Other·September 17, 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 an entity reported incident conducted on 9/14/18 . For Entity Reported Incident CA00599532 regarding Quality of Care/Treatment, a federal deficiency was identified (see F689). A Class "B" citation was also issued. 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: 34383, Health Facilities Evaluator Nurse.

F689 SS=D Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) §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 observation, interview, and record review, the facility failed to ensure appropriate 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: 3LS011 Facility ID: CA070000085 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: _______________ 05A277 (X3) DATE SURVEY COMPLETED 09/14/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INSPIRE BEHAVIORAL HEALTH 401 Ridge Vista Ave San Jose, CA 95127 (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 footwear and adequate assistance were provided to prevent an accident with injury for one sampled resident (Resident 1) when, Resident 1 walked without footwear (such as shoes, boots, and sandals) and fell. The fall incident resulted in Resident 1's left hip fracture. Findings: Review of Resident 1's clinical record indicated, Resident 1 had diagnoses including paranoid schizophrenia (mental disorder), presbyopia (is the gradual loss of your eyes' ability to focus on nearby objects), and hypertension (increase in blood pressure). Review of Resident 1's Care Area Assessment dated 5/2/18, indicated Resident 1 was at risk for fall related to psychotropic (drugs capable of affecting the mind, emotions, and behavior) medication use, decrease in ability to determine safety, cognitive impairment, and vision impairment. Review of Resident 1's Minimum Data Set (MDS, an assessment tool) dated 7/27/18, indicated Resident 1 was modified independent in decision making and would required supervision with activities of daily living (ADLs) including walk in room, walk in corridor, locomotion on unit, and locomotion off unit. Review of Resident 1's Fall Assessment dated 7/21/18, indicated he had a score of 12 (a score greater than 10 indicated high risk for fall). Review of Resident 1's Physical Functioning Deficit care plan dated 5/5/18, indicated the resident was at risk for physical functioning deficit related to history of mobility impairment, risk for self care impairment, and decrease in FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3LS011 Facility ID: CA070000085 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: _______________ 05A277 (X3) DATE SURVEY COMPLETED 09/14/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INSPIRE BEHAVIORAL HEALTH 401 Ridge Vista Ave San Jose, CA 95127 (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 ability to perform ADLs. The intervention for physical functioning deficit was to provide walking assistance. Review of Resident 1's Risk for Fall care plan dated 5/5/18, indicated the resident was at risk for fall related to history of fall, medications, tremor (shaking movement), history of cerebrovascular accident (are caused by blood clots and broken blood vessels in the brain), abdominal hernia (an organ pushes through an opening in the muscle or tissue that holds it in place), poor safety awareness and judgement. The intervention was to have footwear to prevent slipping. Review of Resident 1's Post Fall care plan dated 6/4/18, indicated the resident was found sitting on the floor in the classroom. The intervention was to check for proper shoes while walking. Review of Resident 1's Situation, Background, Assessment, and Recommendation (SBAR, a technique that can be used to facilitate prompt and appropriate communication) dated 8/10/18 indicated, Resident 1 had an unwitnessed fall on 8/10/18. He was found lying on the floor, had sustained a small skin tear on his left forearm, and complained of pain on the left groin. Resident 1 was transferred to the acute hospital for further evaluation. Review of the nurses' progress notes dated 8/11/18, indicated the resident was transferred to the acute hospital with a left hip fracture. During an interview with registered nurse A (RN A) on 8/16/18 at 2 p.m., RN A stated Resident 1 had an unwitnessed fall and was not supervised when the fall happened. She acknowledged, Resident 1 was a high risk for fall and walked in the room with no assistance. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3LS011 Facility ID: CA070000085 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: _______________ 05A277 (X3) DATE SURVEY COMPLETED 09/14/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INSPIRE BEHAVIORAL HEALTH 401 Ridge Vista Ave San Jose, CA 95127 (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 RN A also stated he was not wearing appropriate footwear. During an interview with certified nursing assistant B (CNA B) on 8/16/18 at 3:10 p.m., CNA B confirmed, Resident 1 was wearing socks only and no shoes when he fell. CNA B stated Resident 1 was unstable when walking and used a wheelchair when he walked. CNA B also stated Resident 1 fell close to his roommate's bed and was alone when the fall incident happened. During an interview and concurrent record review with the director of nursing (DON) on 9/5/18 at 2:05 p.m., she confirmed Resident 1 was a high risk for fall and walked in his room with no assistance. She also stated Resident 1 should wear his shoes to prevent slipping and falling. The DON acknowledged Resident 1's care plans should have been followed and implemented to prevent him from falling. Review of the facility's policy, "Fall Prevention and Fall Related Injury Management", dated 4/11/17, indicated the residents would be evaluated for fall risk in order to plan, develop and implement to reduce the risk for fall and injuries. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3LS011 Facility ID: CA070000085 If continuation sheet 4 of 4