 not to receive the necessary oral health care to meet her over all health needs and nutritional status. Findings: During initial tour of the facility at 8:45 a.m., Resident 16 was in bed awake, and responding appropriately. Resident 16 was edentulous. During a review of Resident 16's clinical record on 6/18/19, the "MDS-Section L Oral/Dental Status" dated 4/18/2019, did not indicate Resident 16 had no natural teeth or edentulous. During an interview with the director of nursing (DON) on 6/18/19 at 2:57 p.m., he confirmed his oral assessment was inaccurate and should have marked no natural teeth space. Review of the facility's policy and procedure, "Section L-Oral/Dental Status", indicated to assess the dental status could help identify residents who maybe at risk for aspiration or malnutrition to name a few condition. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YO5Z11 Facility ID: CA070000047 If continuation sheet 4 of 53 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 06/19/2019 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

F655 Baseline Care Plan CFR(s): 483.21(a)(1)-(3)

F655 SS=D PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 07/19/2019 §483.21 Comprehensive Person-Centered Care Planning §483.21(a) Baseline Care Plans §483.21(a)(1) The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must(i) Be developed within 48 hours of a resident's admission. (ii) Include the minimum healthcare information necessary to properly care for a resident including, but not limited to(A) Initial goals based on admission orders. (B) Physician orders. (C) Dietary orders. (D) Therapy services. (E) Social services. (F) PASARR recommendation, if applicable. §483.21(a)(2) The facility may develop a comprehensive care plan in place of the baseline care plan if the comprehensive care plan(i) Is developed within 48 hours of the resident's admission. (ii) Meets the requirements set forth in paragraph (b) of this section (excepting paragraph (b)(2)(i) of this section). §483.21(a)(3) The facility must provide the resident and their representative with a summary of the baseline care plan that includes but is not limited to: (i) The initial goals of the resident. (ii) A summary of the resident's medications and dietary instructions. (iii) Any services and treatments to be FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YO5Z11 Facility ID: CA070000047 If continuation sheet 5 of 53 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 06/19/2019 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 administered by the facility and personnel acting on behalf of the facility. (iv) Any updated information based on the details of the comprehensive care plan, as necessary. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure a care plan was initiated for one of 12 sampled residents. Resident 16 had no oral health care plan started since admission. This failure is potential for Resident 16 not to receive the necessary oral health care needed for her nutritional status and well-being. Findings: During review of Resident 16's clinical record on 6/18/19, indicated Resident 16 was admitted with diagnoses including dysphagia oropharyngeal phase (difficulty swallowing) and gastro-esophageal reflux disease. (GERD,digestive disorder that affects the lower esophageal sphincter). Resident 16 was also edentuluos. The care plan did not include oral health care. During an interview with the director of nursing (DON) on 6/18/19 at 2: 57 p.m. he acknowledged he did not develop an oral care plan for Resident 16. Review of the facility's policy and procedure, "Care Plans", indicated individualized comprehensive care plan would be developed for each patient to meet the residents' medical, nursing, mental, and psychological needs.

F679 SS=D Activities Meet Interest/Needs Each Resident CFR(s): 483.24(c)(1)

F679 07/19/2019 §483.24(c) Activities. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YO5Z11 Facility ID: CA070000047 If continuation sheet 6 of 53 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 06/19/2019 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 §483.24(c)(1) The facility must provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community. This REQUIREMENT is not met as evidenced by: Based on observation, interview and, record review, the facility failed to provide an on-going activity program when the facility did not provide sufficient room visits to one of twelve sampled residents (26). This failure had the potential to affect the psychosocial well-being of the resident. Findings: Multiple observations conducted on 6/17/19 at 8:39 a.m., 11:45 a.m., and 4:49 p.m.; 6/18/19 at 7:08 a.m., 10:53 a.m., and 3 p.m.; and 6/19/19 at 7:15 a.m.. Resident 26 was observed either sleeping or staring on the ceiling. The television was off, no radio, musical device or other form of sensory stimulation provided. During an interview with activity director (AD) on 6/18/19 at 3:59 p.m., he stated he provided Resident 26 a 15 minute minute, three times a week one-on-one activity. He stated Resident 26 was not alert and oriented, stayed in bed most of the times and rarely attended group activity. The AD confirmed he gave Resident 26 a hand massage, listened to music and played musical instruments at least three times a week. He acknowledged he was not aware FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YO5Z11 Facility ID: CA070000047 If continuation sheet 7 of 53 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 06/19/2019 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 the television had not been used in the last few days and there was no radio or listening device at the bedside for the resident to use. A review of Resident 26's admission record indicated she was admitted on 9/2/16 with diagnoses including dementia (a decline in mental ability) and depressive disorder (persistent feeling of sadness and loss of interest). Review of the most recent minimum data set (MDS, an assessment tool) indicated Resident 26's cognition (mental process) was impaired. The activity care plan dated 6/19/19, indicated the resident was dependent on staff for meeting emotional, intellectual, physical, and social needs. One of facility interventions was to provide one-on-one bedside/in-room visits. Resident 26's activity log from 3/1/19 thru 6/14/19 indicated the following activities: hand massage, played instrumental music, listening to music, and watching television. No other documented one-on-one visits after 6/14/19. The facility's policy and procedure, "One-OnOne" dated 1/24/19, indicated resident who are unable to leave their rooms will be provided one-on-one in room activities. Involvement will be documented in the One-On-One/In-Room Visit Log Form.

F695 SS=D Respiratory/Tracheostomy Care and Suctioning F695 CFR(s): 483.25(i) 07/19/2019 § 483.25(i) Respiratory care, including tracheostomy care and tracheal suctioning. The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YO5Z11 Facility ID: CA070000047 If continuation sheet 8 of 53 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 06/19/2019 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 and 483.65 of this subpart. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure appropriate care and treatment was provided for one sampled resident (Resident 13) when the resident was observed receiving oxygen (O2) without physician's order and no "No Smoking, Oxygen in Use" signage posted at the door or anywhere in resident's room. These failures had the potential for the resident to receive too much or too little O2 that may jeopardize his respiratory condition and safety. Findings: Review of Resident 13's clinical record indicated he was readmitted to the facility on 6/10/19 with diagnoses including chronic obstructive pulmonary disease (COPD, is a chronic inflammatory lung disease that causes obstructed airflow from the lungs), pneumonia (lung inflammation caused by bacterial or viral infection), bronchitis (an inflammation of the bronchial tubes, the airways that carry air to your lungs), and acute respiratory failure (a sudden inability of the lungs to maintain normal respiratory function). During an initial tour of the facility on 6/17/19 at 10:04 a.m., Resident 13 was observed receiving oxygen inhalation at 2 liters per minute via nasal cannula (a plastic tubing used to deliver O2) connected from oxygen concentrator machine (a device which concentrates the oxygen from a gas supply (typically ambient air) to supply an oxygen enriched gas stream). In addition, there was no "No Smoking, Oxygen in Use" signage posted in Resident 13's room. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YO5Z11 Facility ID: CA070000047 If continuation sheet 9 of 53 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 06/19/2019 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 On a concurrent interview with certified nursing assistant F (CNA F ), she confirmed there was no "No Smoking, Oxygen in Use" signage posted on Resident 13's room. Further review of Resident 13's clinical record on 6/19/19, indicated there was no physician's order to give O2 inhalation. During an interview with licensed nurse E (LN E) on 6/19/19 at 8:27 a.m., she confirmed there was no physician's order to give O2 inhalation for Resident 13. During an interview with the director of nursing (DON) on 6/19/19 at 8:49 a.m., he acknowledged the facility's licensed nurses should have obtained a physician's order and specific instructions before the administration of O2 for Resident 13. The DON further stated "No Smoking, Oxygen in Use" signage should have been posted at Resident 13's room to prevent possible accidents. Review of the facility's policy and procedures with revision date of 1/24/19, "Oxygen Administration", indicated verify that there is a physician's order for this procedure. Place an "Oxygen in Use" sign in a designated place on or over the resident's bed.

F698 SS=D Dialysis CFR(s): 483.25(l)

F698 07/19/2019 §483.25(l) Dialysis. The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. This REQUIREMENT is not met as evidenced FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YO5Z11 Facility ID: CA070000047 If continuation sheet 10 of 53 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 06/19/2019 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 by: Based on interview and record review the facility failed to ensure dialysis service provided for one of one resident (Resident 29) were consistent when the dialysis communication records were incomplete. This failure may affect the dialysis care provided to the resident. Findings: Review of Resident 29's clinical record indicated he had diagnoses including endstage renal disease (ESRD, a condition in which the kidney no longer function normally to filter waste and excess water from the blood as urine) and dependence on hemodialysis (a process of removing waste and excess water from the blood in those whose kidneys have lost normal function). Resident 29 was scheduled for dialysis every Tuesday, Thursday, and Saturday. Review of Resident 29's hemodialysis communication records (HCRs) dated 3/5/19, 3/7/19, 3/12/19, 3/14/19 , 4/2/19, 4/4/19, 4/20/19, 4/23/19, 4/25/19, 4/27/19, 4/30/19, 5/7/19, 5/11/19, 5/14/19, 5/21/19, 5/23/19, 5/25/19, 5/27/19, 6/1/19, 6/6/19, and 6/13/19 were incomplete. During an interview and record review with the director of nursing (DON) on 6/17/18 at 12:26 p.m., the DON confirmed the HCRs on the above dates were incomplete. He acknowledged the licensed nurses should have followed-up with dialysis center and have completed the HCRs for Resident 29's continuity of dialysis care. Review of the facility's policy and procedure with the revision date of 1/24/19, "End-Stage Renal Disease, Care of a Resident With", indicated agreements between this facility and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YO5Z11 Facility ID: CA070000047 If continuation sheet 11 of 53 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 06/19/2019 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 the contracted ESRD facility include all aspects of how the resident's care will be managed, including how information will be exchanged between the facilities.

F755 SS=E Pharmacy Srvcs/Procedures/Pharmacist/Records CFR(s): 483.45(a)(b)(1)-(3)

F755 07/19/2019 §483.45 Pharmacy Services The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse. §483.45(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. §483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who§483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility. §483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and §483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. This REQUIREMENT is not met as evidenced by: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YO5Z11 Facility ID: CA070000047 If continuation sheet 12 of 53 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 06/19/2019 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 Based on observation, interview, and record review, the facility failed to ensure accurate or effective accountability, storage, and administration of controlled substance (CS, drugs with high potential for abuse or addiction) medications; and safe dispensing of medications, to meet the needs of residents when: 1. The emergency kit (e-kit, a kit/box containing medications and supplies for immediate use during a medical emergency) contained more lorazepam (a CS medication for anxiety/seizures) counts than listed on the contents list; 2. CS medications for a discharged resident (Resident 83) were kept in the medication room where multiple nurses had access to, and there were no daily accounting for these medications. This had the potential for loss/abuse and unaccountability of CS medications; 3. Twelve blister cards of CS medications remained in the medication cart long after they had been discontinued and without daily accounting by the nursing staff. This had the potential for loss/abuse and unaccountability of CS medications; 4. A Percocet tablet (a potent CS medication for pain) was given to Resident 33 without a physician order, resulting a medication error; 5. Pradaxa (a blood thinner) for Resident 4 was not dispensed in original container as specified by the manufacturer. This had the potential for reduced effectiveness of the medication; and 6. The facility did not have current drug information resources available for the staff to utilize to look up necessary drug information for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YO5Z11 Facility ID: CA070000047 If continuation sheet 13 of 53 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 06/19/2019 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 residents. Findings: 1. On 6/17/19 at 8:25 a.m., inspection of the facility's Medication Room with licensed nurse (LN) A identified an e-kit in the medication refrigerator. The contents list on the outside indicated two vials of lorazepam 2 milligrams (mg, unit of measurement) per milliliter (ml). The e-kit contained 3 lorazepam 2 mg/ml vials. LN A confirmed this finding. During a visit to the Medication Room with the director of nursing (DON) on 06/17/19 at 9:51 a.m., the DON observed the refrigerated e-kit and verified the content inside the e-kit did not match the amount on the list. This had the potential for someone removing a vial without the facility detecting the loss. The facility's undated policy, "MEDICATION ORDERING AND RECEIVING FROM PHARMACY", indicated under Section M: "The incoming and outgoing nurses verify the inventory of controlled substances at each change of shift or exchange of keys." During a telephone interview on 6/18/19 at 11:43 a.m., the consultant pharmacist (CP) said the pharmacist who checked the e-kit did not check the contents for accuracy before sending it out to the facility. 2. During the visit to the Medication Room with the DON on 6/17/19 at 9:51 a.m., a locked cabinet containing three emergency e-kits (for general medications) was identified. The medication nurse had the key to this locked cabinet during his/her shift. Inside of the locked cabinet was a plastic bag containing 4 bubble-packs, 3 vials, and 2 bottles of CS medications for Resident 83, as follows: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YO5Z11 Facility ID: CA070000047 If continuation sheet 14 of 53 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 06/19/2019 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 - 22 half tabs lorazepam 1 mg (11 whole tabs) - 30 whole tabs lorazepam 1 mg - 30 whole tabs lorazepam 1 mg - 10 whole tabs of Norco (a narcotic for pain) 5/325 mg - 10 ml of morphine 20 mg/ml - 30 ml of morphine 20 mg/ml Total: 71 tabs of lorazepam; 10 tablets of Norco, and 40 ml of morphine. The accountability sheets (or count sheet or inventory record) for each of these items were included inside the bag. During this visit, the DON stated Resident 83 passed away about three months ago. He stated Resident 83' CS medications should have been given to him to put in a secure place. He said the licensed nurses had access to this locked cabinet, and there was no daily accounting for these medications by the nursing staff. The facility's 9/2010 "Storage of Medication" policy, indicated "The access system (key, security codes) used to lock Schedule II medications and other medications subject to abuse, cannot be the same access system used to obtain the non-scheduled medications." 3. On 06/17/19 at 10:44 a.m., an inspection of one out of one medication cart with LN B revealed 12 bubble-packs of discontinued CS medications inside the locked CS medication compartment. The count sheet for each was wrapped around each bubble-pack. LN B said she did not know how long they had been there. During an interview on 6/17/19 at 3:20 p.m., the DON said the nursing staff had been telling FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YO5Z11 Facility ID: CA070000047 If continuation sheet 15 of 53 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 06/19/2019 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 him of the discontinued CS medications in the medication cart but he forgot to remove them. A review with the DON at this time revealed the following CS medications in the medication cart with their respective discontinue (DC) date: - 9 tablets of Norco 5/325 mg for Resident 25, DC date: 3/13/19; - 39 tablets of Tramadol (medication for pain) 50 mg for Resident 25, DC date 3/14/19 - 13 tablets of morphine 15 mg for Resident 25, DC date 3/21/19 - 30 tablets of tramadol 50 mg for Resident 84, DC date 3/6/19 - 19 tablet of Norco 7.5/325 mg for Resident 85, DC date 5/24/19 - 13 tablets of lorazepam 0.5 mg for Resident 85, DC date 5/24/19 - 27 tablets of Norco 5/325 mg for Resident 23, DC date 6/11/19. - 18 tablets of Oxycontin (a potent narcotic for pain) 15 mg for Resident 34, DC date 3/29/19 - 27 tablets of Norco 5/325 mg for Resident 33, DC date 3/22/19 - 7 tablets of Percocet 10/325 mg for "Emergency Kit use", 1 tablet was used for Resident 33 on 3/21/19 - 18 tablets of Norco 5/325 mg for Resident 29, DC date 2/12/19 - 8 tablets of Tylenol with codeine #3 for Resident 28, DC date 6/3/19 Thus, these CS medications remained in the medication cart long after they had been discontinued; one was dated 2/12/19 (more than 4 months from survey date). During an interview on 06/18/19 at 11:15 a.m., the DON said the nurses were supposed to give them to him as soon as they were discontinued, to put away in a secure place until they could be destroyed with the CP during her visit. He acknowledged that count FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YO5Z11 Facility ID: CA070000047 If continuation sheet 16 of 53 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 06/19/2019 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 sheet was wrapped around each bubble-pack, thus would allow for them to be taken without detection because the nurses did not keep count of these medications during shift changes as they would for the active CS medications. The facility's 9/2010 policy, "Disposal of Medications, Syringes, and Needles" indicated: "Discontinued medications and/or medications left in the nursing care center after a resident's discharge... are identified and removed from current medication supply in a timely manner for disposition. Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances...are subject to special...record keeping in the nursing care center... Controlled Substances...remaining in the nursing care center after the order has been discontinued are retained in the nursing care center in a securely double locked area with restricted access until destroyed. The director of nursing shall log the stored medications as they are received from the nursing station." 4. On 6/17/19 at 3:20 p.m., the review of the above discontinued CS medications identified that 1 tablet of Percocet (oxycodone with acetaminophen) 10/325 mg was used from the "Emergency Kit" supply for Resident 33 on 3/21/19 at 8 p.m. The DON was requested to provide a physician order for this use. On 6/18/19 at 3:13 p.m., a review of Resident 33's medication administration record with the DON revealed the nursing staff documented a dose of Norco 10/325 mg (not Percocet) was given on 3/21/19 at 8 p.m. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YO5Z11 Facility ID: CA070000047 If continuation sheet 17 of 53 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 06/19/2019 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 a concurrent interview and record review on 6/19/19 at 11:57 a.m., the DON stated Resident 33 did not have a physician order for Percocet 10/325 mg. He provided a copy of a physician order written for Resident 33, for Norco 10/325 mg, dated 3/21/19. The DON acknowledged the nursing staff administered a Percocet 10/325 mg tablet to Resident 33 without a physician order, which was a medication error. The facility's undated policy, "MEDICATION ADMINISTRATION - GENERAL GUIDELINES", indicated in part, "FIVE RIGHTS - Right resident, right drug, right dose...are applied for each medication being administered." 5. During a medication pass observation on 6/18/19 at 9:50 a.m., LN C was observed preparing four medications for Resident 4. Included in the medications was a capsule of Pradaxa 150 mg which LN C punched out from a bubble-pack. The labeling on the Pradaxa bubble-pack (by the pharmacy) included a cautionary label, which indicated, "Keep this medicine in the original container and close tightly after each use to prevent loss of potency." During an interview on 6/18/19 at 11:06 a.m., LN C verified the pharmacy provided Resident 4's Pradaxa in a bubble-pack, not in an original container, as per the pharmacy label. To date, the manufacturer for Pradaxa indicates the following for its storage: "Once opened, the product must be used within 4 months. Keep the bottle tightly closed. Store in the original package to protect from moisture." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YO5Z11 Facility ID: CA070000047 If continuation sheet 18 of 53 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 06/19/2019 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 a telephone interview on 6/19/19 at 11:12 a.m., the CP acknowledged Pradaxa capsules for Resident 4 should have been kept in the original container as instructed per manufacturer. The facility's 9/2010 policy, "Medication Storage", indicated "Medications... are stored properly, following manufacturer's... recommendations, to maintain their integrity and to support safe effective drug administration." 6. During an interview on 6/18/19 at 2:39 p.m., LN C was asked to look up drug information for Resident 20. She used the facility's Nursing 2010 Drug Handbook to look up the information. The handbook was nine years old. LN C said if she had any questions on newer medications, she would Google the information on the internet. During an interview on 6/19/19 at 10 a.m., the director of staff development (DSD) said she did not know if the facility had a more up-todate drug information resources for the staff to use. She said she would normally Google drug information on the internet herself. She acknowledged Googling drug information was not a reliable method. During a telephone interview on 6/19/19 at 11:12 a.m., the CP stated she did not know the facility was using an old drug handbook. She agreed the staff should be provided a more current drug resource to look up drug information for the residents. The facility's undated policy, "MEDICATION ORDERING AND RECEIVING FROM PHARMACY", indicated "The consultant pharmacist identifies one or more current medication reference to help staff in the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YO5Z11 Facility ID: CA070000047 If continuation sheet 19 of 53 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 06/19/2019 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 identification of medications and information on the contraindications, side effects and/or adverse effects, dosage levels and other pertinent information. The [Quality Assessment and Assurance Committee] selects one or more reference from the list for the facility to purchase."

F756 SS=E Drug Regimen Review, Report Irregular, Act On CFR(s): 483.45(c)(1)(2)(4)(5)

F756 07/19/2019 §483.45(c) Drug Regimen Review. §483.45(c)(1) The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist. §483.45(c)(2) This review must include a review of the resident's medical chart. §483.45(c)(4) The pharmacist must report any irregularities to the attending physician and the facility's medical director and director of nursing, and these reports must be acted upon. (i) Irregularities include, but are not limited to, any drug that meets the criteria set forth in paragraph (d) of this section for an unnecessary drug. (ii) Any irregularities noted by the pharmacist during this review must be documented on a separate, written report that is sent to the attending physician and the facility's medical director and director of nursing and lists, at a minimum, the resident's name, the relevant drug, and the irregularity the pharmacist identified. (iii) The attending physician must document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YO5Z11 Facility ID: CA070000047 If continuation sheet 20 of 53 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 06/19/2019 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 §483.45(c)(5) The facility must develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident. This REQUIREMENT is not met as evidenced by: 6. On 6/19/19, a review of Resident 12's medical record reflected the resident was admitted to the facility in January 2019 with diagnoses including diabetes, anemia (condition when blood lacks enough healthy red blood cells or hemoglobin), hyperlipidemia (high lipids in the blood), and dehydration. The medical record revealed the CP made a recommendation to the physician during her May 2019 visit, indicating, "Can we please order the following baseline labs to ensure current therapy is appropriate: Lipid panel, ALT, AST, A1C, TSH, Vitamin D." Lipid panel: a blood test that measures fat and fatty substances in the blood; ALT and AST are liver enzymes; A1C is the blood test that reflects your average blood glucose levels over the past 3 months; and TSH is to test if the thyroid is working the way it should. In response to the CP's recommendation, there was a hand-written note: "recently done last April." Review of Resident 12's medical record reflected no laboratory results for lipid panel nor A1C done in April or any other months since the patient's admission in January 2019. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YO5Z11 Facility ID: CA070000047 If continuation sheet 21 of 53 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 06/19/2019 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 6/19/19 at 1:45 p.m. in the presence of the DON, LN C reviewed Resident 12's medical record and confirmed there were no laboratory results for lipid panel and A1C. She stated she reviewed the lab order book which indicated there had been no orders for these lab tests. The DON and LN C confirmed this finding. Based on observation, interview and record review, the facility's consultant pharmacist (CP) failed to identify drug-related issues on three of twelve sampled residents (Residents 1, 20, and 24), and two required medication safety and security as it related to controlled substances and drug information resources as follows: 1. The CP failed to identify the ongoing drug and food interaction for Resident 20 during the monthly Drug Regimen Review (DRR, a review of all medications the resident to identify any potential adverse effects and drug interactions); 2. The CP failed to identify inappropriate use of a vasoconstrictor eye drop (vasoconstrictor works by shrinking the tiny blood vessels in the eyes to reduce eye redness) for Resident 1; 3. The CP failed to identify the lack of rationale and duration exceeding 14 days for a psychotropic medication ordered on "as needed" basis for Resident 24; 4. The CP failed to identify lack of current drug information resources for use by licensed staff; 5. The CP failed to address the discontinued controlled substances (drugs with high potential for abuse or addiction), being held in medication room and medication cart for extended period of time; 6. The facility failed to adequately address a recommendation from the CP for ordering labs FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YO5Z11 Facility ID: CA070000047 If continuation sheet 22 of 53 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 06/19/2019 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 Resident 12. These deficiencies had the potential for unsafe medication use in the facility. Findings: 1. During a medication pass observation on 06/18/19 at 2:24 p.m., LN C was observed giving two medications, including a tablet of ferrous sulfate 325 mg, along with a 4-ounce cup of milk to Resident 20. Review of the physician orders on 6/18/2019 around 3 p.m., indicated the following orders: - Ferrous sulfate tablet 325 mg give one tablet three times daily for anemia, since 11/02/2016 - Provide 8 fluid ounce of non-fat milk three times daily with meals, since 11/4/2016 On 6/18/2019 around 3 p.m., review of the June 2019, Medication Administration Record, indicated ferrous sulfate was scheduled three times daily concurrently with non-fat milk at 9:00 a.m., 2:00 p.m., and 9:00 p.m. On 6/18/19 at around 3 p.m., LN C looked up the facility's drug book, "Nursing Drug Handbook, 2010", which indicated the following for administration of iron tablet: "Give tablets with juice...or water, but not with milk or antacids." LN C stated she was not aware of the interaction between iron and milk products when administered at the same time. To date, Lexi-comp, a nationally recognized drug information resource, indicates "milk may decrease absorption" of iron when administered together. Record review of the monthly Drug Regimen Review (DRR) on 6/19/2019, indicated no interventions by the CP on food and drug FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YO5Z11 Facility ID: CA070000047 If continuation sheet 23 of 53 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 06/19/2019 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 interaction for Resident 20, for the past several months from February 2019 to May 2019. During a telephone interview on 6/19/2019 at 11:12 a.m., the CP stated during her monthly DRR, she could not recall if she identified iron and milk interaction for Resident 20. In an interview on 6/18/19 at 3:12 p.m., the DON stated the facility relied on the CP to address these type of concerns during her monthly DRR. Review of the facility's policy, "Consultant Pharmacist Reports: Medication Regimen Review" last updated on 1/24/2019, indicated the CP evaluation included checking "the administration schedule is appropriate for the resident, considering side effects...compatibility with other medications and diet." 2. During a medication pass observation on 6/18/19 at 4:47 p.m., LN D was observed preparing an eye product labeled as "CareALL Eye Drop - Original Redness Reliever" containing tetrahydrozolin 0.05% (a product is known to be a vasoconstrictor that works by shrinking the tiny blood vessels in the eyes to reduce eye redness) for Resident 1. At the bedside, LN D administered one drop of "CareALL Eye Drop" into each of Resident 1's eyes. Review of Resident 1's medical record on 6/18/19 around 5:06 p.m. indicated the physician ordered the eye drop on 8/21/2017 for "LiquiTears Solution (Polyvinyl Alcohol)" (a lubricant and eye protectant product) one drop in both eyes two times a day for dry eyes. In an interview on 6/18/19 around 5:20 p.m., LN D stated the eye drop stocked in the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YO5Z11 Facility ID: CA070000047 If continuation sheet 24 of 53 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 06/19/2019 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 medication cart was the only product available. She was not aware of the difference between what was ordered and the one she was administering. Furthermore, LN D stated she had been using the same product for awhile, and had multiple bottles of the same eye drop in the medication cart. In an interview on 6/18/19 at 5:30 p.m., the DON stated that he was not aware that the OTC eye product they were using was not an eye lubricant. Furthermore, the DON stated that the consultant pharmacist inspected the medication room and medication cart on monthly basis, and no discrepancy was reported to him. During a telephone interview on 6/19/2019 around 11:30 a.m., the CP stated she may have overlooked checking a product used and stocked in the facility during the monthly visits. Review of the facility's policy, "Consultant Pharmacist Reports: Medication Regimen Review" last updated on 1/24/2019, indicated "The consultant pharmacist performs a comprehensive review of each resident's medication regimen (MRR) at least monthly. The MRR includes evaluating the residents' response to medication ... prevent or minimize adverse consequences." 3. On 6/19/19, review of Resident 24's medical record indicated there was no documented evidence to show a physician addressed a rationale on why the resident needed the lorazepam (medication commonly used to treat anxiety) use beyond 14 days, and there was no specific duration for this as-needed order. In a telephone interview on 6/19/2019 at 11:17 a.m., the consultant pharmacist stated that she may have missed questioning the duration of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YO5Z11 Facility ID: CA070000047 If continuation sheet 25 of 53 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 06/19/2019 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 lorazepam use beyond 14 days. In an interview on 6/19/2019 at 12:03 p.m., the DON stated he was aware of the requirement for a new physician order to re-order beyond 14 days. He additionally stated that the DRR by the consultant pharmacist should have alerted the facility to address the requirement. Review of the facility's policy, "Consultant Pharmacist Reports: Medication Regimen Review" last updated on 1/24/2019, indicated "The consultant pharmacist performs a comprehensive review of each resident's medication regimen (MRR) at least monthly. The MRR includes evaluating the residents' response to medication therapy to ...prevent or minimize adverse consequences to medication therapy. Findings and recommendations are reported to the director of nursing and the attending physician." 4. During an interview on 6/18/19 at 2:39 p.m., LN C used the facility's "Nursing 2010 Drug Handbook" to look up the information regarding a medication administration. The handbook was nine years old. LN C said if she had any questions on newer medications, she would Google the information on the internet. During an interview on 6/19/19 at 10 a.m., the director of staff development (DSD) said she did not know if the facility had a more up-todate drug information resources for the staff to use. She said she would normally Google drug information on the internet herself. She acknowledged Goggling drug information was not a reliable method. During a telephone interview on 6/19/19 at 11:12 a.m., the CP said she did not know the facility was using an old drug handbook. She agreed that the staff should be provided a more FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YO5Z11 Facility ID: CA070000047 If continuation sheet 26 of 53 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 06/19/2019 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 current drug resource to look up drug information for the residents. The facility's undated policy, "MEDICATION ORDERING AND RECEIVING FROM PHARMACY", indicated "The consultant pharmacist identifies one or more current medication reference to help staff in the identification of medications and information on the contraindications, side effects and/or adverse effects, dosage levels and other pertinent information." 5. During a visit to the Medication Room with the DON on 6/17/19 at 9:51 a.m., a locked cabinet containing three emergency e-kits (for general medications) was identified. Inside of the locked cabinet was a plastic bag containing 71 tabs of lorazepam (a CS medication for anxiety/seizures) 1 mg; 10 tablets of Norco (a CS medication for pain) 5/325 mg, and 40 ml of morphine 20 mg/ml for Resident 83. The accountability sheets (or count sheet or inventory record) for each of these items were included inside the bag. During this visit, the DON said Resident 83 passed away about three months ago. He stated Resident 83's CS medications should have been given to him to put in a secure place. He said the licensed nurses had access to this locked cabinet, and there was no daily accounting for these medications by the nursing staff. On 06/17/19 at 10:44 a.m., an inspection of one out of one medication cart with LN B revealed 12 bubble-packs of discontinued CS medications inside the locked CS medication compartment. The count sheet for each was wrapped around each bubble-pack. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YO5Z11 Facility ID: CA070000047 If continuation sheet 27 of 53 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 06/19/2019 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 On 6/17/19 at 3:20 p.m., a review with the DON at this time revealed the following CS medications in the medication cart with their respective discontinue (DC) date: - 9 tablets of Norco 5/325 mg for Resident 25, DC date: 3/13/19; - 39 tablets of Tramadol (medication for pain) 50 mg for Resident 25, DC date 3/14/19 - 13 tablets of morphine 15 mg for Resident 25, DC date 3/21/19 - 30 tablets of tramadol 50 mg for Resident 84, DC date 3/6/19 - 19 tablet of Norco 7.5/325 mg for Resident 85, DC date 5/24/19 - 13 tablets of lorazepam 0.5 mg for Resident 85, DC date 5/24/19 - 27 tablets of Norco 5/325 mg for Resident 23, DC date 6/11/19. - 18 tablets of Oxycontin (a potent narcotic for pain) 15 mg for Resident 34, DC date 3/29/19 - 27 tablets of Norco 5/325 mg for Resident 33, DC date 3/22/19 - 7 tablets of Percocet 10/325 mg for "Emergency Kit use", 1 tablet was used for Resident 33 on 3/21/19 - 18 tablets of Norco 5/325 mg for Resident 29, DC date 2/12/19 - 8 tablets of Tylenol with codeine #3 for Resident 28, DC date 6/3/19 Thus, these CS medications remained in the medication cart long after they had been discontinued; one was dated 2/12/19 (more than 4 months from survey date). During an interview on 6/18/19 at 11:15 a.m., the DON said the nurses were supposed to give them to him as soon as they were discontinued, to put away in a secure place until they could be destroyed with the CP during her visit. He acknowledged the count sheet was wrapped around each bubble-pack, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YO5Z11 Facility ID: CA070000047 If continuation sheet 28 of 53 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 06/19/2019 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 thus would allow for them to be taken without detection because the nurses did not keep count of these medications during shift changes as they would for the active CS medications. During a telephone interview on 6/18/19 at 11:43 a.m., when asked if she identified CS medications being kept in the medication cart and room long after they were discontinued, the CP stated, "Maybe I missed it; maybe it's a human error." She said they were not supposed to be in the medication cart and room. The facility's 9/2010 policy, "Disposal of Medications, Syringes, and Needles", indicated "Discontinued medications and/or medications left in the nursing care center after a resident's discharge... are identified and removed from current medication supply in a timely manner for disposition."

F758 SS=D Free from Unnec Psychotropic Meds/PRN Use F758 CFR(s): 483.45(c)(3)(e)(1)-(5) 07/19/2019 §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 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YO5Z11 Facility ID: CA070000047 If continuation sheet 29 of 53 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 06/19/2019 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 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; §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: 2. During a review of the clinical record for Resident 1, the admission record dated 6/19/19, indicated she was re-admitted to the facility on 8/21/17 with diagnoses including unspecified psychosis (a set of symptoms of mental illnesses that result in strange or bizarre thinking, perceptions, behaviors, and emotions). The physician's order dated 5/30/19 indicated an order for quetiapine fumarate (a medication used to treat certain mental/mood FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YO5Z11 Facility ID: CA070000047 If continuation sheet 30 of 53 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 06/19/2019 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 conditions such as schizophrenia, bipolar disorder, sudden episodes of mania or depression associated with bipolar disorder) initiated on 8/21/17. During an interview with the director of nursing (DON) on 6/19/19 at 8:38 a.m., he stated since Resident 1's readmission, there was no GDR attempted. The DON also confirmed there was no interdisciplinary team (IDT, a group of health care professionals from diverse fields who work in a coordinated fashion toward a common goal for the patient) re-evaluation and consultant pharmacist's recommendation since August 2017. A random review of Resident1's IDT notes and monthly medication regimen review (MRR) did not indicate an attempt for GDR. The facility's policy and procedure, "Medication Monitoring and Management" dated 2013, indicated if a resident is admitted on an antipsychotic medication or the facility initiates antipsychotic therapy, the facility must attempt a GDR in two separate quarters within the first year, unless clinically contraindicated. After the first year, a GDR must be attempted annually unless clinically contraindicated. Based on interview and record review, the facility failed to ensure two of 14 sampled residents (Residents 1 and 24) were free from unnecessary psychotropic (drug that affects brain activities associated with mental processes and behavior) medications when: 1. For Resident 24, the facility did not monitor the effectiveness of the anti-depressant (fluvoxamine); and did not have the prescriberdocumented rationale and specified duration for extended use of the as-needed lorazepam (a psychotropic medication for anxiety) beyond 14 days; and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YO5Z11 Facility ID: CA070000047 If continuation sheet 31 of 53 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 06/19/2019 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 2. For Resident 1, the facility did not attempt a gradual dose reduction (GDR, tapering of dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the medication can be discontinued). These failures had the potential to result in unnecessary use of medications. Findings: 1a. On 6/19/19, a review of Resident 24's medical record indicated she was admitted to the facility with diagnoses including depression and anxiety. Her medications included fluvoxamine 25 mg, 8 tablets at bedtime for difficulty of sleeping, dated 5/17/19. There was no documented evidence in the medical record to show the facility monitored the effectiveness of this medication. During a concurrent interview and review on 6/19/19 at 11:57 a.m., the director of nursing (DON) reviewed Resident 24's medical record and stated the fluvoxamine was for treating the resident's "difficulty sleeping." Further he stated the facility should monitor the resident's sleeping pattern, as well as, the number of hours of sleep to ensure the medication was effective. After a few moments of reviewing the record, he stated the facility had not been monitoring for sleep patterns or hours of sleep. 1b. Included in Resident 24's medication regimen was a physician order, dated 4/29/19, for lorazepam 0.5 mg, 1 tablet by mouth every 4 hours as needed for anxiety or sleep. This order exceeded 14 days. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YO5Z11 Facility ID: CA070000047 If continuation sheet 32 of 53 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 06/19/2019 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 On 6/19/19, review of Resident 24's medical record indicated there was no documented evidence to show the physician documented the rationale why the resident needed the lorazepam beyond 14 days, and there was no specific duration for this as-needed order. During an interview on 06/19/19 at 11:57 a.m., the DON said he was aware of CMS' requirement for as-needed psychotropic medications to not exceed 14 days unless there was documented rationale and duration by the prescriber. When asked to look up Resident 24's medical record for evidence of those, he said, "No, I don't need to look. I know it's not in the record." The facility's undated "Medication Monitoring and Management" policy, indicated "In order to optimize the therapeutic benefit of medication therapy and minimize or prevent potential adverse consequences, facility staff, the attending physician/precriber, and the consultant pharmacist perform ongoing monitoring for appropriate, effective, and safe medication use." The policy addressed the general as-needed (PRN) medication use, but it did not address the PRN psychotropic medications being used beyond 14 days.

F759 SS=E Free of Medication Error Rts 5 Prcnt or More CFR(s): 483.45(f)(1)

F759 07/19/2019 §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 a 11.11% medication FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YO5Z11 Facility ID: CA070000047 If continuation sheet 33 of 53 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 06/19/2019 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 error rate when three errors out of 27 opportunities were observed during medication pass for Resident 1, Resident 3, and Resident 20, as follows: a. For Resident 1, the nursing staff administered an eye drop not in accordance to the physician's order. b. For Resident 3, the nursing staff administered a wrong formulation of aspirin (a medication used to help prevent stroke or heart attack and is coated to prevent stomach discomfort). c. For Resident 20, the nursing staff administered ferrous (iron) sulfate with milk, which was against the manufacturer's specifications for the administration of iron. This failure resulted in Residents 1 and 3 receiving wrong medications, and Resident 20 receiving medication with milk that adversely affect the effectiveness of the medication. Findings: a. During a medication pass observation on 6/18/19 at 4:47 p.m., licensed nurse D (LN D) was observed preparing an eye product labeled as "CareALL Eye Drop - Original Redness Reliever" containing tetrahydrozolin 0.05% (a product is known to be a vasoconstrictor that works by shrinking the tiny blood vessels in the eyes to reduce eye redness) for Resident 1. At the bedside, LN D administered one drop of "CareALL Eye Drop" into each of Resident 1's eyes. Review of Resident 1's medical record on 6/18/19 at 5:06 p.m. indicated the physician ordered the eye drop on 8/21/2017 for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YO5Z11 Facility ID: CA070000047 If continuation sheet 34 of 53 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 06/19/2019 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 "LiquiTears Solution (Polyvinyl Alcohol)" (a lubricant and eye protectant product) one drop in both eyes two times a day for dry eyes. In an interview on 6/18/19 around 5:20 p.m., LN D stated the eye drop stocked in the medication cart was the only product available to use. She was not aware of the difference between what was ordered and the one she was administering. LN D furthermore stated she had been using the same product for a while, and had multiple bottles of the same eye drop in the medication cart. In an interview on 6/18/19 at 5:30 p.m., the director of nursing (DON) stated the over the counter (also known as OTC, medication that does not require a prescription) eye drops were ordered through a wholesaler, and he was not aware the product they were using (CareALL Eye Drop) was not an eye lubricant. b. During a medication pass observation on 6/18/19 at 08:59 a.m., LN C was observed giving 6 medications including a tablet of aspirin EC (enteric coated, coating formation that allows aspirin to pass through the stomach to the small intestine before dissolving) 81 mg to Resident 3. Review of Resident 3's medical record on 6/18/19 at 10:35 a.m. indicated a physician order, dated 10/24/2018, for plain aspirin 81mg one tablet by mouth in the morning for stroke prevention. In an interview on 6/18/2019 at 11:02 a.m., LN C stated it did not matter which type of aspirin to use; and she was told to use either plain or an EC product depending on whether or not the resident could swallow. LN C acknowledged the physician order did not specify to use the enteric coated. She said she should clarify with FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YO5Z11 Facility ID: CA070000047 If continuation sheet 35 of 53 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 06/19/2019 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 the physician which aspirin formulation to give. Review of the facility's undated policy, "Medication Administration- General Guideline", provided by DON on 6/19/2019, indicated: "Medications are administered in accordance with written orders of the prescriber." c. During a medication pass observation on 06/18/19 at 02:24 p.m., LN C was observed giving two medications, including a tablet of ferrous sulfate 325 mg, along with a 4-ounce cup of milk to Resident 20. Resident 20 was observed consuming all of the milk along with her medications. On 6/18/2019 around 3 p.m., review of the June 2019 Medication Administration Record indicated ferrous sulfate was scheduled three times daily concurrently with non-fat milk at 9 a.m., 2 p.m., and 9 p.m. Review of the physician orders on 6/18/2019 around 3 p.m., indicated the following orders: - Ferrous sulfate tablet 325mg give one tablet three times daily for anemia, since 11/02/2016 - Provide 8 fluid ounce of non-fat milk three times daily with meals, since 11/4/2016 On 6/18/19 at around 3 p.m., LN C was asked to look up the drug information regarding the administration of iron sulfate. The facility's drug book, "Nursing Drug Handbook, 2010", indicated "Give tablets with juice...or water, but not with milk or antacids." LN C stated she was not aware of the interaction between iron and milk products when administered at the same time. To date, Lexi-comp, a nationally recognized drug information resource, indicates "milk may decrease absorption" of iron when FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YO5Z11 Facility ID: CA070000047 If continuation sheet 36 of 53 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 06/19/2019 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 administered together. In an interview with the DON on 6/18/19 at 3:12 p.m., he acknowledged the reduced effectiveness of iron with concurrent use of iron and milk products.

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

F761 07/19/2019 §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 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: Based on observation, interview, and record review, the facility failed to: ensure an eye medication for Resident 3 was labeled; label FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YO5Z11 Facility ID: CA070000047 If continuation sheet 37 of 53 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 06/19/2019 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 three unopened insulin (medication to treat high blood sugar) vials after removing them from the refrigerator; discard and replace Resident 29's multi-dose insulin pen after 28 days of use; label Resident 18's insulin pen with an open date; and remove Resident 24's expired medication from stock. The deficient practices had a potential for residents to receive medications with reduced potency from expired medications, and/or medication errors due to medications not being labeled. Findings: On 6/17/19 at 10:44 a.m., inspection of the medication cart with licensed nurse B (LN B) identified the following: a. A brimonidine 0.2% eye drop (for glaucoma) was identified without a pharmacy label. LN B stated it belonged to Resident 3. She stated the pharmacy sent a pack of two bottles with one label, therefore one was not labeled. She acknowledged it should have been labeled with the resident's information such as name, dose, frequency of use, etc. b. Three unopened Novolog (short-acting insulin) vials were stored at room temperature. They were not labeled as to when they were removed from the refrigerator. To date, the manufacturer for Novolog indicates the following for storage: "Unopened vials, cartridges, and prefilled pens may be stored... at room temperature <30°C (<86°F) for 28 days." This indicated the vials were good for 28 days at room temperature. c. Among the insulin supply was a Humalog Kwikpen belonging to Resident 29. The pen FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YO5Z11 Facility ID: CA070000047 If continuation sheet 38 of 53 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 06/19/2019 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 had a labeled open date of 3/28/19. To date, the manufacturer for Humalog indicates, "Cartridges and prefilled pens that have been punctured (in use) should be stored at room temperatures <30°C (<86°F) and used within 28 days; do not freeze or refrigerate." During the inspection, LN B stated insulin pens were good for 28 days after opened. She acknowledged this pen would have expired on 4/26/19 (52 days before survey date) and should have been discarded. On 6/17/19, a review of Resident 29's medical record reflected a physician order, dated 2/17/19, for insulin lispro (Humalog), inject as per sliding scale (a set of instructions for administering insulin dosages based on specific blood glucose readings). A review of Resident 29's June 2019 medication administration record (MAR) with LN B during the inspection showed insulin lispro was administered once on 6/10/19. On 6/17/19, review of the May 2019 MAR, indicated insulin lispro was administered twice on 5/7/19 and 5/24/19. Thus, insulin lispro was used three times past its 28-day expiration date. LN B acknowledged the finding. d. Also among the insulin supply was Lantus (long acting insulin) SoloStar pen for Resident 18. It did not have an open date. LN B stated it should be labeled with an open date since it was good for 28 days after opened. To date, the manufacturer for Lantus SoloStar indicates: "...Once in use, store prefilled pens at room temperature <30°C (<86°F) and use FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YO5Z11 Facility ID: CA070000047 If continuation sheet 39 of 53 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 06/19/2019 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 within 28 days; do not refrigerate." e. Further inspection on 6/17/19 at 10:44 a.m. with LN B identified a large multi-vitamin bottle for Resident 24. It had the manufacturer expiration date of February 2019. LN B verified it had expired and said it should have been put away. The facility's undated "Labeling of Medication Containers" policy, indicated "All medications maintained in the facility shall be properly labeled... Labels for individual drug containers shall include all necessary information" such as resident's name; prescribing physician's name; the name, strength, and quantity of the drug; the date that the medication was dispensed; direction for use; etc. The facility's 9/2010 "Storage of Medication" policy, "Insulin products should be stored in the refrigerator until opened. Note the date on the label for insulin vials and pens when first used... Outdated...medications are immediately removed from stock...".

F791 SS=D Routine/Emergency Dental Srvcs in NFs CFR(s): 483.55(b)(1)-(5)

F791 07/19/2019 §483.55 Dental Services The facility must assist residents in obtaining routine and 24-hour emergency dental care. §483.55(b) Nursing Facilities. The facility§483.55(b)(1) Must provide or obtain from an outside resource, in accordance with §483.70(g) of this part, the following dental services to meet the needs of each resident: (i) Routine dental services (to the extent covered under the State plan); and (ii) Emergency dental services; FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YO5Z11 Facility ID: CA070000047 If continuation sheet 40 of 53 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 06/19/2019 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 §483.55(b)(2) Must, if necessary or if requested, assist the resident(i) In making appointments; and (ii) By arranging for transportation to and from the dental services locations; §483.55(b)(3) Must promptly, within 3 days, refer residents with lost or damaged dentures for dental services. If a referral does not occur within 3 days, the facility must provide documentation of what they did to ensure the resident could still eat and drink adequately while awaiting dental services and the extenuating circumstances that led to the delay; §483.55(b)(4) Must have a policy identifying those circumstances when the loss or damage of dentures is the facility's responsibility and may not charge a resident for the loss or damage of dentures determined in accordance with facility policy to be the facility's responsibility; and §483.55(b)(5) Must assist residents who are eligible and wish to participate to apply for reimbursement of dental services as an incurred medical expense under the State plan. This REQUIREMENT is not met as evidenced by: Based on interview, and record review, the facility failed to ensure dental services was provided for one of 12 sampled residents (16). Resident 16's dental services were not initiated or followed up since Resident 16 was admitted to the facility on 1/8/19. This failure had the potential to affect Resident 16's oral health needs, nutritional status and well-being not met. Findings: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YO5Z11 Facility ID: CA070000047 If continuation sheet 41 of 53 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 06/19/2019 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 observation of Resident 16 on 6/17/19 at 8:50 a.m., Resident 16 was in bed awake, alert, and responding appropriately to questions. Resident 16 was also edentulous. During a review of Resident 16's clinical record indicated she was admitted to the facility with diagnoses including dementia (a decline in mental ability severe enough to interfere with daily life), schizophrenia (a chronic and severe mental disorder that affects how a person thinks, feels, and behaves), and dysphagia oropharyngeal (difficulty swallowing). Further record review, indicated no evidence a dental services consult was initiated and followed-up since admission on 1/8/19. During an interview with the director of nursing (DON) on 6/18/19 at 2:57 p.m., he confirmed there was no consult done for dental services for Resident 16. During an interview with the social service director (SSD), she confirmed after reviewing the client's record there was no follow-up done for Resident 16's dental services. Review of the facility's policy and procedure, "Dental Services", indicated routine and emergency services care are available to meet the resident's oral health services in accordance with their assessment and plan of care.

F802 SS=F Sufficient Dietary Support Personnel CFR(s): 483.60(a)(3)(b)

F802 07/19/2019 §483.60(a) Staffing The facility must employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YO5Z11 Facility ID: CA070000047 If continuation sheet 42 of 53 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 06/19/2019 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 service, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.70(e). §483.60(a)(3) Support staff. The facility must provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. §483.60(b) A member of the Food and Nutrition Services staff must participate on the interdisciplinary team as required in § 483.21(b)(2)(ii). This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure sufficient staff with competencies to carry out the function of food and nutrition services as evidence by the following: 1) The cook (A) was not able to perform the test strip for chlorine (a litmus paper test) and quaternary test strip (measure the concentration of Quaternary Sanitizers) correctly. 2) Cook A used a ladle (a large long-handled spoon with a cup-shaped bowl) instead of a number 12 scooper (the number of level scoops it takes to fill a 32 oz container) for a regular portion as usually use. 3) Cook A gave one portion instead of double portion for one non sampled resident (8) while for Resident 236 and Resident 6 Cook A did not give extra gravy with margarine for their fortified diet. 4) Cook B did not completely drain the water from the partially thawed cooked breaded fish before pureeing. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YO5Z11 Facility ID: CA070000047 If continuation sheet 43 of 53 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 06/19/2019 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 These failures are potential to cause food borne illness and affect the well-being of the residents in the facility. Findings: 1. During an initial tour of the kitchen on 6/17/19 at 8: 13 a.m. Cook A demonstrated how she performed the chlorine test strip for the chemical dish washer and quaternary strip for the red bucket (a container for the sanition cloth in the kitchen). Cook A had to do both test several times to get the correct color. During a concurrent interview with Cook A she stated the dish washer was checked recently by Ecolab (provider for commercial Cleaning Products). Cook A acknowledged an inservice would be helpful. 2. During trayline (a food service assembly line) Cook A used a ladle with one of the dishes instead of a number 12 scooper for a regular portion. During a concurrent interview with Cook A she acknowledged she should use and do what was the practice in the kitchen to use scooper 12 for serving the regular portion. Cook A stated the ladle was the same with the scooper 12 from her experience. 3. Additional observation with Cook A indicated she gave one scoop of a dish for Resident 8 but the menu card indicated double portion. For Resident 236 and Resident 6, Cook A did not give extra gravy with margarine for their fortified diet. During a concurrent interview with Cook A, she confirmed she missed the extra gravy for both residents and gave it after. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YO5Z11 Facility ID: CA070000047 If continuation sheet 44 of 53 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 06/19/2019 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 4. During observation with Cook B, she performed the puree diet. Cook B did not completely drain the water from the partially thawed cooked breaded fish before pureeing. During a concurrent interview with Cook B she stated the extra water was for the consistency so she did not have to add more liquid. Review of the facility's policy and procedure for puree diet indicated to add broth or gravy to preserve the flavor.

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

F812 07/19/2019 §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 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 food was stored,prepared , and served under sanitary FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YO5Z11 Facility ID: CA070000047 If continuation sheet 45 of 53 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 06/19/2019 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 condition as evidence of the following: 1) Kitchen paper dispenser was broken, staff had to manually turn the side knob to get the paper. 2) Cheddar cheese (a relatively hard, off-white (or orange if spices such as annatto are added), sometimes sharp-tasting, natural cheese) was opened and undated inside the refrigerator. 3) Freezer door gasket (a shaped piece or ring of rubber or other material sealing the junction between two surfaces of a device) was broken. Water condensation around the door of a double door was observed. 4) A thermometer (an instrument for measuring and indicating temperature) inside the freezer was not working. 5) No log for refrigerator and freezer cleaning to monitor the cleaning and maintenance schedule of the equipment. 6) Cook A did not consistently change gloves in between tasks and did not wash hands before and after donning new gloves. These failures had the potential to cause for food-borne illnesses and cross-contamination which could affect the residents in the facility. Findings: During an initial tour with Cook A in the kitchen on 6/17/19 at 8:05 a.m., the following were observed: 1) Kitchen paper dispenser was broken. The staff had to manually turn the side knob to get the paper. 2) Cheddar cheese was opened and undated inside the refrigerator. 3) Freezer door's gasket was broken. Water condensation around the door of a double door was observed. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YO5Z11 Facility ID: CA070000047 If continuation sheet 46 of 53 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 06/19/2019 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 4) A thermometer inside the freezer was not working. 5) No log for refrigerator and freezer cleaning to monitor the cleaning and maintenance schedule of the equipment. 6) Cook A did not consistently change gloves in between tasks and did not wash hands before and after donning new gloves. During a concurrent interview with Cook A she acknowledged the above observations. Cook A also stated it was difficult if she was the only one in the morning and the dietary aide came only for two days per week to help out. Review of the facility's policy and procedure, "Gloves Use Policy", indicated wash hands when changing to a fresh pair. Gloves must never be used in place of hand washing. Change gloves before beginning a different task.

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

F880 07/19/2019 §483.80 Infection Control 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 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YO5Z11 Facility ID: CA070000047 If continuation sheet 47 of 53 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 06/19/2019 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 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 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 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YO5Z11 Facility ID: CA070000047 If continuation sheet 48 of 53 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 06/19/2019 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 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: Based on observation, interview, and record review, the facility failed to ensure safe infection control practices to prevent spread of infection on 4 sampled residents (Residents 2, 3,11, and 235) out of a census of 33. a. Licensed nurse (LN) C failed to change gloves after touching potentially contaminated objects before an eye drop administration on Resident 3. b. LN B failed to allow adequate contact time for cleaning glucometer (a device used to measure the blood sugar level) after the blood glucose checks for Resident 2 and Resident 235. c. Facility's LN did not replace an outdated asepto syringe for Resident 11. These failures had the potential for spreading infections in the facility. Findings: a. During a medication administration observation on 6/18/2019 at 9:08 a.m., LN C was observed putting 1 drop of olapantadine (an eye drop medication used for eye allergy) each of Resident 3's eyes using one piece of tissue. While waiting to give a second eye medication, LN C touched the overbed table and Resident 3's clothing with gloved hands. Then she administered the second eye FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YO5Z11 Facility ID: CA070000047 If continuation sheet 49 of 53 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 06/19/2019 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 medication, timolol 0.25% (an eye drop used to treat glaucoma), without changing gloves. In an interview with LN C on 6/18/2019 at 09:15 a.m., she stated she should have changed gloves and used a fresh tissue between left and right eyes. Review of the undated facility's policy, "Medication Administration- General Guideline" provided by the DON on 6/19/2018, indicated "Person administering medications adheres to good hand hygiene...after coming into direct contact with resident, and before and after administration of ophthalmic...medications..." Review of the facility's policy, "Handwashing/Hand Hygiene" and last reviewed on 1/21/2019, indicated the hand hygiene should be followed "after contact with inanimate objects (e.g., medical equipment) in the immediate vicinity of the resident." b. On 6/17/2019 at 11:13 a.m., LN B was observed performing a blood sugar check on Resident 2 using the facility's EvenCareG2 glucometer (a device used to measure the blood sugar level). After finished, LN B wiped the outer surfaces of the glucometer with the disinfectant labeled as "Asepti-Wipe II." The wipe down of the glucometer outer surface lasted less than 1 minute, and LN B placed the glucometer back in the medication cart. On 6/17/2019 at 11:29 a.m., the LN B performed another blood sugar measurement on Resident 235 using the same glucometer. The wipe down of glucometer after use for Resident 235 was less than 30 seconds contact time using the "Asepti-Wipe II" disinfectant. A review of the labeling on Asepti-Wipe II FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YO5Z11 Facility ID: CA070000047 If continuation sheet 50 of 53 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 06/19/2019 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 container, with LN B on 6/17/19 at 12:06 p.m., indicated users to allow a "3 minute Contact Time" for the elimination and prevention of bacteria and common viruses. LN B stated she wiped the outer surface of the glucometer for less than one minute contact time. She stated did not read the disinfectant label requiring minimum of 3 minute contact time after each use. In an interview with the director of staff development (DSD) on 6/19/19 at 10:05 a.m., she stated all licensed nurses go through orientation and annual training on basic skills and infection control competency. When asked about glucometer care on preventing spread of infection, the DSD repeated the same contact time of 1 minute or less with disinfectant. The DSD was not able to provide any document on staff education on glucometer care and use. In an interview with the DON on 6/19/2019 at 12:15 p.m., he confirmed the practice of cleaning the glucometer were not meeting the manufacturer's instructions. Review of the facility's policy, "Obtaining a Fingerstick Glucose Level" last revised on 1/24/2019, indicated to "[c]lean reusable equipment according to the manufacturer's instructions." c. Review of Resident 11's clinical record indicated he had diagnoses including dysphagia (difficulty of swallowing) and with gastrostomy tube (GT, a device surgically inserted into the stomach through the abdomen used to supply nutrition or liquid medication when clients are unable to take anything by mouth). His physician order dated 6/9/19 indicated continuous GT feeding of Jevity (liquid nutrition) at 40 milliliter (ml, unit of measurement) per hour. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YO5Z11 Facility ID: CA070000047 If continuation sheet 51 of 53 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 06/19/2019 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 initial tour on 6/17/19 at 9:11 a.m., an asepto syringe dated 6/13/19 was found hanging on the IV pole for Resident 11. On a concurrent observation and interview with LN A, she confirmed the observation. She stated Resident 11's asepto syringe was outdated for 4 days and should have been replaced with the new one. LN A further stated asepto syringe used for GT feeding is being changed every day. Review of the facility's policy and procedures dated 1/24/19, "Changing Administration Set and Container", indicated all enteral administration sets and containers will be changed every 24 hours to prevent conditions that could pose a risk for microbial contamination. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YO5Z11 Facility ID: CA070000047 If continuation sheet 52 of 53 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 06/19/2019 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)

F912 Bedrooms Measure at Least 80 Sq Ft/Resident F912 CFR(s): 483.90(e)(1)(ii) SS=D ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 06/18/2019 §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 Total Sq. Ft. Sq. Ft./Bed Beds 6 7 10 287.86 287.86 286.66 71.965 71.965 71.665 No. of 4 4 4 During observations throughout the survey, none of the rooms were observed to inhibit the staff from providing care or the residents from receiving adequate care. The staff and the residents moved freely in the rooms. The residents and staff verbalized no complaints or concerns regarding space and privacy. Continuance of the room waiver is recommended. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YO5Z11 Facility ID: CA070000047 If continuation sheet 53 of 53