Other·February 4, 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 standard abbreviated survey regarding investigation of a facility report incident conducted on 1/18/19. For Facility Report Incident CA00618468 regarding Quality of Care/Treatment/Resident Safety/Falls, a federal deficiency was identified (see F689 with S/S of G). In addition, a Class "B" citation was issued. Inspection was limited to the specific facility 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.

F689 SS=G Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) 03/06/2019 §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 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 monitor the whereabouts and implement fall care plan interventions for one of 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: RDTH11 Facility ID: CA070000057 If continuation sheet 1 of 4 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 01/18/2019 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 two residents (1) when Resident 1 fell while ambulating with no staff present at the time of the fall. These failures resulted in Resident 1 sustaining a proximal right humeral fracture (fracture at the top of the right arm bone). Findings: Review of Resident 1's Admission Record indicated she was admitted with diagnoses including Alzheimer's disease (an irreversible, progressive brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks) and disorders of bone density and structure. Review of Resident 1's Morse Fall Scale (a method of assessing a resident's likelihood of falling), from 6/18/18 to 12/24/18, indicated she was moderate to high risk for falling. Review of Resident 1's Post Fall Incident Investigation, dated 7/11/18, indicated she fell in the courtyard and sustained front right knee redness. Review of Resident 1's fall care plan, initiated on 7/11/18 and revised on 11/19/18, indicated an intervention of visual check. Review of Resident 1's Fall Incident Interdisciplinary Team (IDT, a group of health care professionals from diverse fields who work in a coordinated fashion toward a common goal for the resident) reports, dated 7/11/18, 11/11/18, and 12/10/18, indicated the intervention was to monitor Resident 1's whereabouts. Review of Resident 1's Post Fall Incident Investigations, from 10/10/18 to 12/10/18, indicated Resident 1 fell four times while ambulating with no staff present at the times of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RDTH11 Facility ID: CA070000057 If continuation sheet 2 of 4 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 01/18/2019 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 falls: On 10/10/18 Resident 1 fell in the courtyard and sustained a bruise at the corner of the mouth and redness on the right cheek; On 10/14/18 Resident 1 fell in the courtyard with no injury; On 11/11/18 Resident 1 fell in another resident's room and sustained a skin tear on the bridge of her nose; and On 12/10/18 Resident 1 fell in the hallway with no injury. Review of Resident 1's Minimum Data Set (MDS, a clinical assessment tool), dated 12/17/18, indicated her cognitive skills for daily decision making were severely impaired and Resident 1 needed supervision when she ambulated. The MDS under section G "Walk in corridor", "Locomotion on unit", and "Locomotion off unit" indicated Resident 1 needed supervision and with one-person physical assist. Review of Resident 1's Physical Therapist Progress notes, dated 12/20/18, indicated Resident 1 had standing balance and muscle strength deficits and required hand held assist with initiation cue, visual instruction/cues for safety when she ambulated on level surfaces. Review of Resident 1's Post Fall Incident Investigation, dated 1/2/19, indicated Resident 1 fell in the courtyard while ambulating and sustained a front right knee abrasion. No staff were present at the time of the fall. Resident 1 was sent to the hospital for complaint of pain on the right shoulder. Review of Resident 1's acute care emergency department provider notes, dated 1/2/19, indicated Resident 1 sustained a proximal right humeral fracture and final diagnosis of closed FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RDTH11 Facility ID: CA070000057 If continuation sheet 3 of 4 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 01/18/2019 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 fracture of proximal end of right humerus. During an interview with restorative nursing assistant A (RNA A) on 1/8/19 at 10:45 a.m., she stated she was in the smoking area and heard a sound from the side of the building. She went over and saw Resident 1 lying on the ground. During an interview with certified nursing assistant B (CNA B) on 1/10/19 at 1:45 p.m., she stated there was no staff watching the residents while they ambulated in the courtyard. If she did not see her residents in the building, she would look for them in the courtyard. During an interview with CNA C on 1/10/19 at 2 p.m., she stated there was no staff watching the residents while they ambulated in the courtyard. If she did not see her residents in the building, she would look for them in the courtyard. During an interview with CNA D on 1/10/19 at 2:15 p.m., he stated the residents were not allowed to go to the courtyard because there was no staff watching them there. He monitored the residents, but sometimes he was busy and residents went outside. If he did not see his residents in the building, he would look for them in the courtyard. Review of the facility's undated policy, "Fall Prevention Program Policies and Procedures", indicated "The Registered Nurse Care Manager (RNCM) will complete an assessment of the resident's fall risk and a care plan will be implemented to reduce falls and prevent injury within State and Federal time frames beginning at admission." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RDTH11 Facility ID: CA070000057 If continuation sheet 4 of 4