Other·August 2, 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 7/25/19. For Complaint CA00639888 regarding Quality of Care/Treatment, federal deficiencies were identified (F684 and F772). A "B" Citation was also issued. Inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. Representing the California Department of Public Health: 39949, Health Facilities Evaluator Nurse.

F684 SS=D Quality of Care CFR(s): 483.25

F684 08/12/2019 § 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive personcentered care plan, and the residents' choices. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to follow the physician's order when medication as needed for constipation was not administered for Resident 1. This failure could potentially impact Resident 1's health and safety. 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: 2B5B11 Facility ID: CA070000073 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: _______________ 555635 (X3) DATE SURVEY COMPLETED 07/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE COURTYARD CARE CENTER 340 Northlake Dr San Jose, CA 95117 (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 Findings: During a review of the clinical record for Resident 1, the Progress Notes dated 6/6/19 indicated Resident 1 was admitted on 12/23/16 with diagnoses of other obstructive and reflux uropathy (blockage of urine drainage), tubular interstitial nephritis (a kidney disorder), traumatic subdural hemorrhage (bleeding often occurs outside the brain) with loss of consciousness of unspecified duration and major depressive disorder (a mental disorder). During a review of the clinical record for Resident 1, the Follow-Up Question Report from 5/20/19 to 5/27/19 indicated Resident 1 did not have a bowel movement on 5/23/19, 5/24/19, 5/25/19, and 5/29/19. During a review of the clinical record for Resident 1, the Medication Administration Record dated 5/1/19 to 5/31/19 indicated an order for Milk of Magnesia Suspension (over the counter medication that can treat constipation, upset stomach, and heart burn) 1200 mg (milligrams, a unit of measurement)/15 ml (milliliters, a unit of measurement) (Magnesium Hydroxide) give 30 ml by mouth as needed for constipation daily if no bowel movement for three days. During an interview with licensed vocation nurse A (LVN A) on 6/6/19 at 2:13 p.m., she confirmed that Resident 1 did not have bowel movements for four days. LVN A also confirmed that Milk of Magnesia should have been given after the third day of not having a bowel movement. During an interview with director of nursing (DON) on 6/6/19 at 2:30 p.m., she confirmed Resident 1 should have received medication as FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2B5B11 Facility ID: CA070000073 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: _______________ 555635 (X3) DATE SURVEY COMPLETED 07/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE COURTYARD CARE CENTER 340 Northlake Dr San Jose, CA 95117 (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 needed for constipation after three days of not having a bowel movement. The DON also added that nurses need to follow the physician's orders.

F772 SS=D Lab Services Not Provided On-Site CFR(s): 483.50(a)(1)(iv)

F772 08/12/2019 §483.50(a)(1) The facility must provide or obtain laboratory services to meet the needs of its residents. The facility is responsible for the quality and timeliness of the services. (iv) If the facility does not provide laboratory services on site, it must have an agreement to obtain these services from a laboratory that meets the applicable requirements of part 493 of this chapter. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to provide laboratory services in a timely manner when Resident 1 had a STAT (without delay; immediately) blood test five and a half hours after receiving orders from the physician. This failure could potentially impact Resident 1's health and safety. Findings: During a review of the clinical record for Resident 1, the Progress Notes dated 6/6/19 indicated Resident 1 was admitted on 12/23/16 with diagnoses of other obstructive and reflux uropathy (blockage of urine drainage), tubular interstitial nephritis (a kidney disorder), traumatic subdural hemorrhage (bleeding often occurs outside the brain) with loss of consciousness of unspecified duration, and major depressive disorder (a mental disorder). During a review of the clinical record for Resident 1, the Progress Notes dated 5/27/19 at 12:23 p.m. indicated Resident 1 looked weak FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2B5B11 Facility ID: CA070000073 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: _______________ 555635 (X3) DATE SURVEY COMPLETED 07/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE COURTYARD CARE CENTER 340 Northlake Dr San Jose, CA 95117 (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 with no shortness of breath, not in distress, complains of abdominal pain. Progress notes also indicated, "Notify MD with new order STAT CBC, CMP, urinalysis and urine culture and sensitivity. Order noted and carried out. Resident and daughter made aware." During a review of the clinical record for Resident 1, the Progress Notes dated 5/27/19 at 15:33 p.m. indicated facility staff placed a call to the laboratory and spoke with laboratory staff after lunch and scheduled a STAT CBC (complete blood count, a blood test), CMP (comprehensive metabolic panel, a blood test), UA (urine analysis, a urine test), and C and S (culture and sensitivity, urine test). During a review of the clinical record for Resident 1, the Progress Notes dated 5/27/19 at 18:48 p.m. indicated urine specimen collected by lab and blood extraction done at 6 p.m. During an interview with director of nursing (DON) on 6/6/19 at 1:46 p.m., she stated they have four hours to notify the laboratory for any new STAT orders and two hours for the laboratory staff to come into the facility and draw. During an interview with the administrator (ADM) on 6/18/19 at 10:14 a.m. he stated facility policy did not specify specific times regarding STAT laboratory orders. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2B5B11 Facility ID: CA070000073 If continuation sheet 4 of 4