Other·April 11, 2017

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during a recertification survey conducted from 3/27/17 through 3/29/17. This was conducted in conjunction with the relicensing survey. The facility was licensed for 99 beds. The census at the time of the survey was 92. The sample size was 19. A Class "B" Citation was issued for F 226. Representing the California Department of Public Health: 29765, Health Facilities Evaluator Nurse; 36043, Health Facilities Evaluator Nurse; 35790, Health Facilities Evaluator Nurse; 38068, Health Facilities Evaluator Nurse; and 37883, Health Facilities Evaluator Nurse.

F226 SS=D DEVELOP/IMPLMENT ABUSE/NEGLECT, ETC POLICIES CFR(s): 483.12(b)(1)-(3), 483.95(c)(1)-(3)

F226 04/21/2017 483.12 (b) The facility must develop and implement written policies and procedures that: (1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, (2) Establish policies and procedures to investigate any such allegations, and (3) Include training as required at paragraph §483.95, 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: RRC911 Facility ID: CA070000057 If continuation sheet 1 of 18 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: _______________ 555831 (X3) DATE SURVEY COMPLETED 03/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HERMAN HEALTH CARE CENTER 2295 Plummer Ave San Jose, CA 95125 (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 483.95 (c) Abuse, neglect, and exploitation. In addition to the freedom from abuse, neglect, and exploitation requirements in § 483.12, facilities must also provide training to their staff that at a minimum educates staff on(c)(1) Activities that constitute abuse, neglect, exploitation, and misappropriation of resident property as set forth at § 483.12. (c)(2) Procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property (c)(3) Dementia management and resident abuse prevention. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to implement their policy and procedure in reporting an injury of unknown origin for one of 19 sampled residents (Resident 14) when Resident 14 had a purple discoloration on his right eye. Resident 14's skin discoloration of unknown origin was not reported to the Ombudsman. This failure had a potential for this resident to be subjected to abuse. Findings: Resident 14's clinical record was reviewed. The resident was admitted to the facility on 12/16/15 with a diagnosis of Alzheimer's disease (a progressive, degenerative disorder that attacks the brain, resulting in loss of memory, thinking and language skills, behavioral changes, and affecting a person's daily functioning). Review of Resident 14's Minimum Data Set FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RRC911 Facility ID: CA070000057 If continuation sheet 2 of 18 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: _______________ 555831 (X3) DATE SURVEY COMPLETED 03/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HERMAN HEALTH CARE CENTER 2295 Plummer Ave San Jose, CA 95125 (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 (MDS, an assessment tool) dated 1/23/17, indicated his cognition was severely impaired. Review of Resident 14's Progress Notes dated 3/24/17 at 12:12 a.m., indicated Resident 14 was found with skin discoloration around his right eye measuring four by two centimeters. There was no documented evidence of the cause of the skin discoloration. During an observation on 3/27/17 at 3:00 p.m., Resident 14 had a purplish greenish discoloration around his right eye. During an interview with the certified nursing assistant J (CNA J), on 3/29/17, at 2:00 p.m., he stated on 3/24/17 at 11:45 p.m., Resident 14 was in the dining room when he observed the resident had a purple discoloration around his right eye. The CNA stated they don't know where the resident got the bruise. During an interview with the licensed vocational nurse I (LVN I), on 3/28/17, at 3:00 p.m., she stated on 3/24/27, Resident 14 was found with purple discoloration around his right eye from unknown origin. During an interview with the director of nursing (DON), on 3/29/17, at 4:10 p.m., she acknowledged the incident wasn't reported to the ombudsman. The DON stated Resident 14's injury of unknown origin should be reported to the ombudsman and California Department of Public Health (CDPH). The facility policy "Abuse Investigations" dated 7/2014, indicated the individual in charge of the abuse investigation will notify the ombudsman that an abuse investigation is being conducted. The facility policy "Investigating Unexplained Injuries" dated 4/2011, indicated the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RRC911 Facility ID: CA070000057 If continuation sheet 3 of 18 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: _______________ 555831 (X3) DATE SURVEY COMPLETED 03/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HERMAN HEALTH CARE CENTER 2295 Plummer Ave San Jose, CA 95125 (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 investigation will follow the protocols set forth in the facility's abuse investigation guidelines.

F253 SS=D HOUSEKEEPING & MAINTENANCE SERVICES CFR(s): 483.10(i)(2)

F253 04/21/2017 (i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior; This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to provide housekeeping and maintenance services to ensure an orderly and comfortable interior when: (1) Several floor tiles were broken in bathrooms and hallways; (2) ventilation windows were covered with thick black particles, and (3) one table in social dining hall B had a broken edge. These failures had the potential to negatively impact the physical and mental health of the residents. Findings: 1. During observation on 3/28/17, at 11:03 am, several vinyl floor tiles were broken in hallways A, B, and C. There were also broken tiles in bathroom C and missing base tiles surrounding the residents' bathtub in bathroom A. During interview with the maintenance director (MD), on 3/28/17, at 11:04 am, the MD stated they had not identified those broken tiles and they should be replaced. The facility policy and procedure titled "Cleaning/Maintaining/Repairing Flooring" revised date 03/14, indicated "...5. Flooring will be repaired as needed." 2. During observation on 3/28/17, at 10:31 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RRC911 Facility ID: CA070000057 If continuation sheet 4 of 18 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: _______________ 555831 (X3) DATE SURVEY COMPLETED 03/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HERMAN HEALTH CARE CENTER 2295 Plummer Ave San Jose, CA 95125 (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.m., ventilation windows in residents' bathroom C, the hopper room and shower room in building B, and resident's room B were covered with thick black particles. During interview with the MD, on 3/28/17, at 10:31 a.m., the MD stated the last time those were cleaned was a week ago. The facility policy and procedure titled "Housekeeping" revised date 02/16, indicated "...Cleaning Routine for Other Areas: All public areas, hallways, nursing stations, offices, walls, floors, windows, window frames, utility rooms, dining areas, supply/storage areas, medication rooms, housekeeping carts, wheelchairs, gerichairs, shower chairs, commodes, etc., fixtures and furniture shall be on a routine cleaning schedule..." 3. During observation on 3/28/17, at 12:05 p.m. one table in social dining hall B had a broken edge. There was one resident seated at the table reading a magazine while waiting for the lunch meal tray to be served. During an interview with registered nurse D (RN D), on 3/29/17, at 8:45 a.m., RN A stated the table can possibly lead residents to skin tear injury so it should be replaced. During review of the maintenance repair log record, no documentation related to broken table.

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

F281 04/21/2017 (b)(3) Comprehensive Care Plans The services provided or arranged by the facility, as outlined by the comprehensive care FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RRC911 Facility ID: CA070000057 If continuation sheet 5 of 18 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: _______________ 555831 (X3) DATE SURVEY COMPLETED 03/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HERMAN HEALTH CARE CENTER 2295 Plummer Ave San Jose, CA 95125 (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 plan, must(i) Meet professional standards of quality. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to provide services according to accepted standards of clinical practice for three of 19 sampled residents (2, 4, and 14). For Resident 2, the gastrostomy feeding tube (GT, a medical device used to provide nutrition to patients who cannot obtain nutrition by mouth) schedule was not followed. For Residents 4 and 14, the care plan for their pacemakers (a battery-powered medical device for heart failure implanted inside the heart to restore normal heart beat) was not implemented. These failures had the potential to cause health complications to the residents. Findings: 1. Resident 4's clinical record was reviewed. The resident was admitted to the facility on 1/17/17 with a diagnosis of congestive heart failure and had cardiac pacemaker. Review of Resident 4's Care Plan dated 1/19/17, indicated to monitor and document signs and symptoms of pacemaker malfunction such as dizziness, syncope, and difficulty of breathing. The care plan also indicated to monitor site for infection such as redness, drainage, and warmth when touched. Review of Resident 4's clinical notes on 3/28/17, there was no documented evidence the pacemaker site and malfunction had been monitored. During an interview with licensed vocational nurse G (LVN G) on 3/28/17, at 11:35 a.m., FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RRC911 Facility ID: CA070000057 If continuation sheet 6 of 18 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: _______________ 555831 (X3) DATE SURVEY COMPLETED 03/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HERMAN HEALTH CARE CENTER 2295 Plummer Ave San Jose, CA 95125 (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 she stated she was not aware Resident 4 had a pacemaker. LVN G reviewed the clinical notes of the resident but could not find any documentation the pacemaker site and malfunction had been monitored. 2. Resident 14's clinical record was reviewed. The resident was admitted to the facility on 12/16/15 with diagnosis of atrial fibrillation (is an irregular and often rapid heart rate that can increase your risk of stroke, heart failure and other heart-related complications) and had a cardiac pacemaker. Review of Resident 14's Care Plan dated 1/19/17, indicated to monitor and document signs and symptoms of pacemaker malfunction such as dizziness, syncope, and difficulty of breathing. The care plan also indicated to monitor the site for infection such as redness, drainage, and warmth when touched. Review of Resident 14's clinical notes on 3/28/17, there was no documented evidence that the pacemaker site and malfunction had been monitored. During an interview with registered nurse F (RN F) on 3/29/17, at 9:05 a.m., she stated she was not aware Resident 14 had pacemaker. RN F reviewed the clinical notes of the resident but could not find any documentation the site and malfunction of the pacemaker had been monitored. According to National Institutes for Health (NIH) Residents with implanted pacemakers are a real challenge, especially to nurses, in longterm care. The facility is accountable for the quality and timeliness of care and service to the resident. Documenting the physical assessment, developing and implementing a significant plan of care, and monitoring that FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RRC911 Facility ID: CA070000057 If continuation sheet 7 of 18 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: _______________ 555831 (X3) DATE SURVEY COMPLETED 03/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HERMAN HEALTH CARE CENTER 2295 Plummer Ave San Jose, CA 95125 (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 care, for a resident with a pacemaker, are serious professional nursing responsibilities. 3. During observation of Resident 2 in her room on 3/29/17 at 8:50 a.m. Resident 2's GT feeding bag was connected to a feeding pump machine on a pole. The GT feeding tubing was hung on the feeding pump pole with the feeding tubing tip open to air without a cover. During a concurrent interview with the licensed vocational nurse (LVN C), LVN C stated the GT feeding was at beginning of her shift and would be restarted at 10:00 a.m. Concurrent review of Resident 2's clinical record indicated the following physician GT feeding schedule order dated 3/20/17: "Isosource (nutritionally complete, calorically dense tube feeding formula containing fiber) 1.5 at 70 milliliter (ml)/hour (hr) for 16 hrs to provide 1120 ml, 1680 Kcal in 24 hrs. 2:00 p.m. on, 10 p.m. off, 2 a.m. on, 10 a.m. off every shift." On the same date at 9:10 a.m., LVN C was informed about Resident 2's physician's order. LVN C acknowledged the GT feeding should have been on since 2:00 a.m. Review on 3/29/17 of the facility's policy and procedure "Enteral Tubes and Enteral Feedings-Safety Precautions" indicated the selection of enteral formulas, routes and methods of administration, and the decision to administer medications via enteral tubes are based on nursing assessment of the resident's condition, in consultation with the physician, dietician, and pharmacist. The staff should maintain strict aseptic technique at all times in preparing and administering enteral nutrition. On the formula label document initials, date, time the formula was hung and that the label was checked against the physician order. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RRC911 Facility ID: CA070000057 If continuation sheet 8 of 18 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: _______________ 555831 (X3) DATE SURVEY COMPLETED 03/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HERMAN HEALTH CARE CENTER 2295 Plummer Ave San Jose, CA 95125 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

F332 FREE OF MEDICATION ERROR RATES OF 5% OR MORE CFR(s): 483.45(f)(1)

F332 SS=D PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 04/21/2017 (f) Medication Errors. The facility must ensure that its(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 an 8% medication error rate when two medication errors in 25 opportunities were observed during medication passes for two non-sampled residents (20 and 21). These failures had the potential to jeopardize the residents' health. Findings: During medication pass observation on 3/27/17 and 3/28/17 in hallway B the medication errors included: 1. Licensed vocational nurse A (LVN A) missed one of Resident 20's medications (ferrous sulfate) 2. Licensed vocational nurse B (LVN B) administered one of Resident 21's medications at the wrong time (amlodipine) 1. Review of Resident 20's medication administration record (MAR) indicated an order for ferrous sulfate, dated 3/1/17, 7.5 milliliters (ml, a unit of volume) by mouth two times a day for supplement. The medication was scheduled to be administered at 8:00 a.m. During an observation on 3/27/17, at 4:41 p.m., LVN A administered scheduled medications to Resident 20. LVN A did not administer ferrous FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RRC911 Facility ID: CA070000057 If continuation sheet 9 of 18 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: _______________ 555831 (X3) DATE SURVEY COMPLETED 03/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HERMAN HEALTH CARE CENTER 2295 Plummer Ave San Jose, CA 95125 (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 sulfate. During a concurrent interview, LVN A stated ferrous sulfate was not available in the medication cart. During an interview with LVN A, on 3/28/17, at 5:24 p.m., she stated she did not administer ferrous sulfate to Resident 20. The facility policy and procedure titled "MEDICATION ADMINISTRATION SCHEDULE" dated 12/2012, indicated "two times daily" medications are to be scheduled for 8:00 a.m./8 p.m. administration. 2. Review of Resident 21's medication administration record (MAR) indicated an order for amlodipine, dated 12/17/16, 10 milligrams (mg, a unit of measure) by mouth one time a day for hypertension (elevated pressure of blood against the walls of the blood vessels). The medication was scheduled to be administered at 8:00 a.m. During an observation on 3/28/17, at 10:07 a.m., LVN B administered amlodipine to Resident 21. In an interview with LVN B, on 3/28/17, at 3:31 p.m., she stated medications should be given no more than one hour before or one hour after the scheduled administration time and the amlodipine was given late. The facility policy and procedure titled "MEDICATION ADMINISTRATION SCHEDULE" dated 12/2012, indicated "daily" medications are to be scheduled for 8:00 a.m. administration.

F425 SS=D PHARMACEUTICAL SVC - ACCURATE PROCEDURES, RPH FORM CMS-2567(02-99) Previous Versions Obsolete

F425 Event ID: RRC911 04/21/2017 Facility ID: CA070000057 If continuation sheet 10 of 18 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: _______________ 555831 (X3) DATE SURVEY COMPLETED 03/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HERMAN HEALTH CARE CENTER 2295 Plummer Ave San Jose, CA 95125 (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 CFR(s): 483.45(a)(b)(1) (a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. (b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who-(1) Provides consultation on all aspects of the provision of pharmacy services in the facility; This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure medications were available to meet the needs of each resident when ferrous sulfate (an essential mineral) was not available for administration for one non-sampled resident (20). This failure had the potential to jeopardize the resident's health. Findings: Review of Resident 20's medication administration record (MAR) indicated an order for ferrous sulfate, dated 3/1/17, 7.5 milliliters (ml, a unit of volume) by mouth two times a day for supplement. The medication was scheduled to be administered at 8:00 a.m. During an observation on 3/27/17, at 4:41 p.m., licensed vocational nurse A (LVN A) administered scheduled medications to Resident 20. LVN A did not administer ferrous sulfate. During a concurrent interview, LVN A stated ferrous sulfate was not available in the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RRC911 Facility ID: CA070000057 If continuation sheet 11 of 18 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: _______________ 555831 (X3) DATE SURVEY COMPLETED 03/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HERMAN HEALTH CARE CENTER 2295 Plummer Ave San Jose, CA 95125 (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. During an interview with LVN A, on 3/28/17, at 5:24 p.m., she stated she did not administer ferrous sulfate to Resident 20. The facility policy and procedure titled "MEDICATION ADMINISTRATION SCHEDULE" dated 12/2012, indicated "two times daily" medications are to be scheduled for 8:00 a.m./8:00 p.m. administration.

F441 SS=E INFECTION CONTROL, PREVENT SPREAD, F441 LINENS CFR(s): 483.80(a)(1)(2)(4)(e)(f) 04/21/2017 (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: (1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable 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 (facility assessment implementation is Phase 2); (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; FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RRC911 Facility ID: CA070000057 If continuation sheet 12 of 18 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: _______________ 555831 (X3) DATE SURVEY COMPLETED 03/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HERMAN HEALTH CARE CENTER 2295 Plummer Ave San Jose, CA 95125 (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) 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. (4) A system for recording incidents identified under the facility’s IPCP and the corrective actions taken by the facility. (e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. (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 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RRC911 Facility ID: CA070000057 If continuation sheet 13 of 18 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: _______________ 555831 (X3) DATE SURVEY COMPLETED 03/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HERMAN HEALTH CARE CENTER 2295 Plummer Ave San Jose, CA 95125 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE review, the facility failed to maintain infection control program for one of 19 sampled residents (2) and two non sampled residents (22 and 23) when: Glucometer devices were not sanitized according to manufacturer specifications for Resident 23; Intravenous (IV) tubing for Resident 22 was not replaced after 24 hours and tip of feeding tube for Resident 2 was uncovered when not in use. This failure had the potential to result to crosscontamination and spread of infectious diseases in the facility. Findings: 1. During observation on 3/27/17, at 8:41 am, Resident 22's IV tubing connected to IV Cefazolin (antibiotic) 2 grams per 100 milliliters (2 gm /100 ml) had a label indicating "change tubing at 10:45 p.m. on 3/28/17. There was no date and time indicating when the IV bag was started and hung. Review of a physician's order for Resident 22 dated 3/28/17 indicated "Cefazolin in D5W solution 2 gm/100 ml. Use 2 gram intravenously every 6 hours for MSSA (Methycillin Sensitive Staphylococcus Aureus) right shoulder septic arthritis until 04/28/2017." During an interview with registered nurse E (RN E), on 3/27/17, at 2:00 p.m., RN E stated they change the IV tubings every three days. During observation on 3/29/17, at 9:00 a.m. IV tubing connected to IV Cefazolin (2 gm/100 ml) had a label indicating "change tubing on 3/31/17." During an interview with RN F, on 3/29/17, at 9:01 a.m., RN F stated she changed the IV tubing that was placed three days ago early this morning. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RRC911 Facility ID: CA070000057 If continuation sheet 14 of 18 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: _______________ 555831 (X3) DATE SURVEY COMPLETED 03/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HERMAN HEALTH CARE CENTER 2295 Plummer Ave San Jose, CA 95125 (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 director of staff development (DSD) on 3/29/17, at 9:05 a.m., the DSD stated IV tubings should be changed every 24 hours and not every three days for infection control. The facility policy and procedure titled "Changing the Needleless Connection Device and Extension Tubing" revised date 01/2014, indicated "....6. Change needleless connection device and extension tubing with administration set change, every 24 hours...." 2. During an observation on 3/27/17, at 4:01 p.m., in hallway B, licensed vocational nurse A (LVN A) administered scheduled medications to Resident 23. LVN A measured Resident 23's blood sugar using a glucometer (a medical device for determining the approximate concentration of sugar in the blood). LVN A did not disinfect (to clean something in order to destroy bacteria) the glucometer before or after use. During a concurrent interview, LVN A stated the glucometer is cleaned with alcohol before and after use. During an interview with LVN G, on 3/28/17, at 12:35 p.m., in hallway B, she stated the glucometer is cleaned with alcohol. During an interview with LVN H, on 3/28/17, at 12:53 p.m., in hallway C, he stated the glucometer is cleaned with alcohol. During an interview with RN F, on 3/28/17, at 1:03 p.m., in hallway A, she stated the glucometer is cleaned with alcohol. During an interview with the DSD, on 3/29/17, at 7:46 a.m., she stated staff cleans but does not sanitize the glucometer. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RRC911 Facility ID: CA070000057 If continuation sheet 15 of 18 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: _______________ 555831 (X3) DATE SURVEY COMPLETED 03/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HERMAN HEALTH CARE CENTER 2295 Plummer Ave San Jose, CA 95125 (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 facility policy and procedure titled "CLEANING AND DISINFECTION OF RESDIENT-CARE ITEMS AND EQUIPMENT" dated 07/2014, indicated "reusable items are cleaned and disinfected or sterilized between residents". The manufacturer's guidelines titled "CLEANING AND DISINFECTING YOUR ASSURE® PLATINUM BLOOD GLUCOSE METER" dated 12/2014, indicated "disinfecting can be accomplished with an EPA-registered disinfectant detergent or germicide that is approved for healthcare settings or a solution of 1:10 concentration of sodium hypochlorite (bleach)." 3. Resident 2 was admitted to the facility with diagnoses including gastrostomy feeding (a feeding tube through the skin and the stomach wall for administration of nutrition and medications). During observation of Resident 2 in her room on 3/29/17 at 8:50 a.m. Resident 2's GT feeding bag was connected to a feeding pump machine on a pole. The GT feeding tubing was hung on the feeding pump pole with the feeding tubing tip open to the air without a cover. During a concurrent interview with the licensed vocational nurse C (LVN C), LVN C stated the GT feeding was off at the beginning of her shift and would be restarted at 10:00 a.m. LVN C acknowledged the feeding tubing tip should be covered when not in use. Review of the facility's policy and procedure "Enteral Feedings-Safety Precautions" indicated to maintain strict aseptic technique at all times when working with enteral nutrition systems. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RRC911 Facility ID: CA070000057 If continuation sheet 16 of 18 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: _______________ 555831 (X3) DATE SURVEY COMPLETED 03/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HERMAN HEALTH CARE CENTER 2295 Plummer Ave San Jose, CA 95125 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

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

F458 SS=B PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 04/21/2017 (e)(1)(ii) Measure at least 80 square feet per resident in multiple resident bedrooms, and at least 100 square feet in single resident rooms; This REQUIREMENT is not met as evidenced by: Based on observation and interview, the facility failed to ensure multiple bedrooms had at least 80 square feet per resident. Having less than 80 square feet per resident could potentially compromise the care and service the residents receive. Findings: On 3/28/17 at 11:00 a.m., the maintenance director (MD) measured the rooms containing four beds. Based on those measurements, the following rooms had less than the required 80 sq. ft. per bed: Gertrude Hall Rooms: Room Total Sq. Ft Sq. Ft./Bed No. of Beds 8 9 10 11 17 19 22 289 298 288 298 297 298 299 72 74 72 74 74 74 74 4 4 4 4 4 4 4 Natalie Hall Rooms: Room Total Sq. Ft. Sq. Ft./Bed No. of Beds 29 297 74 FORM CMS-2567(02-99) Previous Versions Obsolete 4 Event ID: RRC911 Facility ID: CA070000057 If continuation sheet 17 of 18 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: _______________ 555831 (X3) DATE SURVEY COMPLETED 03/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HERMAN HEALTH CARE CENTER 2295 Plummer Ave San Jose, CA 95125 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) 31 33 34 36 38 40 300 301 299 300 299 302 75 75 74 75 74 75 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 4 4 4 4 4 4 Interviews with the staff and the residents indicated the room sizes did not adversely impact the quality of care received by the residents. Recommend continuance of the room size waiver. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RRC911 Facility ID: CA070000057 If continuation sheet 18 of 18