Other·July 11, 2018

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during a standard abbreviated survey regarding investigation of entity reported incidents conducted on 7/9/18. For Entity Reported Incident CA00592342 regarding Resident Abuse; Employee to Resident, the Department did not substantiate a violation of federal or state regulations. For Entity Reported Incident CA00591668 regarding Injury of Unknown Origin, the Department did not substantiate a violation of federal or state regulations. However, a federal deficiency was identified for a violation unrelated to the entity reported incident. A Class "B" Citation was issued. Inspection was limited to the specific entity reported incidents investigated and does not represent the findings of a full inspection of the facility. Representing the California Department of Public Health: 29258, Health Facilities Evaluator Supervisor and 39949, Health Facilities Evaluator Nurse.

F689 SS=D Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) 07/21/2018 §483.25(d) Accidents. The facility must ensure that §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate 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: 43DC11 Facility ID: CA070000057 If continuation sheet 1 of 3 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555831 (X3) DATE SURVEY COMPLETED 07/09/2018 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 supervision and assistance devices to prevent accidents. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to provide adequate supervision for 1 of 3 sampled residents (1), when Resident 1 had six falls within three months and no new interventions were in place. This failure had a potential to put Resident 1 at risk for serious injury. Findings: Review of Resident 1's current clinical record indicated Resident 1 had diagnoses including Parkinson's disease (a progressive disorder of the nervous system that affects movement), dementia, (memory loss), delusional disorder, and history of falls. Review of the same clinical record indicated Resident 1 had several fall incidents on: 1. 3/31/18 - Resident 1 was found lying on the floor on her back. Lost her balance while walking with a walker towards the closet. 2. 4/5/18 - Resident 1 was found lying on the floor with a walker over her that resulted in a discoloration on her back left hand, no swelling noted. 3. 4/9/18 - Resident 1 was found sitting on the floor holding onto the chair in her room trying to get up from the floor which resulted in skin tears to her right elbow 1 cm x 1 cm, above her right ring finger 0.8 cm x 0.5 cm, and right index finger 1 cm x 0.2 cm. 4. 4/22/18 - Resident 1 was found sitting on the floor beside her bed with no injury. 5. 4/30/18 - Resident 1 was found sitting on the floor beside bed and commode with no injury. 6. 5/17/18 - Resident 1 was found sitting on the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 43DC11 Facility ID: CA070000057 If continuation sheet 2 of 3 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555831 (X3) DATE SURVEY COMPLETED 07/09/2018 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 floor which resulted in an upper lip skin abrasion. Review of Morse Fall Scale (a fall assessment tool) indicated Resident 1 had scored 110 (>45 is high risk for fall) on 3/31/18. Review of Resident 1's care plan on 3/12/18 indicated Resident 1 was non-compliant with safety issues, had behavior problems noncompliant related to delusional disorder and history of falling. During a concurrent interview and record review with the care manager on 7/2/18 at 2:44 p.m., she admitted there were no new interventions after the falls on 3/31/18, 4/5/18, 4/9/18, 4/22/18, 4/30/18, and 5/17/18. Review of the facility's policy "Falls and Fall Risk Managing", dated September 2012, indicated if falling recurs despite initial interventions, staff will implement additional or different interventions. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 43DC11 Facility ID: CA070000057 If continuation sheet 3 of 3