Other·July 11, 2017

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 an entity reported incident conducted on 6/14/17, 6/16/17, 6/22/17, 6/26/17 to 6/28/17, and 6/30/17. For Entity Reported Incident CA00538807 regarding Quality of Care/Treatment/Resident Safety/Falls, a federal deficiency was identified (see F323). In addition, a Class "B" Citation was identified. Inspection was limited to the specific entity reported incident investigated and does not represent the findings of a full inspection of the facility. Representing the California Department of Public Health: 37409, Health Facilities Evaluator Nurse.

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

F323 07/21/2017 (d) Accidents. The facility must ensure that (1) The resident environment remains as free from accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. (n) - Bed Rails. The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the 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: 4GG811 Facility ID: CA070000057 If continuation sheet 1 of 5 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 06/30/2017 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 facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements. (1) Assess the resident for risk of entrapment from bed rails prior to installation. (2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation. (3) Ensure that the bed’s dimensions are appropriate for the resident’s size and weight. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to provide supervision and a safe environment for one of three residents (Resident 1) when staff did not supervise Resident 1 while she was sitting upright in a wheelchair without footrests. This resulted in a fall with injury (forehead lacerations and rib fractures). Findings: Review of Resident 1's admission record indicated Resident 1 was admitted with diagnoses including dementia (a progressive and sometimes chronic brain condition that causes problems with thinking, behavior, and memory), dementia with Lewy bodies (Lewy bodies are clumps of protein that can form in the brain and cause problems with the way the brain works, including memory, movement, thinking skills, mood, and behavior), major depressive disorder (low self-esteem, loss of interest in normally enjoyable activities, low energy, and pain without a clear cause), and anxiety disorders (restlessness, feeling on edge or easily fatigued, difficulty concentrating, muscle tension or problems sleeping). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4GG811 Facility ID: CA070000057 If continuation sheet 2 of 5 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 06/30/2017 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 of the Minimum Data Set (MDS, an assessment tool) dated 4/18/17 indicated Resident 1 was total dependent for all activities of daily living (ADL's). Review of Resident 1's Morse Fall Scale (a method of assessing a patient's likelihood of falling) dated 4/18/17 indicated she was a high risk for falls. During an interview with the director of nursing (DON) on 6/14/17 at 1:15 p.m., she stated Resident 1 was assessed by the occupational therapist (OT, a person who helps people to fully engage in their daily lives, from their work and recreation to activities of daily living like getting dressed, cooking, eating and driving) to have poor trunk control. The DON also stated, as per OT's assessment Resident 1 required a Tilt-in-Space wheelchair (a wheelchair that reduces the risk of slumping and sliding for people who are at risk of falling out of a wheelchair) for safety. During an interview with certified nursing assistant A (CNA A), on 6/26/17, at 10:20 a.m., she stated after lunch she prepared to transfer Resident 1 from wheelchair to bed. She set the wheelchair to upright position and removed the footrests. While waiting at the room door for CNA B to come and help her with the transfer, she saw CNA C helped a resident who almost fell. She then went to help CNA C. While helping CNA C, CNA B came and told her Resident 1 fell. She came to the room and saw Resident 1 with her face turned to her side and her head was lying on a bloody floor. During an interview with CNA B, on 6/14/17, at 2:10 p.m., she went in to Resident 1's room to help CNA A with the transfer and saw Resident 1 lying chest down on the floor. Her head FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4GG811 Facility ID: CA070000057 If continuation sheet 3 of 5 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 06/30/2017 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 turned to the side, and was lying on a bloody floor. CNA A was not in the room. During an interview with CNA C, on 6/14/17, at 4:20 p.m., she stated CNA A came to help her with a resident who almost fell from the hallway bathroom back to her room. While in the room she heard someone asked someone to call 911 for Resident 1. She came to Resident 1's room and saw her on the floor lying on her chest, her face turned to the side and her head lying on a bloody floor. Resident 1's wheelchair was in upright position and had no footrests on. During an observation on 6/14/17, at 1:45 p.m., Resident 1 was lying in bed with her eyes opened. There was 1.5 x 1.5 centimeters (cm. - unit of measurement) dry reddish brown scab on the right side of her forehead. The area was slightly swollen. Review of Resident 1's Interdisciplinary Meeting notes indicated Resident 1 sustained a laceration on right side of forehead and fractures on second to fourth ribs because of the fall. During an interview with licensed vocational nurse D (LVN D), on 6/16/17, at 3:45 p.m., she stated she had been working with Resident 1 since her admission. When Resident 1 was in the wheelchair, she needed to have the footrests and the wheelchair should be tilted back. Otherwise, she would fall because she had tendency to lean forward. During an interview with the director of staff development (DSD), on 6/22/17, at 11:55 a.m., she stated for Resident 1's safety she could not be left alone while she was in the wheelchair in upright position and the footrests were off. Even if the wheelchair was in the tilted back FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4GG811 Facility ID: CA070000057 If continuation sheet 4 of 5 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 06/30/2017 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 position and the footrests were on, Resident 1 could be left alone only for a short time. Review of Resident 1's OT Progress & Discharge Summary dated 4/24/13 indicated, "The patient tolerates upright sitting in chair/wheelchair maintaining proper postural alignment for 1 minute. Patient demonstrates continuous non purposeful motor movements... The patient did not make significant progress toward goals. Standard manual wheelchair not appropriate for this patient due to motor movements. Requested Broda chair (tilt and recline positioning chair) from medical group... Precautions Fall risk... " The facility policy and procedure titled "Safe Lifting and Movement of Residents" revision dated 12/2013, indicated "In order to protect the safety and well-being of staff and residents, and to promote quality of care, this facility uses appropriate techniques and devices to lift and move residents... Resident safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4GG811 Facility ID: CA070000057 If continuation sheet 5 of 5