Other·December 7, 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 an abbreviated survey regarding investigation of a complaint conducted on 11/28/18. For Complaint CA00603886 regarding Quality of Care/Treatment, federal deficiencies were identified (see F656 and F757). Two "G" level deficiencies were identified. A Class "AA" citation was also issued. Investigation 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: 29328, Health Facilities Evaluator Manager II; 35157, Health Facilities Evaluator Nurse

F656 SS=G Develop/Implement Comprehensive Care Plan F656 CFR(s): 483.21(b)(1) §483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 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: 73IM11 Facility ID: CA070000082 If continuation sheet 1 of 22 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: _______________ 055866 (X3) DATE SURVEY COMPLETED 11/28/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PLUM TREE CARE CENTER 2580 Samaritan Dr San Jose, CA 95124 (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 or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record. (iv)In consultation with the resident and the resident's representative(s)(A) The resident's goals for admission and desired outcomes. (B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to develop and implement a care plan to monitor one of three residents (Resident 1) who was on high risk medication. Resident 1 was on Methotrexate, a high risk medication. (Methotrexate is an anticancer drug also used for rheumatoid arthritis [RA], chronic disorder causing swelling and pain in joints). The facility failed to adequately monitor Resident 1 consistent with the manufacturer's guidelines, standards of practice, or Resident 1's Rheumatoid Arthritis care plan. Resident 1's physician ordered stat lab test yet the facility failed to follow up on the results and advise FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 73IM11 Facility ID: CA070000082 If continuation sheet 2 of 22 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: _______________ 055866 (X3) DATE SURVEY COMPLETED 11/28/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PLUM TREE CARE CENTER 2580 Samaritan Dr San Jose, CA 95124 (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 Resident 1's physician of the out of range findings. The lab results reflected a need for prompt medical attention. These failures resulted in Resident 1's transfer to an acute hospital with diagnoses of sepsis, severe neutropenia, methotrexate-induced thrombocytopenia, and mucositis, leading to her death. Findings: Review of Resident 1's closed record indicated she was an 81-year-old female, who was admitted to the facility on 7/11/18 for physical and occupational rehabilitation services, following a laminectomy (surgical procedure to remove the posterior arch of the vertebra (backbone). Resident 1's post hospital diagnoses included spinal stenosis (spinal narrowing), hypertension (high blood pressure), metabolic encephalopathy (abnormalities of the hormones, electrolytes [substances such as sodium, potassium etc. that perform a variety of function within the body], other chemicals that are off range and can adversely affect brain function), urinary retention, chronic kidney disease, diabetes (high blood sugar), and rheumatoid arthritis. Review of Resident 1's admission minimum data set (MDS, an assessment tool), dated 7/18/18, indicated Resident 1's cognition (mental process) was intact. She required extensive assistance in activities of daily living. She was continent of bowel and bladder. An order for an indwelling catheter (flexible tube to drain the bladder) was discontinued on 7/16/18. Review of Resident 1's acute hospital's history and physical (H&P) dated 7/3/18, under list of current medications, listed "Methotrexate 4 tablets per week". FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 73IM11 Facility ID: CA070000082 If continuation sheet 3 of 22 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: _______________ 055866 (X3) DATE SURVEY COMPLETED 11/28/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PLUM TREE CARE CENTER 2580 Samaritan Dr San Jose, CA 95124 (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 Resident 1's physician's admission orders in the facility dated 7/11/18, indicated for 2 medications for RA: Methotrexate 2.5 milligrams (mg., a unit of measure) one tablet orally daily, and Plaquenil 200 mg. one tablet orally daily. According to the DailyMed website (https://daily med.nlm.nih.gov), a website operated by the U.S. National Library of Medicine (NLM) that publishes up-to-date accurate drug labels (package insert) to health care providers and the general public, Methotrexate comes with a black box warning (the strongest warning that the food and drug administration (FDA) requires, and signifies that medical studies indicate a significant risk of serious or even lifethreatening adverse effects. During a telephone interview with registered pharmacist C (RPh C) on 11/27/18 at 3:10 p.m., he stated the manufacturer of Methotrexate was Quality Test/PAR and the National Drug Code (NDC) # 67253-0320-10. Review of the black box warning on methotrexate indicated the following warnings: Methotrexate should be used only by physicians whose knowledge and experience include the use of antimetabolite therapy because of the possibility of serious reactions (which can be fatal). Methotrexate should be used only in life threatening neoplastic disease, or in patients with psoriasis or rheumatoid arthritis with severe, recalcitrant, disabling disease which is not adequately responsive to other forms of therapy. Deaths have been reported with the use of methotrexate in the treatment of malignancy, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 73IM11 Facility ID: CA070000082 If continuation sheet 4 of 22 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: _______________ 055866 (X3) DATE SURVEY COMPLETED 11/28/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PLUM TREE CARE CENTER 2580 Samaritan Dr San Jose, CA 95124 (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 psoriasis, and rheumatoid arthritis. Patients should be closely monitored for bone marrow, liver, lung, and kidney toxicities. Patients should be informed by their physicians of the risks involved and be under a physician's care throughout the therapy. Review of the section on Information for Patients from the DailyMed website indicated "both the physician and pharmacist should emphasize to the patient that the recommended dose is taken weekly in rheumatoid arthritis and psoriasis, and that mistaken daily use of the recommended dose has led to fatal toxicity". Review of the section on Laboratory Tests from the DailyMEd website indicated "patients should be closely monitored so that toxic effects are detected promptly. Baseline assessments should include a complete blood count with differential and platelet counts, hepatic enzymes, renal function tests and a chest x-ray". Review of the section on Adverse Reactions from the DailyMed website indicated "the most frequently reported adverse reactions include ulcerative stomatitis, leukopenia (low blood cells), nausea, and abdominal distress. Other frequently adverse effects are malaise, undue fatigue, chills, and fever, dizziness and decrease resistance to infection". Review of the section on Over dosage from the DailyMed website indicated "Leucovorin is indicated to diminish the toxicity and counteract the effect of inadvertently administered over dosages of methotrexate". Review of the section on Dosage and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 73IM11 Facility ID: CA070000082 If continuation sheet 5 of 22 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: _______________ 055866 (X3) DATE SURVEY COMPLETED 11/28/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PLUM TREE CARE CENTER 2580 Samaritan Dr San Jose, CA 95124 (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 Administration from the DailyMed website indicated "Adult Rheumatoid Arthritis, recommended starting dosage schedules: 1) single oral doses of 7.5 mg once weekly; 2) Divided oral dosages of 2.5 mg at 12 hour intervals for 3 doses given as a course once weekly". Review of the section on How Supplied from the DailyMed website indicated "Methotrexate Tablets, USP contain an amount of methotrexate sodium equivalent to 2.5 mg of methotrexate and are yellow, round, uncoated, scored, flat tablets with diameter of 6 mm and embossed with code [ORN57] on one side; NDC 47335-235-96 (Bottle of 36); NDC 47335235-83 (Bottle of 100)". Review of the section on Patient Information from the DailyMed website indicated "the most common side effects of methotrexate include mouth sores, low white blood cells, nausea, upset stomach, feeling poorly, tiredness, chills, fever, dizziness, higher chance of infections, diarrhea, vomiting, hair loss and easy bruising and to stop taking methotrexate and call your doctor right away if your get diarrhea, mouth sore, fever, dehydration, cough, bleeding, shortness of breath, any signs of infection or a skin rash". Review of facility pharmacy's Black Box Warning Policy and Procedure dated 9/2016 indicated "Pharmacy will place "a black box warning" notification on the prescription label and Nursing to document in the care plan the black box warning when a resident is on a medication with a black box warning". Review of Resident 1's care plans indicated there were no care plans for Resident 1's Methotrexate, a medication that needs black box warning. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 73IM11 Facility ID: CA070000082 If continuation sheet 6 of 22 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: _______________ 055866 (X3) DATE SURVEY COMPLETED 11/28/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PLUM TREE CARE CENTER 2580 Samaritan Dr San Jose, CA 95124 (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 registered nurse C (RN C) on 11/19/18 at 12 noon, she stated "I don't recall [Resident 1's] Methotrexate came in with a black warning information and if it would, we would have a [comprehensive] care plan for it". She recalled "it came in an ordinary bubble pack with no black box warning". Review of Resident 1's medication administration record (MAR) indicated Resident 1 received methotrexate 2.5 mg. daily from 7/12/18 to 8/19/18, except for three undocumented days. This indicated Resident 1 received a total of 36 tablets when Resident 1's H&P from the acute care hospital indicated 24 tablets based on her dosage of 4 tablets every week. During a telephone interview with the registered pharmacist B (RPH B) on 10/18/18 at 2:30 p.m., he stated he stated he "did not see the recommendation for black box warning for Methotrexate but when he checked the system, he finally saw the black box warning for Methotrexate". When asked if pharmacy should have sent a black box warning to the facility, RPH B replied, "if it is indicated, pharmacy will fax to facility". During a telephone interview with registered pharmacist A (RPH A) on 10/2/18 at 1:15 p.m., she stated some of the side effects of the methotrexate are vomiting, diarrhea, and gingivitis (swollen gums). Review of Resident 1's nurse's notes dated 8/10/18 indicated Resident 1 had three loose stools (bowel movement) in the morning. The licensed nursed called the physician and received a telephone order dated 8/10 18 for a stat complete blood count (CBC), and comprehensive metabolic panel (CMP, a panel FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 73IM11 Facility ID: CA070000082 If continuation sheet 7 of 22 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: _______________ 055866 (X3) DATE SURVEY COMPLETED 11/28/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PLUM TREE CARE CENTER 2580 Samaritan Dr San Jose, CA 95124 (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 of tests that show a snapshot of the body's chemistry, blood sugar level, kidney, and liver function). The physician also ordered a urinalysis with culture and sensitivity (UA with C&S, a test to find out the bacteria that cause the infection and the antibiotic that would be most appropriate to treat the infection), and a stool for Clostridium difficille (C-diff, bacteria that causes inflammation of the bowels). Review of Resident 1's Comprehensive Care Plan for Rheumatoid Arthritis dated 7/12/18 under Interventions indicated: "Medication and treatments as ordered, Laboratory/Diagnostic works as ordered by the physician, Notify the MD, RP, the results of the lab works for prompt intervention". Review of Resident 1's laboratory results dated 8/12/18 indicated negative result for C. diff. Review of Resident 1's lab results taken last 8/10/18 and their reference range (within normal limits) are as follows: CMP Panel: Glucose:135 High (H) (65-99 mg./dl [unit of measurement used to measure blood]); BUN:45 H (7-25 mg/dl); Creatinine: 1.42 H (0.6 - 0.88 mg/dl); BUN/Creatinine ratio: 31 H ((6-22); Chloride: 111 H (98-110 mmol/L (millimoles per liter, measurement, substance that contain molecule or atoms); Protein, Total: 5.7 L (low) (6.1-8.1 g/dl); Albumin (a form of protein): 3.4 L (3.6-5.1 g/dl). CBC: (including differential/total) WBC: 3.0 L (3.8-10.8 thousand /uL (unit per liter); RBC (red blood cell): 2.70 L (3.80-5.10 million/uL); Hemoglobin (red protein that caries oxygen in FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 73IM11 Facility ID: CA070000082 If continuation sheet 8 of 22 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: _______________ 055866 (X3) DATE SURVEY COMPLETED 11/28/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PLUM TREE CARE CENTER 2580 Samaritan Dr San Jose, CA 95124 (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 blood): 8.3 L (11.7-15.5 g/dl); Hematocrit (ratio of the volume of red blood cells to the total volume of blood): 25.2 L (3545%); Absolute lymphocytes: 510 L (850-3900 cells/uL); Absolute monocytes (largest type of WBC, influence the process of adaptive immunity. During a telephone interview with the customer service representative (CSR) of the laboratory service provider on 10/16/18 at 9:45 a.m., CSR stated according to their record, the results were sent to the facility at 7:14 p.m. on 8/10/18. He stated the results were refaxed to the facility on 9/9/18 per the facility's request. Review of Resident 1's nurse's notes dated from 8/10/18 to 8/20/18, indicated there was no follow-up on the status of the stat laboratory ordered on 8/10/18, and there was no documentation the physician was notified of the stat lab results. Review of Resident 1's physician's Progress Notes dated 9/10/18 "Late entry note for post discharge 8/24/18", indicated she "got report on stool for C-diff. toxin negative". "I did not get the reports on other labs ordered". During an interview with licensed vocational nurse A (LVN A) on 10/2/18 at 1 p.m. she stated she took care of Resident 1 at least once. She stated Resident 1 has a sore "like a blister" on her lip with minimal bleeding, but could not remember if it was the upper or lower lip. LVN A stated she did not do an oral assessment because Resident 1 could not open her mouth fully because of the sore. During an interview with certified nursing assistant D (CNA D) on 10/2/18 at 1:55 p.m., she stated Resident 1 had three to four loose stools but could not recall the exact date it FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 73IM11 Facility ID: CA070000082 If continuation sheet 9 of 22 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: _______________ 055866 (X3) DATE SURVEY COMPLETED 11/28/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PLUM TREE CARE CENTER 2580 Samaritan Dr San Jose, CA 95124 (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 occurred or when the episodes of loose stools started. These observations were not documented in Resident 1's medical record. During an interview with CNA E on 10/12/18 at 1:20 p.m., she stated Resident 1 had frequent stools (two to three times per shift) but it did not occur daily. She stated the stools were not diarrhea or watery stools but had the consistency of an "oatmeal". These observations were not documented in Resident 1's medical record. Review of Resident 1's MAR for 8/2018 indicated Resident 1 received Loperamide (anti-diarrhea medication) on 8/12/18 at 2 p.m. and 8/14/18 at 2 p.m. for diarrhea. Review of Resident 1's Nurse's Notes dated 8/17/18 written at 11 a.m. RN F noted "small blister on resident lower lip, 3/10 pain noted"; written at 1 p.m., "placed a call again to MD regarding resident's sores on lower lip"; and written at 3 p.m., "received a call from MD with orders for Lidocaine viscous ..." During a telephone interview with registered nurse B (RN B) on 10/2/18 at 4:20 p.m., he stated Resident 1 complained of diarrhea and abdominal cramping on 8/20/18 at 3 p.m. He notified the physician with orders to repeat Cdiff test, a gastrointestinal consult (GI consult), and an order to give Pepto-Bismol (antidiarrheal). He stated on 8/19/18, the day before Resident 1's transfer to the hospital, Resident 1 appeared weak and stayed in bed. Resident 1 also refused her morning medications on 8/20/18. RN B stated Resident 1's responsible party (RP, a person who is responsible for decisions related to the resident's care) requested Resident 1 be sent to the hospital for further evaluation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 73IM11 Facility ID: CA070000082 If continuation sheet 10 of 22 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: _______________ 055866 (X3) DATE SURVEY COMPLETED 11/28/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PLUM TREE CARE CENTER 2580 Samaritan Dr San Jose, CA 95124 (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 Resident 1 was transferred to the acute hospital on 8/20/18 at 3:45 p.m. Review of Resident 1's physician discharge summary from the facility dated 8/21/18, indicated under Condition of Discharge, "Abdominal pain/ cramps/ diarrhea/ lip ulcer. need to rule out infection/ colitis/ any drug reaction, Patient on methotrexate". Review of Resident 1's acute hospital's history and physical (H&P) dated 8/20/18, indicated Resident 1 came in with "chief complaint of diarrhea and abdominal pain, numerous sores in her mouth that were painful, cracking, and bleeding and make it difficult for her to eat". The laboratory report indicated Resident 1 had "absolute neutropenia [ANC, abnormally low count of neutrophils, white blood cells (WBC) important to fight infection] of 250 cells". ANC is calculated by multiplying the total WBC count by the percentage of segmented neutrophils plus the band forms of the neutrophils in the CBC differential. The laboratory report also indicated WBC count cells of 500 per milliliter (ml., a unit of measure), and thrombocytopenia (low platelet count) of 31,000 (normal count ranges from 150,000 to 450,000 platelets per microliter of blood). The H&P also indicated Resident 1 recalled that her methotrexate dose was "four tablets every Tuesday" and that she "did not realize she was now taking once a day". Resident 1's H&P assessment indicated "Acute and severe neutropenia and thrombocytopenia of recent onset, diffuse abdominal pain, distention, tenderness and diarrhea, subacute onset and negative for C. diff, in the presence of evidence of mucositis and neutropenia" and Resident 1 received 25 mg. of Leucovorin and the Methotrexate was stopped. Review of Resident 1's acute hospital's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 73IM11 Facility ID: CA070000082 If continuation sheet 11 of 22 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: _______________ 055866 (X3) DATE SURVEY COMPLETED 11/28/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PLUM TREE CARE CENTER 2580 Samaritan Dr San Jose, CA 95124 (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 Discharge Summary dated 8/24/18 indicated Resident 1 died on 8/24/18. Discharge Diagnoses included: "Death due to acute sepsis" (also called septicemia, a life threatening complication of an illness), 2. "Death due to acute and severe neutropenia", 3. "Methotrexate- induced thrombocytopenia and neutropenia", 4. "Mucositis", 5. "Rheumatoid Arthritis", and "Deterioration due to acute illness". Review of Resident 1's death certificate indicated the cause of death included: a. Acute Respiratory Failure, b. Septicemia, c. Neutropenia, d. Rheumatoid Arthritis.

F757 SS=G Drug Regimen is Free from Unnecessary Drugs CFR(s): 483.45(d)(1)-(6)

F757 §483.45(d) Unnecessary Drugs-General. Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used§483.45(d)(1) In excessive dose (including duplicate drug therapy); or §483.45(d)(2) For excessive duration; or §483.45(d)(3) Without adequate monitoring; or §483.45(d)(4) Without adequate indications for its use; or §483.45(d)(5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or §483.45(d)(6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section. This REQUIREMENT is not met as evidenced FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 73IM11 Facility ID: CA070000082 If continuation sheet 12 of 22 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: _______________ 055866 (X3) DATE SURVEY COMPLETED 11/28/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PLUM TREE CARE CENTER 2580 Samaritan Dr San Jose, CA 95124 (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 by: Based on interview and record review, the facility failed to develop and implement a care plan to monitor one of three residents (Resident 1) who was on high risk medication. Resident 1 was on Methotrexate, a high risk medication. (Methotrexate is an anticancer drug also used for rheumatoid arthritis [RA], chronic disorder causing swelling and pain in joints). The facility failed to adequately monitor Resident 1 consistent with the manufacturer's guidelines, standards of practice, or Resident 1's Rheumatoid Arthritis care plan. Resident 1's physician ordered stat lab test yet the facility failed to follow up on the results and advise Resident 1's physician of the out of range findings. The lab results reflected a need for prompt medical attention. These failures resulted in Resident 1's transfer to an acute hospital with diagnoses of sepsis, severe neutropenia, methotrexate-induced thrombocytopenia, and mucositis, leading to her death. Findings: Review of Resident 1's closed record indicated she was an 81 year old female, who was admitted to the facility on 7/11/18 for physical (focused on strength, mobility) and occupational (focused on activities daily living) rehabilitation (rehab) services, following a laminectomy (surgical procedure to remove the posterior arch of the vertebra (backbone). Resident 1 was also treated for urinary tract infection (UTI) in the hospital. Diagnoses included spinal stenosis (spinal narrowing), hypertension (high blood pressure), metabolic encephalopathy (abnormalities of the hormones,electrolytes [substances such as sodium, potassium etc.,that perform a variety of function within the body], other chemicals that are off range and can adversely affect brain FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 73IM11 Facility ID: CA070000082 If continuation sheet 13 of 22 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: _______________ 055866 (X3) DATE SURVEY COMPLETED 11/28/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PLUM TREE CARE CENTER 2580 Samaritan Dr San Jose, CA 95124 (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 function), urinary retention, chronic kidney disease, diabetes (high blood sugar), and rheumatoid arthritis. Review of the admission minimum data set )MDS, an assessment tool), dated 7/18/18, indicated Resident 1's cognition(mental process) was intact. She required extensive assistance in activities of daily living. She was continent of bowel and bladder. An order for an indwelling catheter (flexible tube to drain the bladder) was discontinues on 7/16/18. Review of Resident 1's acute hospital's history and physical (H&P) dated 7/3/18, under list of current medications, listed "Methotrexate 4 tablets per week". Review of the physician's admission orders, dated 7/11/18, included medications for rheumatoid arthritis (RA): methotrexate 2.5 milligrams (mg., a unit of measure) one tablet orally daily, and Plaquenil 200 mg., one tablet daily. According to the DailyMed website ( https://daily med.nlm.nih.gov ), a website operated by the U.S. National Library of Medicine (NLM) that publishes up-to-date accurate drug labels (package insert) to health care providers and the general public, methotrexate comes with a black box warning ( the strongest warning that the food and drug administration (FDA) requires, and signifies that medical studies indicate a significant risk of serious or even life-threatening adverse effects. During a telephone interview with registered pharmacist C (RPh C) on 11/27/18 at 3;10 p.m., he stated the manufacturer of Methotrexate was Quality Test/PAR and the Mational Drug Code (NDC) # 67253-0320-10. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 73IM11 Facility ID: CA070000082 If continuation sheet 14 of 22 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: _______________ 055866 (X3) DATE SURVEY COMPLETED 11/28/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PLUM TREE CARE CENTER 2580 Samaritan Dr San Jose, CA 95124 (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 black box warning on methotrexate indicated the following warnings: Methotrexate should be used only by physicians whose knowledge and experience include the use of antimetabolite therapy because of the possibility of serious reactions (which can be fatal). Methotrexate should be used only in life threatening neopalstic disease, or in patients with psoriasis or rheumatoid arthritis with severe recalcitrant, disabling disease which is not adequately responsive to other forms of therapy. Deaths have been reported with the use of ethereal in the treatment of malignancy, psoriasis, an rheumatoid arthritis. Patients should be closely monitored for bone marrow, liver, lung, and kidney toxicities. Patients should be informed by their physicians of the risks involved and be under a physician's care throughout the therapy. Review of the section on Information for Patients from the DailyMed website indicated "both the physician and pharmacist should emphasize to the patient that the recommended dose is taken weekly in rheumatoid arthritis and psoriasis, and that mistaken daily use of the recommended dose has led to fatal toxicity". Review of the section on Laboratory Tests from the DailyMEd website indicated "patients should be closely monitored so that toxic effects are detected promptly. Baseline assessments should include a complete blood count with differential and platelet counts, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 73IM11 Facility ID: CA070000082 If continuation sheet 15 of 22 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: _______________ 055866 (X3) DATE SURVEY COMPLETED 11/28/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PLUM TREE CARE CENTER 2580 Samaritan Dr San Jose, CA 95124 (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 hepatic enzymes, renal function tests and a chest x-ray". Review of the section on Adverse Reactions from the DailyMed website indicated "the most frequently reported adverse reactions include ulcerative stomatitis, leukopenia (low blood cells), nausea, and abdominal distress. Other frequently adverse effects are malaise, undue fatigue, chills, and fever, dizziness and decrease resistance to infection". Review of the section on Over dosage from the DailyMed website indicated "Leucovorin is indicated to diminish the toxicity and counteract the effect of inadvertently administered over dosages of methotrexate". Review of the section on Dosage and Administration from the DailyMed website indicated "Adult Rheumatoid Arthritis, recommended starting dosage schedules: 1) single oral doses of 7.5 mg once weekly; 2) Divided oral dosages of 2.5 mg at 12 hour intervals for 3 doses given as a course once weekly". Review of the section on How Supplied from the DailyMed website indicated "Methotrexate Tablets, USP contain an amount of methotrexate sodium equivalent to 2.5 mg of methotrexate and are yellow, round, uncoated, scored, flat tablets with diameter of 6 mm and embossed with code [ORN57] on one side; NDC 47335-235-96 (Bottle of 36); NDC 47335235-83 (Bottle of 100)". Review of the section on Patient Information from the DailyMed website indicated "the most common side effects of methotrexate include mouth sores, low white blood cells, nausea, upset stomach, feeling poorly, tiredness, chills, fever, dizziness, higher chance of infections, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 73IM11 Facility ID: CA070000082 If continuation sheet 16 of 22 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: _______________ 055866 (X3) DATE SURVEY COMPLETED 11/28/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PLUM TREE CARE CENTER 2580 Samaritan Dr San Jose, CA 95124 (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 diarrhea, vomiting, hair loss and easy bruising and to stop taking methotrexate and call your doctor right away if your get diarrhea, mouth sore, fever, dehydration, cough, bleeding, shortness of breath, any signs of infection or a skin rash". Review of facility pharmacy's Black Box Warning Policy and Procedure dated 9/2016 indicated "Pharmacy will place "a black box warning" notification on the prescription label and Nursing to document in the care plan the black box warning when a resident is on a medication with a black box warning. Review of Resident 1's care plans indicated there were no care plans for Resident 1's Methotrexate, a medication that needs black box warning. During an interview with the registered nurse C (RN C) on 11/19/18 at 12 noon, she stated "I don't recall [Resident 1's] Methotrexate came in with a black warning information and if it would, we would have a [comprehensive] care plan for it". She recalled "it came in an ordinary bubble pack with no black box warning". Review of Resident 1's medication administration record (MAR) indicated Resident 1 received methotrexate 2.5 mg. daily from 7/12/18 to 8/19/18, except for three undocumented days. This indicated Resident 1 received a total of 36 tablets when the acute care hospital had prescribed only 24 tablets based on her dosage of 4 tablets every week. During a telephone interview with the registered pharmacist B (RPH B) on 10/18/18 at 2:30 p.m., he stated he "did not see the recommendation for black box warning for Methotrexate but when he checked the system, he finally saw the black box warning for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 73IM11 Facility ID: CA070000082 If continuation sheet 17 of 22 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: _______________ 055866 (X3) DATE SURVEY COMPLETED 11/28/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PLUM TREE CARE CENTER 2580 Samaritan Dr San Jose, CA 95124 (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 Methotrexate". When asked if pharmacy should have sent a black box warning to the facility, RPH B replied, "if it is indicated, pharmacy will fax to facility". During a telephone interview with registered pharmacist A (RPH A) on 10/2/18 at 1:15 p.m., she stated some of the side effects of the methotrexate are vomiting, diarrhea, and gingivitis (swollen gums). Review of the nurse's notes dated 8/10/18, indicated Resident 1 had three loose stools (bowel movement) in the morning. The licensed nursed called the physician and received a telephone order for a stat (from the Latin word statum, meaning immediately) complete blood count (CBC), comprehensive metabolic panel (CMP, a panel of tests that show a snapshot of the body's chemistry, blood sugar level, kidney, and liver function). The physician also ordered a urinalysis with culture and sensitivity ( UA with C&S, a test to find out the bacteria that cause the infection and the antibiotic that would be most appropriate to treat the infection), and a stool for Clostridium difficille (C-diff, a bacteria that causes inflammation of the bowels). Review of Resident 1's Comprehensive Care Plan for Rheumatoid Arthritis dated 7/12/18 under Interventions indicated: "Medication and treatments as ordered, Laboratory/Diagnostic works as ordered by the physician, Notify the MD, RP, the results of the lab works for prompt intervention". Review of Resident 1's laboratory results dated 8/12/18 indicated negative result for C. diff. Review of Resident 1's lab results taken last 8/10/18 and their reference range (within normal limits) are as follows: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 73IM11 Facility ID: CA070000082 If continuation sheet 18 of 22 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: _______________ 055866 (X3) DATE SURVEY COMPLETED 11/28/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PLUM TREE CARE CENTER 2580 Samaritan Dr San Jose, CA 95124 (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 CMP Panel: Glucose:135 High (H) (65-99 mg./dl [unit of measurement used to measure blood]); BUN:45 H (7-25 mg/dl); Creatinine: 1.42 H (0.6 - 0.88 mg/dl); BUN/Creatinine ratio: 31 H ((6-22); Chloride: 111 H (98-110 mmol/L (millimoles per liter, measurement, substance that contain molecule or atoms); Protein, Total: 5.7 L (low) (6.1-8.1 g/dl); Albumin (a form of protein): 3.4 L (3.6-5.1 g/dl). CBC: (including differential/total) WBC: 3.0 L (3.8-10.8 thousand /uL (unit per liter); RBC (red blood cell): 2.70 L (3.80-5.10 million/uL); Hemoglobin (red protein that caries oxygen in the blood): 8.3 L (11.7-15.5 g/dl); Hematocrit (ratio of the volume of red blood cells to the total volume of blood): 25.2 L (3545%); Absolute lymphocytes: 510 L (850-3900 cells/uL); Absolute monocytes (largest type of WBC, influence the process of adaptive immunity. During a telephone interview with the customer service representative (CSR) of the laboratory service provider on 10/16/18 at 9:45 a.m., CSR stated according to their record, the results were sent to the facility at 7:14 p.m. on 8/10/18. He stated the results were refaxed to the facility on 9/9/18 per the facility's request. Review of Resident 1's nurse's notes dated from 8/10/18 to 8/20/18, indicated there was no follow-up on the status of the stat laboratory ordered on 8/10/18, and there was no documentation the physician was notified of the stat lab results. Review of Resident 1's physician's Progress FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 73IM11 Facility ID: CA070000082 If continuation sheet 19 of 22 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: _______________ 055866 (X3) DATE SURVEY COMPLETED 11/28/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PLUM TREE CARE CENTER 2580 Samaritan Dr San Jose, CA 95124 (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 Notes dated 9/10/18 "Late entry note for post discharge 8/24/18", indicated she "got report on stool for C-diff. toxin negative". "I did not get the reports on other labs ordered". During an interview with licensed vocational nurse A (LVN A) on 10/2/18 at 1 p.m. she stated she took care of Resident 1 at least once. She stated Resident 1 has a sore "like a blister" on her lip with minimal bleeding, but could not remember if it was the upper or lower lip. LVN A stated she did not do an oral assessment because Resident 1 could not open her mouth fully because of the sore. During an interview with certified nursing assistant D (CNA D) on 10/2/18 at 1:55 p.m., she stated Resident 1 had three to four loose stools but could not recall the exact date it occurred or when the episodes of loose stools started. These observations were not documented in Resident 1's medical record. During an interview with CNA E on 10/12/18 at 1:20 p.m., she stated Resident 1 had frequent stools (two to three times per shift) but it did not occur daily. She stated the stools were not diarrhea or watery stools but had the consistency of an "oatmeal". These observations were not documented in Resident 1's medical record. Review of Resident 1's MAR for 8/2018 indicated Resident 1 received Loperamide (anti-diarrhea medication) on 8/12/18 at 2 p.m. and 8/14/18 at 2 p.m. for diarrhea. Review of Resident 1's Nurse's Notes dated 8/17/18 written at 11 a.m. RN F noted "small blister on resident lower lip, 3/10 pain noted"; written at 1 p.m., "placed a call again to MD regarding resident's sores on lower lip"; and written at 3 p.m., "received a call from MD with FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 73IM11 Facility ID: CA070000082 If continuation sheet 20 of 22 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: _______________ 055866 (X3) DATE SURVEY COMPLETED 11/28/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PLUM TREE CARE CENTER 2580 Samaritan Dr San Jose, CA 95124 (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 orders for Lidocaine viscous ..." During a telephone interview with registered nurse B (RN B) on 10/2/18 at 4:20 p.m., he stated Resident 1 complained of diarrhea and abdominal cramping on 8/20/18 at 3 p.m. He notified the physician with orders to repeat Cdiff test, a gastrointestinal consult (GI consult), and an order to give Pepto-Bismol (antidiarrheal). He stated on 8/19/18, the day before Resident 1's transfer to the hospital, Resident 1 appeared weak and stayed in bed. Resident 1 also refused her morning medications on 8/20/18. RN B stated Resident 1's responsible party (RP, a person who is responsible for decisions related to the resident's care) requested Resident 1 be sent to the hospital for further evaluation. Resident 1 was transferred to the acute hospital on 8/20/18 at 3:45 p.m. Review of Resident 1's physician discharge summary from the facility dated 8/21/18, indicated under Condition of Discharge, "Abdominal pain/ cramps/ diarrhea/ lip ulcer. need to rule out infection/ colitis/ any drug reaction, Patient on methotrexate". Review of Resident 1's acute hospital's history and physical (H&P) dated 8/20/18, indicated Resident 1 came in with "chief complaint of diarrhea and abdominal pain, numerous sores in her mouth that were painful, cracking, and bleeding and make it difficult for her to eat". The laboratory report indicated Resident 1 had "absolute neutropenia [ANC, abnormally low count of neutrophils, white blood cells (WBC) important to fight infection] of 250 cells". ANC is calculated by multiplying the total WBC count by the percentage of segmented neutrophils plus the band forms of the neutrophils in the CBC differential. The laboratory report also FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 73IM11 Facility ID: CA070000082 If continuation sheet 21 of 22 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: _______________ 055866 (X3) DATE SURVEY COMPLETED 11/28/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PLUM TREE CARE CENTER 2580 Samaritan Dr San Jose, CA 95124 (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 indicated WBC count cells of 500 per milliliter (ml., a unit of measure), and thrombocytopenia (low platelet count) of 31,000 (normal count ranges from 150,000 to 450,000 platelets per microliter of blood). The H&P also indicated Resident 1 recalled that her methotrexate dose was "four tablets every Tuesday" and that she "did not realize she was now taking once a day". Resident 1's H&P assessment indicated "Acute and severe neutropenia and thrombocytopenia of recent onset, diffuse abdominal pain, distention, tenderness and diarrhea, subacute onset and negative for C. diff, in the presence of evidence of mucositis and neutropenia" and Resident 1 received 25 mg. of Leucovorin and the Methotrexate was stopped. Review of Resident 1's acute hospital's Discharge Summary dated 8/24/18 indicated Resident 1 died on 8/24/18. Discharge Diagnoses included: "Death due to acute sepsis" (also called septicemia, a life threatening complication of an illness), 2. "Death due to acute and severe neutropenia", 3. "Methotrexate- induced thrombocytopenia and neutropenia", 4. "Mucositis", 5. "Rheumatoid Arthritis", and "Deterioration due to acute illness". Review of Resident 1's death certificate indicated the cause of death included: a. Acute Respiratory Failure, b. Septicemia, c. Neutropenia, d. Rheumatoid Arthritis. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 73IM11 Facility ID: CA070000082 If continuation sheet 22 of 22