Other·July 29, 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 an abbreviated survey regarding investigation of a complaint conducted on 7/24/19. For Complaint CA00645147 regarding Admission, Transfer, and Discharge Rights a deficiency was identified (see F626). A Class "B" citation was also issued. Inspection was limited to the specific complaint investigated and does not represent the finding of a full inspection of the facility. Representing the California Department of Public Health: 34432, Health Facilities Evaluator Nurse.

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

F626 07/24/2019 §483.15(e)(1) Permitting residents to return to facility. A facility must establish and follow a written policy on permitting residents to return to the facility after they are hospitalized or placed on therapeutic leave. The policy must provide for the following. (i) A resident, whose hospitalization or therapeutic leave exceeds the bed-hold period under the State plan, returns to the facility to their previous room if available or immediately upon the first availability of a bed in a semiprivate room if the resident(A) Requires the services provided by the facility; and (B) Is eligible for Medicare skilled nursing facility services or Medicaid nursing facility services. 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: GUP511 Facility ID: CA070000050 If continuation sheet 1 of 6 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: _______________ 056026 (X3) DATE SURVEY COMPLETED 07/24/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EMPRESS CARE CENTER, LLC 1299 S Bascom Ave San Jose, CA 95128 (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 (ii) If the facility that determines that a resident who was transferred with an expectation of returning to the facility, cannot return to the facility, the facility must comply with the requirements of paragraph (c) as they apply to discharges. §483.15(e)(2) Readmission to a composite distinct part. When the facility to which a resident returns is a composite distinct part (as defined in § 483.5), the resident must be permitted to return to an available bed in the particular location of the composite distinct part in which he or she resided previously. If a bed is not available in that location at the time of return, the resident must be given the option to return to that location upon the first availability of a bed there. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to permit one of five sampled residents (1) to return to the facility after a transfer to a general acute care hospital (GACH), even though Resident 1's previous room was available. This deficient practice resulted in a violation of Resident 1's rights and his admission to another facility which had the potential to result in an interruption of his continuity of care. Findings: A review of the clinical record for Resident 1 indicated admission on 4/8/19 with diagnoses of muscle weakness, paranoid (believing everyone is out to cause the sufferer harm) schizophrenia (a severe mental disorder that can result in hallucination, delusions (misinterpretation of reality), and extremely disordered thinking and behavior) and anxiety (nervousness) disorder. Review of Resident 1's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GUP511 Facility ID: CA070000050 If continuation sheet 2 of 6 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: _______________ 056026 (X3) DATE SURVEY COMPLETED 07/24/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EMPRESS CARE CENTER, LLC 1299 S Bascom Ave San Jose, CA 95128 (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 "Physician's Orders" dated 4/24/19, indicated lorazepam (a medication that produces calming effects to reduce symptoms of anxiety) 1 milligram (mg, a unit of measure) every 8 hours as needed for agitation manifested by constant yelling. Review of Resident 1's "Medication Administration Record" for the months of April, May, and June 2019, indicated Resident 1 received lorazepam 1 mg on 30 occasions during the 43 days between 4/24/19 to 6/5/19 for agitation manifested by constant yelling. A review of Resident 1's "Physician's Orders" dated 6/20/19, indicated to transfer Resident 1 to the GACH for evaluation and treatment. A review of the GACH's "Inpatient Medicine Discharge Summary" dated 7/9/19, indicated Resident 1 was admitted to the GACH on 6/20/19 and was discharged from the GACH on 7/9/19 in good condition. Further, the summary indicated Resident 1 had been successfully treated for clostridium difficile (C. diff, a diarrheal infection which can spread to others and requires procedures, known as C diff. contact isolation, which includes the requirement of a private bedside commode but not a private room, to prevent contact between the infected resident and others). The report indicated the problem of C diff was resolved at the time of Resident 1's discharge from the GACH. A review of the GACH's "Case Management Consult Note (CMCN)" dated 6/28/19 at 5:12 p.m., indicated the facility's administrator (ADM) informed case manager A (CM A) on 6/28/19, the facility did not have a bed available to accommodate Resident 1's need for contact isolation should he be discharged from the GACH. A review of the GACH's CMCN dated 7/1/19 at FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GUP511 Facility ID: CA070000050 If continuation sheet 3 of 6 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: _______________ 056026 (X3) DATE SURVEY COMPLETED 07/24/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EMPRESS CARE CENTER, LLC 1299 S Bascom Ave San Jose, CA 95128 (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 12:03 p.m., indicated Resident 1 no longer required C diff. isolation. The CMCN further indicated the facility's director of nursing (DON) informed CM A they had no open beds available for Resident 1, even if he no longer required C diff. isolation. A review of the GACH's CMCN, dated 7/1/19 at 4:34 p.m., indicated CM A informed the facility's ADM, Resident 1's responsible party (RP) requested Resident 1 to return to the facility; the RP had done a lot of work with the facility regarding Resident 1's discharge plan to a previous living situation. A review of the GACH's CMCN dated 7/8/19 at 3:05 p.m. indicated Resident 1's RP requested Resident 1 to return to the facility because Resident 1 was happy there and RP received good support from the facility's social worker. A review of the GACH's GMCN dated 7/9/19 at 11:49 a.m., indicated CM A informed the facility's ADM of Resident 1's discharge from the GACH and the RPs desire for Resident 1 to return to the facility. The GMCN indicated the ADM reported the facility did not have an available bed for Resident 1 due to low staffing. A review of facility X's daily census indicated Resident 1's bed remained unoccupied beginning on 6/21/19 to 7/9/19. The census on 6/20/19 was 57 residents which included Resident 1. The census from 6/21/19 to 6/26/19 was 56 residents, from 6/27/19 to 7/1/19 it was 55 residents, and from 7/2/19 to 7/9/19 it was 56 residents. A review of the facility's census dated 7/2/19, indicated while there were no discharges, the facility was able to admit a new resident on 7/2/19. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GUP511 Facility ID: CA070000050 If continuation sheet 4 of 6 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: _______________ 056026 (X3) DATE SURVEY COMPLETED 07/24/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EMPRESS CARE CENTER, LLC 1299 S Bascom Ave San Jose, CA 95128 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of the facility's "Census and Direct Care Service Hours Per Patient Day (DHPPD, a method used to calculate the actual number of direct patient care hours spent with each resident in a 24-hour period) indicated from 6/23/19 to 7/16/19, the facility met the state law required number of overall direct patient care hours (3.5) on each of the days reviewed. The DHPPD indicated, during the same time period, the facility met the state law required number of CNA hours (2.4) for all but two of the days (7/1/19 at 2.187 hours and 7/7/19 at 2.065 hours). A review of the facility's X's DHPPD for 7/9/19, the date of Resident 1's discharge from the GACH when CM A was informed the facility did not have a bed for Resident 1 due to low staffing, indicated the facility had an overall direct patient care hours rate of 3.895 and a CNA direct patient care hours rate of 2.732, well over the required minimum rates. During a telephone interview with the DON on 7/17/19 at 8:45 a.m., she stated the facility could not accept Resident 1's readmission because the facility did not have a private room available on 7/9/19. During an interview with the director of staff development (DSD) on 7/17/19 at 10:50 a.m., she stated the facility did not accept Resident 1's readmission to the facility on 7/9/19 because of low staffing. The DSD stated she did not receive the report Resident 1 required contact isolation while hospitalized. During an interview with the director of social services (DSS) on 7/17/19 at 12:45 p.m., she stated poor staffing was the reason the facility did not readmit Resident 1 after hospitalization. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GUP511 Facility ID: CA070000050 If continuation sheet 5 of 6 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: _______________ 056026 (X3) DATE SURVEY COMPLETED 07/24/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EMPRESS CARE CENTER, LLC 1299 S Bascom Ave San Jose, CA 95128 (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 with the ADM on 7/17/19 at 2:05 p.m., he stated when he spoke to the GACH's case manager about the facility's low staffing, he was referring to projected staffing. The ADM stated, "if you went by the actual staffing, then yes, our staffing was adequate and we should have accepted Resident 1 back to the facility." Review of the complaint intake form dated 7/9/19, indicated a 2:35 p.m. addendum with a report Resident 1 was accepted into another facility. Review of the facility's 2015 policy, "Readmission to the Facility", indicated residents who are not receiving Medicaid benefits will be readmitted to the facility upon the first availability of a bed if the resident needs care and medical treatment that can be provided by the facility. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GUP511 Facility ID: CA070000050 If continuation sheet 6 of 6